Brunner and Suddarth's Canadian Textbook of Medical-Surgical Nursing [3 ed.] 9781451193336, 2014043943

Table of contents :
BRUNNER & SUDDARTH’S: Canadian Textbook of Medical-Surgical Nursing, Third Edition
Half Title Page
Title Page
Copyright
Contributors New to the Third Canadian Edition
Contributors to the Second Canadian Edition
Contributors to the 12th U.S. Edition
Preface and
Acknowledgements
About the Third Canadian Edition
NANDA, NIC, NOC: Links, Languages, and Concept Maps
Organization
Features
Acknowledgements
Contents
UNIT 1
Basic Concepts in Nursing
CHAPTER 1 Health Care Delivery and Nursing Practice
THE HEALTH CARE SYSTEM AND THE NURSING PROFESSION
HEALTH, WELLNESS, AND HEALTH PROMOTION
INFLUENCES ON HEALTH CARE DELIVERY
ROLES OF THE NURSE
ADVANCED NURSING PRACTICE ROLES
REFERENCES AND SELECTED READINGS
CHAPTER 2 Community-Based Nursing Practice
COMMUNITY-BASED CARE
HOME CARE
COMMUNITY RESOURCES AND REFERRALS
HOME VISITS
OTHER COMMUNITY-BASED HEALTH CARE SETTINGS
REFERENCES AND SELECTED READINGS
CHAPTER 3 Critical Thinking, Ethical Decision Making, and the Nursing Process
CRITICAL THINKING
ETHICAL NURSING CARE
THE NURSING PROCESS
REFERENCES AND SELECTED READINGS
CHAPTER 4 Health Education and Health Promotion
HEALTH EDUCATION TODAY
THE NATURE OF TEACHING AND LEARNING
THE NURSING PROCESS IN PATIENT TEACHING
HEALTH PROMOTION
HEALTH PROMOTION THROUGHOUT THE LIFESPAN
NURSING IMPLICATIONS
REFERENCES AND SELECTED READINGS
CHAPTER 5 Adult Health and Nutritional Assessment
CONSIDERATIONS FOR CONDUCTING A HEALTH HISTORY AND PHYSICAL ASSESSMENT
HEALTH HISTORY
PHYSICAL ASSESSMENT
NUTRITIONAL ASSESSMENT
ASSESSMENT IN THE HOME AND COMMUNITY
REFERENCES AND SELECTED READINGS
CHAPTER 6 Obesity
DEFINITIONS
TYPES OF OBESITY
PREVALENCE OF OBESITY
HEALTH IMPACT OF OBESITY
DETERMINANTS OF OBESITY
PREVENTION OF OBESITY
MANAGEMENT OF OBESITY
SUMMARY OF KEY POINTS
REFERENCES AND SELECTED READINGS
JOURNALS AND ELECTRONIC DOCUMENTS
RESOURCES
UNIT 2 Biophysical and Psychosocial Concepts in Nursing Practice
CHAPTER 7 Homeostasis, Stress, and Adaptation
FUNDAMENTAL CONCEPTS
OVERVIEW OF STRESS
STRESS AT THE CELLULAR LEVEL
STRESS MANAGEMENT: NURSING INTERVENTIONS
REFERENCES AND SELECTED READINGS
CHAPTER 8 Individual and Family Considerations Related to Illness
HOLISTIC APPROACH TO HEALTH AND HEALTH CARE
THE BRAIN AND PHYSICAL AND EMOTIONAL HEALTH
MENTAL HEALTH AND EMOTIONAL DISTRESS
FAMILY HEALTH AND DISTRESS
LOSS AND GRIEF
DEATH AND DYING
SPIRITUALITY AND SPIRITUAL DISTRESS
REFERENCES AND SELECTED READINGS
CHAPTER 9 Perspectives in Transcultural Nursing
CULTURAL CONCEPTS
TRANSCULTURAL NURSING
CULTURALLY MEDIATED CHARACTERISTICS
CAUSES OF ILLNESS
FOLK HEALERS
CULTURAL ASSESSMENT
ADDITIONAL CULTURAL CONSIDERATIONS: KNOW THYSELF
HEALTH DISPARITIES
THE FUTURE OF TRANSCULTURAL NURSING CARE
REFERENCES AND SELECTED READINGS
CHAPTER 10 Genetics and Genomics Perspectives in Nursing
GENOMIC FRAMEWORK FOR NURSING PRACTICE
INTEGRATING GENETIC AND GENOMIC KNOWLEDGE
GENETIC AND GENOMIC TECHNOLOGIES IN PRACTICE
PERSONALIZED GENOMIC TREATMENTS
APPLICATIONS OF GENETICS AND GENOMICS IN NURSING PRACTICE
ETHICAL ISSUES
REFERENCES AND SELECTED READINGS
CHAPTER 11 Chronic Illness
THE PHENOMENON OF CHRONICITY
CHARACTERISTICS OF CHRONIC CONDITIONS
NURSING CARE OF PEOPLE LIVING WITH CHRONIC CONDITIONS
REFERENCES AND SELECTED READINGS
CHAPTER 12 Principles and Practices of Rehabilitation Including Disabilities
SUPPORTING PERSONS WITH DISABILITIES
PATIENT RESPONSES TO DISABILITY
THE REHABILITATION TEAM
AREAS OF SPECIALTY REHABILITATION
ASSESSMENT OF FUNCTIONAL ABILITY
DISABILITY AND SEXUALITY ISSUES
FATIGUE
HOME AND COMMUNITY-BASED CARE
COMPLEMENTARY AND ALTERNATIVE THERAPIES
FOLLOW-UP CARE
REFERENCES AND SELECTED READINGS
CHAPTER 13 Health Care of the Older Adult
OVERVIEW OF AGING
AGE-RELATED CHANGES
PHARMACOLOGIC ASPECTS OF AGING
MENTAL HEALTH ISSUES IN THE OLDER ADULT
GERIATRIC SYNDROMES
OTHER ASPECTS OF HEALTH CARE OF THE OLDER ADULT
REFERENCES AND SELECTED READINGS
UNIT 3 Concepts and Challenges in Patient Management
CHAPTER 14 Pain Management
IMPORTANCE OF PAIN ASSESSMENT AND MANAGEMENT
TYPES OF PAIN
HARMFUL EFFECTS OF PAIN
PATHOPHYSIOLOGY OF PAIN
FACTORS INFLUENCING PAIN RESPONSE
THE NURSE’S ROLE IN ASSESSMENT AND CARE OF PATIENTS WITH PAIN
PAIN MANAGEMENT STRATEGIES
PHARMACOLOGIC INTERVENTIONS
NONPHARMACOLOGIC INTERVENTIONS
EVALUATING PAIN MANAGEMENT STRATEGIES
REFERENCES AND SELECTED READINGS
CHAPTER 15 Fluid and Electrolytes: Balance and Disturbance
FUNDAMENTAL CONCEPTS
REGULATION OF BODY FLUID COMPARTMENTS
FLUID VOLUME DISTURBANCES
ELECTROLYTE IMBALANCES
POTASSIUM IMBALANCES
CALCIUM IMBALANCES
MAGNESIUM IMBALANCES
PHOSPHORUS IMBALANCES
CHLORIDE IMBALANCES
ACID–BASE DISTURBANCES
REFERENCES AND SELECTED READINGS
CHAPTER 16 Shock and Multiple Organ Dysfunction Syndrome
OVERVIEW OF SHOCK
STAGES OF SHOCK
GENERAL MANAGEMENT STRATEGIES IN SHOCK
HYPOVOLEMIC SHOCK
CARDIOGENIC SHOCK
CIRCULATORY SHOCK
MULTIPLE ORGAN DYSFUNCTION SYNDROME
PROMOTING HOME AND COMMUNITY-BASED CARE
REFERENCES AND SELECTED READINGS
CHAPTER 17 Oncology: Nursing Management in Cancer Care
EPIDEMIOLOGY OF CANCER
PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS
DETECTION AND PREVENTION OF CANCER
DIAGNOSIS OF CANCER
TUMOUR STAGING AND GRADING
MANAGEMENT OF CANCER
NURSING CARE OF PATIENTS WITH CANCER
CANCER SURVIVORSHIP
REFERENCES AND SELECTED READINGS
CHAPTER 18 Hospice Palliative Care at the End-of-Life
NURSING AND HOSPICE PALLIATIVE CARE AT THE END-OF-LIFE CARE
GENERAL CONSIDERATIONS IN THE CARE OF PATIENTS WITH ADVANCED ILLNESS AND THEIR FAMILIES
PROVIDING CULTURALLY COMPETENT CARE AT THE END-OF-LIFE
PRINCIPLES OF PALLIATIVE SEDATION
PROVIDING SUPPORT TO PATIENTS WHO ARE ACTIVELY DYING AND THEIR FAMILIES
COPING WITH DEATH AND DYING: PROFESSIONAL CAREGIVER ISSUES
REFERENCES AND SELECTED READINGS
UNIT 4 Perioperative Concepts and Nursing Management
CHAPTER 19 Preoperative Nursing Management
PERIOPERATIVE NURSING
ADVANCES IN TECHNOLOGY AND ANESTHESIA
SURGICAL CLASSIFICATIONS
PREADMISSION TESTING
SPECIAL CONSIDERATIONS DURING THE PERIOPERATIVE PERIOD
INFORMED CONSENT
PREOPERATIVE ASSESSMENT
GENERAL PREOPERATIVE NURSING INTERVENTIONS
IMMEDIATE PREOPERATIVE NURSING INTERVENTIONS
EXPECTED PATIENT OUTCOMES
REFERENCES AND SELECTED READINGS
CHAPTER 20 Intraoperative Nursing Management
THE SURGICAL TEAM
THE SURGICAL ENVIRONMENT
THE SURGICAL EXPERIENCE
POTENTIAL INTRAOPERATIVE COMPLICATIONS
REFERENCES AND SELECTED READINGS
CHAPTER 21 Postoperative Nursing Management
CARE OF THE PATIENT IN THE POSTANESTHESIA CARE UNIT
CARE OF THE HOSPITALIZED POSTOPERATIVE PATIENT
REFERENCES AND SELECTED READINGS
UNIT 5 Gas Exchange and Respiratory Function
CHAPTER 22 Assessment of Respiratory Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 23 Management of Patients With Upper Respiratory Tract Disorders
UPPER AIRWAY INFECTIONS
PHARYNGITIS
OBSTRUCTION AND TRAUMA OF THE UPPER RESPIRATORY AIRWAY
REFERENCES AND SELECTED READINGS
CHAPTER 24 Management of Patients With Chest and Lower Respiratory Tract Disorders
ATELECTASIS
RESPIRATORY INFECTIONS
PLEURAL CONDITIONS
PULMONARY EDEMA
ACUTE RESPIRATORY FAILURE
ACUTE RESPIRATORY DISTRESS SYNDROME
PULMONARY HYPERTENSION
PULMONARY HEART DISEASE (COR PULMONALE)
PULMONARY EMBOLISM
SARCOIDOSIS
OCCUPATIONAL LUNG DISEASES: PNEUMOCONIOSES
CHEST TUMOURS
CHEST TRAUMA
ASPIRATION
REFERENCES AND SELECTED READINGS
CHAPTER 25 Management of Patients With Chronic Obstructive Pulmonary Disease
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
BRONCHIECTASIS
ASTHMA
CYSTIC FIBROSIS
REFERENCES AND SELECTED READINGS
CHAPTER 26 Respiratory Care Modalities
NONINVASIVE RESPIRATORY THERAPIES
AIRWAY MANAGEMENT
THE PATIENT UNDERGOING THORACIC SURGERY
REFERENCES AND SELECTED READINGS
UNIT 6 Cardiovascular, Circulatory, and Hematologic Function
CHAPTER 27 Assessment of Cardiovascular Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT OF THE CARDIOVASCULAR SYSTEM
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 28 Management of Patient With Dysrhythmias and Conduction Problems
DYSRHYTHMIAS
ADJUNCTIVE MODALITIES AND MANAGEMENT
REFERENCES AND SELECTED READINGS
CHAPTER 29 Management of Patients With Coronary Vascular Disorders
CORONARY ARTERY DISEASE
INVASIVE CORONARY ARTERY PROCEDURES
REFERENCES AND SELECTED READINGS
CHAPTER 30 Management of Patients With Structural, Infections, and Inflammatory Cardiac Disorders
VALVULAR DISORDERS
VALVE REPAIR AND REPLACEMENT PROCEDURES
INFECTIOUS DISEASES OF THE HEART
REFERENCES AND SELECTED READINGS
CHAPTER 31 Management of Patients With Complications From Heart Disease
CARDIAC HEMODYNAMICS
HEART FAILURE
OTHER COMPLICATIONS
REFERENCES AND SELECTED READINGS
CHAPTER 32 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
ASSESSMENT OF VASCULAR FUNCTION
ASSESSMENT
DIAGNOSTIC EVALUATION
ARTERIAL DISORDERS
VENOUS DISORDERS
LYMPHATIC DISORDERS
CELLULITIS
REFERENCES AND SELECTED READINGS
CHAPTER 33 Assessment and Management of Patients With Hypertension
PATHOGENESIS OF HYPERTENSION
COMPLICATIONS OF HYPERTENSION
DIAGNOSIS AND CLASSIFICATION OF BLOOD PRESSURE
INVESTIGATION OF THE PATIENT WHO IS HYPERTENSIVE
MONITORING PEOPLE DIAGNOSED WITH HYPERTENSION
ASSESSMENT OF CARDIOVASCULAR RISK
TREATMENT OF HIGH BLOOD PRESSURE
HYPERTENSIVE CRISES
REFERENCES
CHAPTER 34 Assessment and Management of Patients With Hematologic Disorders
HEMATOLOGIC ASSESSMENT
ASSESSMENT AND DIAGNOSTIC EVALUATION
ANEMIA
POLYCYTHEMIA
LEUKOPENIA
MYELOFIBROSIS
LYMPHOMA
BLEEDING DISORDERS
ACQUIRED COAGULATION DISORDERS
THERAPIES FOR BLOOD DISORDERS
PROCURING BLOOD AND BLOOD PRODUCTS
TRANSFUSION
PERIPHERAL BLOOD STEM CELL TRANSPLANTATION AND BONE MARROW TRANSPLANTATION
REFERENCES AND SELECTED READINGS
UNIT 7 Digestive and Gastrointestinal Function
CHAPTER 35 Assessment of Digestive and Gastrointestinal Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT OF THE GASTROINTESTINAL SYSTEM
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 36 Management of Patients With Oral and Esophageal Disorders
DISORDERS OF THE ORAL CAVITY
DISORDERS OF THE JAW
DISORDERS OF THE SALIVARY GLANDS
CANCER OF THE ORAL CAVITY AND PHARYNX
NECK DISSECTION
DISORDERS OF THE ESOPHAGUS
REFERENCES AND SELECTED READINGS
CHAPTER 37 Gastrointestinal Intubation and Special Nutritional Modalities
GASTROINTESTINAL INTUBATION
TUBE FEEDINGS WITH NASOGASTRIC AND NASOENTERIC DEVICES
GASTROSTOMY
PARENTERAL NUTRITION
REFERENCES AND SELECTED READINGS
CHAPTER 38 Management of Patients With Gastric and Duodenal Disorders
GASTRITIS
PEPTIC ULCER DISEASE
OBESITY
GASTRIC CANCER
GASTRIC SURGERY
DUODENAL TUMOURS
REFERENCES AND SELECTED READINGS
CHAPTER 39 Management of Patients With Intestinal and Rectal Disorders
ABNORMALITIES OF FECAL ELIMINATION
CONDITIONS OF MALABSORPTION
INFLAMMATORY BOWEL DISEASE
INTESTINAL OBSTRUCTION
DISEASES OF THE ANORECTUM
REFERENCES AND SELECTED READINGS
UNIT 8 Metabolic and Endocrine Function
CHAPTER 40 Assessment and Management of Patients With Hepatic Disorders
ASSESSMENT OF THE LIVER
ASSESSMENT
DIAGNOSTIC EVALUATION
MANIFESTATIONS OF HEPATIC DYSFUNCTION
VIRAL HEPATITIS
NONVIRAL HEPATITIS
FULMINANT HEPATIC FAILURE
HEPATIC CIRRHOSIS
CANCER OF THE LIVER
REFERENCES AND SELECTED READINGS
CHAPTER 41 Assessment and Management of Patients With Biliary Disorders
ANATOMIC AND PHYSIOLOGIC OVERVIEW
DISORDERS OF THE GALLBLADDER
DISORDERS OF THE PANCREAS
REFERENCES AND SELECTED READINGS
CHAPTER 42 Assessment and Management of Patients With Diabetes Mellitus
CLASSIFICATION OF DIABETES
DIABETES MANAGEMENT
NURSING MANAGEMENT
ACUTE COMPLICATIONS OF DIABETES
LONG-TERM COMPLICATIONS OF DIABETES
SPECIAL ISSUES IN DIABETES CARE
REFERENCES AND SELECTED READINGS
CHAPTER 43 Assessment and Management of Patients With Endocrine Disorders
ASSESSMENT OF THE ENDOCRINE SYSTEM
ASSESSMENT
DIAGNOSTIC EVALUATION
THE PITUITARY GLAND
THE THYROID GLAND
THE PARATHYROID GLANDS
THE ADRENAL GLANDS
CORTICOSTEROID THERAPY
REFERENCES AND SELECTED READINGS
UNIT 9 Urinary Tract Function
CHAPTER 44 Assessment of Renal and Urinary Tract Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT OF THE RENAL AND URINARY TRACT SYSTEMS
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 45 Management of Patients With Renal Disorders
FLUID AND ELECTROLYTE IMBALANCES IN RENAL DISORDERS
RENAL DISORDERS
PRIMARY GLOMERULAR DISEASES
POLYCYSTIC KIDNEY DISEASE
RENAL CANCER
RENAL FAILURE
CHRONIC RENAL FAILURE (END-STAGE RENAL DISEASE)
RENAL REPLACEMENT THERAPIES
KIDNEY SURGERY
KIDNEY TRANSPLANTATION
RENAL TRAUMA
REFERENCES AND SELECTED READINGS
CHAPTER 46 Management of Patients With Urinary Disorders
INFECTIONS OF THE URINARY TRACT
ADULT VOIDING DYSFUNCTION
UROLITHIASIS AND NEPHROLITHIASIS
GENITOURINARY TRAUMA
URINARY TRACT CANCERS
URINARY DIVERSIONS
REFERENCES AND SELECTED READINGS
UNIT 10 Reproductive Function
CHAPTER 47 Assessment and Management of Female Physiologic Processes
ROLE OF NURSES IN WOMEN’S HEALTH
ASSESSMENT OF THE FEMALE REPRODUCTIVE SYSTEM
ASSESSMENT
DIAGNOSTIC EVALUATION
MANAGEMENT OF FEMALE PHYSIOLOGIC PROCESSES
REFERENCES AND SELECTED READINGS
CHAPTER 48 Management of Patients With Female Reproductive Disorders
VULVOVAGINAL INFECTIONS
STRUCTURAL DISORDERS
BENIGN DISORDERS
MALIGNANT CONDITIONS
HYSTERECTOMY
RADIATION THERAPY
REFERENCES AND SELECTED READINGS
CHAPTER 49 Assessment and Management of Patients With Breast Disorders
BREAST ASSESSMENT
ASSESSMENT
DIAGNOSTIC EVALUATION
CONDITIONS AFFECTING THE NIPPLE
BREAST INFECTIONS
BENIGN CONDITIONS OF THE BREAST
MALIGNANT CONDITIONS OF THE BREAST
DISEASES OF THE MALE BREAST
JOURNALS AND ELECTRONIC DOCUMENTS
REFERENCES AND SELECTED READINGS
CHAPTER 50 Assessment and Management of Concerns Related to Male Reproductive Processes
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT
DIAGNOSTIC EVALUATION OF THE MALE
DISORDERS OF MALE SEXUAL FUNCTION
INFECTIONS OF THE MALE GENITOURINARY TRACT
CONDITIONS OF THE PROSTATE
CONDITIONS AFFECTING THE TESTES AND ADJACENT STRUCTURES
CONDITIONS AFFECTING THE PENIS
REFERENCES AND SELECTED READINGS
UNIT 11 Immunologic Function
CHAPTER 51 Assessment of Immune Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ADVANCES IN IMMUNOLOGY
ASSESSMENT OF THE IMMUNE SYSTEM
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 52 Management of Patients With Immunodeficiency
PRIMARY IMMUNODEFICIENCIES
PHAGOCYTIC DYSFUNCTION
B-CELL DEFICIENCIES
T-CELL DEFICIENCIES
COMBINED B-CELL AND T-CELL DEFICIENCIES
DEFICIENCIES OF THE COMPLEMENT SYSTEM
SECONDARY IMMUNODEFICIENCIES
NURSING MANAGEMENT FOR PATIENTS WITH IMMUNODEFICIENCIES
REFERENCES AND SELECTED READINGS
CHAPTER 53 Management of Patients With HIV Illness and AIDS
HIV INFECTION AND AIDS
EMOTIONAL AND ETHICAL CONCERNS
REFERENCES AND SELECTED READINGS
CHAPTER 54 Assessment and Management of Patients With Allergic Disorders
ALLERGIC ASSESSMENT
ASSESSMENT
DIAGNOSTIC EVALUATION
ALLERGIC DISORDERS
REFERENCES AND SELECTED READINGS
CHAPTER 55 Assessment and Management of Patients With Rheumatic Disorders
RHEUMATIC DISEASES
DIFFUSE CONNECTIVE TISSUE DISEASES
DEGENERATIVE JOINT DISEASE (OSTEOARTHRITIS)
SPONDYLOARTHROPATHIES
METABOLIC AND ENDOCRINE DISEASES ASSOCIATED WITH RHEUMATIC DISORDERS
FIBROMYALGIA
ARTHRITIS ASSOCIATED WITH INFECTIOUS ORGANISMS
NEOPLASMS AND NEUROVASCULAR, BONE, AND EXTRA-ARTICULAR DISORDERS
MISCELLANEOUS DISORDERS
REFERENCES
UNIT 12 Integumentary Function
CHAPTER 56 Assessment of Integumentary Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT OF THE INTEGUMENT
SKIN CONSEQUENCES OF SELECTED SYSTEMIC DISEASES
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 57 Management of Patients With Dermatologic Conditions
SKIN CARE FOR PATIENTS WITH SKIN CONDITIONS
WOUND CARE FOR SKIN CONDITIONS
PRURITUS
INFECTIOUS DERMATOSES: BACTERIAL SKIN INFECTIONS
VIRAL SKIN INFECTIONS
FUNGAL (MYCOTIC) SKIN INFECTIONS
PARASITIC SKIN INFESTATION
CONTACT DERMATITIS
NONINFECTIOUS INFLAMMATORY DERMATOSES
BLISTERING DISEASES
ULCERATIONS
BENIGN TUMOURS OF THE SKIN
MALIGNANT TUMOURS OF THE SKIN: SKIN CANCER
OTHER MALIGNANCIES OF THE SKIN
DERMATOLOGIC AND PLASTIC RECONSTRUCTIVE SURGERY
LASER TREATMENT OF CUTANEOUS LESIONS
REFERENCES AND SELECTED READINGS
CHAPTER 58 Management of Patients With Burn Injury
INCIDENCE OF BURN INJURY
OUTLOOK FOR SURVIVAL AND RECOVERY
PATHOPHYSIOLOGY OF BURNS
MANAGEMENT OF THE PATIENT WITH A BURN INJURY
BURN CARE IN THE HOME
REFERENCES AND SELECTED READINGS
UNIT 13 Sensorineural Function
CHAPTER 59 Assessment and Management of Patients With Eye and Vision Disorders
ANATOMIC AND PHYSIOLOGIC OVERVIEW
ASSESSMENT
IMPAIRED VISION
GLAUCOMA
CATARACTS
CORNEAL DISORDERS
RETINAL DISORDERS
ORBITAL AND OCULAR TRAUMA
INFECTIOUS AND INFLAMMATORY CONDITIONS
ORBITAL AND OCULAR TUMOURS
SURGICAL PROCEDURES AND ENUCLEATION
OCULAR CONSEQUENCES OF SYSTEMIC DISEASE
CONCEPTS IN OCULAR MEDICATION ADMINISTRATION
ISSUES IN OPHTHALMOLOGY
PATIENT SAFETY
REFERENCES AND SELECTED READINGS
CHAPTER 60 Assessment and Management of Patients With Hearing and Balance Disorders
ANATOMY AND PHYSIOLOGY OVERVIEW
ASSESSMENT OF HEARING AND BALANCE
DIAGNOSTIC EVALUATION OF HEARING AND BALANCE
HEARING LOSS
CONDITIONS OF THE EXTERNAL EAR
CONDITIONS OF THE MIDDLE EAR
CONDITIONS OF THE INNER EAR
AURAL REHABILITATION
REFERENCES AND SELECTED READINGS
UNIT 14 Neurologic Function
CHAPTER 61 Assessment of Neurologic Function
ANATOMY AND PHYSIOLOGY OVERVIEW
ASSESSMENT OF THE NERVOUS SYSTEM
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 62 Management of Patients With Neurologic Dysfunction
ALTERED LEVEL OF CONSCIOUSNESS
INCREASED INTRACRANIAL PRESSURE
INTRACRANIAL SURGERY
REFERENCES AND SELECTED READINGS
CHAPTER 63 Management of Patients With Cerebrovascular Disorders
ISCHEMIC STROKE
HEMORRHAGIC STROKE
REFERENCES AND SELECTED READINGS
CHAPTER 64 Management of Patients With Neurologic Trauma
HEAD INJURIES
SCALP INJURY
SKULL FRACTURES
BRAIN INJURY
TYPES OF BRAIN INJURY
SPINAL CORD INJURY
REFERENCES AND SELECTED READINGS
CHAPTER 65 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies
INFECTIOUS NEUROLOGIC DISORDERS
AUTOIMMUNE PROCESSES
CRANIAL NERVE DISORDERS
DISORDERS OF THE PERIPHERAL NERVOUS SYSTEM
REFERENCES AND SELECTED READINGS
CHAPTER 66 Management of Patients With Oncologic or Degenerative Neurologic Disorders
ONCOLOGIC DISORDERS OF THE BRAIN AND SPINAL CORD
DEGENERATIVE DISORDERS
REFERENCES AND SELECTED READINGS
UNIT 15 Musculoskeletal Function
CHAPTER 67 Assessment of Musculoskeletal Function
ANATOMIC AND PHYSIOLOGIC OVERVIEW
HEALTH ASSESSMENT
DIAGNOSTIC EVALUATION
REFERENCES AND SELECTED READINGS
CHAPTER 68 Musculoskeletal Care Modalities
THE PATIENT IN A CAST, SPLINT, OR BRACE
THE PATIENT WITH AN EXTERNAL FIXATOR
THE PATIENT IN TRACTION
THE PATIENT UNDERGOING ORTHOPEDIC SURGERY
REFERENCES AND SELECTED READINGS
CHAPTER 69 Management of Patients With Musculoskeletal Disorders
LOW BACK PAIN
COMMON UPPER EXTREMITY PROBLEMS
COMMON FOOT PROBLEMS
METABOLIC BONE DISORDERS
MUSCULOSKELETAL INFECTIONS
BONE TUMOURS
REFERENCES AND SELECTED READINGS
CHAPTER 70 Management of Patients With Musculoskeletal Trauma
CONTUSIONS, STRAINS, AND SPRAINS
JOINT DISLOCATIONS
INJURIES TO THE TENDONS, LIGAMENTS, AND MENISCI
FRACTURES
FRACTURES OF SPECIFIC SITES
SPORTS-RELATED INJURIES
OCCUPATION-RELATED INJURIES
AMPUTATION
PREVENTION OF INJURIES IN NURSING PERSONNEL
REFERENCES AND SELECTED READINGS
UNIT 16 Other Acute Problems
CHAPTER 71 Management of Patients With Infectious Diseases
THE INFECTIOUS PROCESS
HOME-BASED CARE OF THE PATIENT WITH AN INFECTIOUS DISEASE
DIARRHEAL DISEASES
SEXUALLY TRANSMITTED INFECTIONS
EMERGING INFECTIOUS DISEASES
TRAVEL AND IMMIGRATION
REFERENCES AND SELECTED READINGS
CHAPTER 72 Emergency Nursing
SCOPE AND PRACTICE OF EMERGENCY NURSING
PRINCIPLES OF EMERGENCY CARE
AIRWAY OBSTRUCTION
HEMORRHAGE
HYPOVOLEMIC SHOCK
WOUNDS
TRAUMA
ENVIRONMENTAL EMERGENCIES
POISONING
SUBSTANCE ABUSE
VIOLENCE, ABUSE, AND NEGLECT
PSYCHIATRIC EMERGENCIES
REFERENCES AND SELECTED READINGS
CHAPTER 73 Emergency Preparedness and Disaster Nursing
REFERENCES
Index

Citation preview

BRUNNER & SUDDARTH’S

Canadian Textbook of Medical-Surgical Nursing THIRD EDITION Pauline Paul, PhD, RN Associate Professor Faculty of Nursing, University of Alberta Edmonton, Alberta Rene A. Day, PhD, RN Professor Emerita Faculty of Nursing, University of Alberta Edmonton, Alberta Bev Williams, PhD, RN Professor Faculty of Nursing, University of Alberta Edmonton, Alberta

Authors of Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 12th Edition Suzanne C. Smeltzer, EdD, RN, FAAN Professor and Director, Center for Nursing Research Villanova University College of Nursing Villanova, Pennsylvania Brenda G. Bare, RN, MSN Formerly, Associate Administrator/Chief Nurse Executive Inova Mount Vernon Hospital Alexandria, Virginia Janice L. Hinkle, PhD, RN, CNRN Formerly, Senior Research Fellow, Acute Stroke Programme Oxford Brookes University and John Radcliffe Hospital Oxford, United Kingdom Kerry H. Cheever, PhD, RN Professor and Chairperson St. Luke’s School of Nursing at Moravian College Assistant Vice President St. Luke’s Hospital & Health Network Bethlehem, Pennsylvania

Executive Editor: Sherry Dickinson Supervising Product Development Editor: Annette Ferran Editorial Assistant: Dan Reilly Marketing Manager: Dean Karampelas Production Project Manager: David Saltzberg Design Coordinator: Joan Wendt Art Coordinator: Jen Clements Manufacturing Coordinator: Karin Duffield Prepress Vendor: Aptara, Inc. Third Canadian edition. Copyright © 2016 Wolters Kluwer. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1996 by Lippincott-Raven Publishers. Copyright © 1992, 1988, 1984, 1975, 1970, 1964 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Brunner & Suddarth’s textbook of Canadian medical-surgical nursing Brunner & Suddarth’s Canadian textbook of medical-surgical nursing / [edited by] Pauline Paul, Rene A. Day, Bev Williams.—Third Canadian edition. p. ; cm. Canadian textbook of medical-surgical nursing Preceded by Brunner & Suddarth's textbook of Canadian medical-surgical nursing / [edited by] Rene A. Day ... [et al.]. 2nd Canadian ed. 2010. Includes bibliographical references and index. ISBN 978-1-4511-9333-6 (alk. paper) I. Paul, Pauline, 1958- , editor. II. Day, Rene A., editor. III. Williams, Bev, 1951- , editor. IV. Title. V. Title: Canadian textbook of medical-surgical nursing. [DNLM: 1. Nursing Care. 2. Perioperative Nursing. WY 150] RT41 610.730971—dc23 2014043943 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com

Preface and Acknowledgements

As we complete the second decade of the 21st century, nursing continues to be influenced by the expansion of science and technology and by social, cultural, economic, and environmental changes throughout the world. At the same time, today’s nurses are faced with the many challenges that result from the acute shortage of nurses throughout health care settings. This worldwide nursing shortage has resulted in the need for nurses to have increasingly high levels of nursing knowledge and skills in meeting the acute care, long-term care, and health promotion needs of individuals and groups. Nurses must be particularly skilled in critical thinking and clinical decision making as well as in consulting and collaborating with other members of the interprofessional health care team. Along with the challenges that today’s nurses confront, there are many opportunities for them to provide skilled, compassionate nursing care in a variety of health care settings, for patients in various stages of illness, and for patients across the age continuum. At the same time, there are significant opportunities for fostering health promotion activities for individuals and groups; this is an integral part of providing nursing care.

About the Third Canadian Edition This third Canadian edition builds on the 12th U.S. edition of Brunner & Suddarth’s Textbook of MedicalSurgical Nursing and is designed to assist nursing students in preparing for their roles and responsibilities within the complex health care system. A goal of the textbook is to provide balanced attention to both the art and science of adult medical-surgical nursing. The focus of the textbook is on physiologic, pathophysiologic, psychosocial, and spiritual concepts as they relate to nursing care. Emphasis is placed on integrating a variety of concepts from other disciplines such as nutrition, pharmacology, and gerontology. Throughout the textbook, particular attention has been placed on addressing the nursing care and health care needs of older adults and people with disabilities, both of which are important priorities in the education of tomorrow’s health care professionals. In addition, content relative to nursing research findings and evidence-based practice has been expanded to provide opportunities for the nurse to refine clinical decision-making skills.

Canadian contributors have reviewed each chapter and have changed the following as needed: drug names, names of tests and procedures, spelling, laboratory values to the international system of units, and all measurements to their metric equivalents. Whenever possible, the contributors have added Canadian citations, references, and research studies and have provided Canadian statistics related to disease entities. This third Canadian edition includes new and updated material that reflects the differences in Canadian nursing practice in terms of the health care system, community health, ethics, culture, epidemiology, pain management, gerontology, infection control, nursing and medical management, pharmacology, diagnostic tests and investigations, as well as support groups and Web resources specific to Canada. In this new edition a full chapter has been added on the topic of obesity, which is increasingly prevalent in Canadians. Many of the chapters have been significantly updated to reflect the latest evidence.

NANDA, NIC, NOC: Links, Languages, and Concept Maps Although Brunner & Suddarth’s Textbook of MedicalSurgical 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 Intervention Classification (NIC) and Nursing Outcomes Classification (NOC). Each unit begins with a case study and a chart presenting examples. Concept maps, which provide a visual representation of the NANDA, NIC, and NOC chart for each case study, are presented in each chapter. This material is included to introduce students and nurses 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.

Organization Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing, 3rd edition, is organized into 16 units. Units 1 through 4 cover core concepts related to medical-surgical nursing practice. Units 5 through 16 discuss adult health xi

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conditions that are treated medically or surgically. Each unit covering adult health conditions is structured in the following way to facilitate understanding: • The first chapter in the unit covers assessment and includes a review of normal anatomy and physiology of the body system being discussed. • The subsequent chapters in the unit cover management of specific disorders. Pathophysiology, clinical manifestations, assessment and diagnostic findings, medical management, and nursing management are presented. Special Nursing Process sections, provided for selected conditions, clarify and expand on the nurse’s role in caring for patients with these conditions.

Features Nurses assume many different roles when caring for patients. Many of the features in this textbook have been developed to help nurses fulfill these varied roles.

Acknowledgements We gratefully acknowledge our Canadian contributors who took on the challenge of continuing to “Canadianize” and update this edition of Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing. At the Faculty of Nursing, University of Alberta, we thank: • Our students who are using the textbook and who have provided us with helpful suggestions • Our colleagues who have supported us through the process of bringing 73 chapters to production • L. Wayne Day, our project manager, for his outstanding Internet searching skills. At Wolters Kluwer, we thank Annette Ferran, Supervising Product Development Editor, Nursing Education for her patience and commitment to this project. Thanks also to Corey Wolfe, Barry Wight, and Dan Renaud for their ongoing support. Pauline Paul, PhD, RN Rene A. Day, PhD, RN Bev Williams, PhD, RN

Contents

UNIT 1 Basic Concepts in Nursing . . . . . . . . . . 2 1 Health Care Delivery and Nursing Practice 4 2 Community-Based Nursing Practice 13 3 Critical Thinking, Ethical Decision Making, and the Nursing Process 21 4 Health Education and Health Promotion 38 5 Adult Health and Nutritional Assessment 53 6 Obesity 7 7

UNIT 2 Biophysical and Psychosocial Concepts in Nursing Practice . . . . . . . . . . . . . . . 96

7 Homeostasis, Stress, and Adaptation 98 8 Individual and Family Considerations Related to Illness 117 9 Perspectives in Transcultural Nursing 130 10 Genetics and Genomics Perspectives in Nursing 142 11 Chronic Illness 166 12 Principles and Practices of Rehabilitation Including Disabilities 180 13 Health Care of the Older Adult 216

19 Preoperative Nursing Management 444 20 Intraoperative Nursing Management 464 21 Postoperative Nursing Management 483

UNIT 5 Gas Exchange and Respiratory Function . . . . . . . . . . . . . . . . . . . . . . 506

22 Assessment of Respiratory Function 508 23 Management of Patients With Upper Respiratory Tract Disorders 539 24 Management of Patients With Chest and Lower Respiratory Tract Disorders 574 25 Management of Patients With Chronic Obstructive Pulmonary Disease 632 26 Respiratory Care Modalities 667

UNIT 6 Cardiovascular, Circulatory, and Hematologic Function . . . . . . . . . . . 714

UNIT 3 Concepts and Challenges in Patient Management. . . . . . . . . . . . . . . . . . . 244

14 Pain Management 246 15 Fluid and Electrolytes: Balance and Disturbance 282 16 Shock and Multiple Organ Dysfunction Syndrome 334 17 Oncology: Nursing Management in Cancer Care 359 18 Hospice Palliative Care at the End-of-Life

UNIT 4 Perioperative Concepts and Nursing Management. . . . . . . . . . . . . . . . . . . 442

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27 Assessment of Cardiovascular Function 716 28 Management of Patient With Dysrhythmias and Conduction Problems 754 29 Management of Patients With Coronary Vascular Disorders 790 30 Management of Patients With Structural, Infections, and Inflammatory Cardiac Disorders 840 31 Management of Patients With Complications From Heart Disease 867 32 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation 896

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33 Assessment and Management of Patients With Hypertension 938 34 Assessment and Management of Patients With Hematologic Disorders 961

UNIT 7 Digestive and Gastrointestinal Function . . . . . . . . . . . . . . . . . . . . . 1038

35 Assessment of Digestive and Gastrointestinal Function 1040 36 Management of Patients With Oral and Esophageal Disorders 1060 37 Gastrointestinal Intubation and Special Nutritional Modalities 1086 38 Management of Patients With Gastric and Duodenal Disorders 1114 39 Management of Patients With Intestinal and Rectal Disorders 1139

UNIT 8 Metabolic and Endocrine Function. . . . 1188

40 Assessment and Management of Patients With Hepatic Disorders 1190 41 Assessment and Management of Patients With Biliary Disorders 1243 42 Assessment and Management of Patients With Diabetes Mellitus 1271 43 Assessment and Management of Patients With Endocrine Disorders 1334

UNIT 9 Urinary Tract Function . . . . . . . . . . 1380

44 Assessment of Renal and Urinary Tract Function 1382 45 Management of Patients With Renal Disorders 1402 46 Management of Patients With Urinary Disorders 1450

UNIT 10 Reproductive Function . . . . . . . . . . 1488

47 Assessment and Management of Female Physiologic Processes 1490 48 Management of Patients With Female Reproductive Disorders 1531 49 Assessment and Management of Patients With Breast Disorders 1566

50 Assessment and Management of Concerns Related to Male Reproductive Processes 1600

UNIT 11 Immunologic Function . . . . . . . . . . 1634

51 Assessment of Immune Function 1636 52 Management of Patients With Immunodeficiency 1655 53 Management of Patients With HIV Illness and AIDS 1667 54 Assessment and Management of Patients With Allergic Disorders 1706 55 Assessment and Management of Patients With Rheumatic Disorders 1734

UNIT 12 Integumentary Function . . . . . . . . . 1762

56 Assessment of Integumentary Function 1764 57 Management of Patients With Dermatologic Conditions 1782 58 Management of Patients With Burn Injury 1838

UNIT 13 Sensorineural Function . . . . . . . . . . 1888

59 Assessment and Management of Patients With Eye and Vision Disorders 1890 60 Assessment and Management of Patients With Hearing and Balance Disorders 1938

UNIT 14 Neurologic Function . . . . . . . . . . . . 1970

61 Assessment of Neurologic Function 1972 62 Management of Patients With Neurologic Dysfunction 2003 63 Management of Patients With Cerebrovascular Disorders 2044 64 Management of Patients With Neurologic Trauma 2071 65 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 2104

Contents

66 Management of Patients With Oncologic or Degenerative Neurologic Disorders 2132

UNIT 15 Musculoskeletal Function . . . . . . . . 2166

67 Assessment of Musculoskeletal Function 2168 68 Musculoskeletal Care Modalities 2185 69 Management of Patients With Musculoskeletal Disorders 2215 70 Management of Patients With Musculoskeletal Trauma 2244

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UNIT 16 Other Acute Problems . . . . . . . . . . 2284

71 Management of Patients With Infectious Diseases 2286 72 Emergency Nursing 2321 73 Emergency Preparedness and Disaster Nursing 2360

Appendix A: Understanding Clinical Pathways online Appendix B: Diagnostic Studies and Interpretation online Index 2383

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Case Study Applying Concepts From NANDA-I, NIC, and NOC The Community With an Identified Health Problem A nurse working in an urgent care clinic that serves an economically depressed urban area notes a high incidence of older patients with dehydration and heatstroke in the summer months. The nurse verifies the observations by accessing data about hospital admissions for dehydration and heatstroke. The nurse determines that many of the admitted patients live in the area served by the clinic and that many of the patients live alone and have chronic illnesses. The nurse sees the need for a plan that includes a community response to this situation. The plan includes arranging an education program about the prevention of dehydration; a community support buddy system in which neighbours or volunteers call or visit homebound older adults during critical periods in the summer; and economic support to air condition the senior citizens’ centre. Visit to view a concept map that illustrates the relationships that exist among the nursing diagnoses, interventions, and outcomes for the patient’s clinical conditions.

A community with an identified health problem receives the nursing diagnoses Ineffective Therapeutic Regimen Management

requires nursing interventions

supports the need for

Community Health Development

supports the need for

and

outcomes should show improvement in improves

Community Competence

improves

Program Development and

and

Ineffective Community Coping

may also demonstrate Readiness for Enhanced Community Coping

supports the need for

improves and

may require intensive

Surveillance: Community

will help assess

and

will help assess

supports the need for

may enhance community

Environmental Risk Protection

Community Health Status

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

Deficient Community Health Presence of one or more health problems or factors that deter wellness or increase the risk of health problems experienced by an aggregate.

NIC Nursing Interventions

NOC Nursing Outcomes

Return to functional baseline status, stabilization of, or improvement in:

Community Health Development— Assisting members of a community to identify a community’s health concerns, mobilize resources, and implement solutions Program Development—Planning, implementing, and evaluating a coordinated set of activities designed to enhance wellness or to prevent, reduce, or eliminate one or more health problems for a group or community

Ineffective Community Coping— Pattern of community activities (for adaptation and problem solving) that is unsatisfactory for meeting the demands or needs of the community

Surveillance: Community— Purposeful and ongoing acquisition, interpretation, and synthesis of data for decision making in the community

Community Competence— Capacity of a community to collectively problem solve to achieve community goals

Readiness for Enhanced Community Coping—Pattern of community activities for adaptation and problem solving that is sufficient for meeting the demands or needs of the community but can be improved for management of current and future problems/stressors and can be strengthened.

Environmental Risk Protection— Preventing and detecting disease and injury in populations at risk from environmental hazards

Community Health Status—The general state of well-being of a community or population

From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier; Herdman, T. H. (Ed.) (2012). NANDA International nursing diagnosis: Definitions & classifications, 2012–2014. Oxford, UK: Wiley-Blackwell; Johnson, M., Bulechek, G., McCloskey Dochterman, J., et al. (2012). NOC and NIC linkages to NANDA-I (3rd ed.). St. Louis, MO: Mosby; Moorhead, S., Johnson, M., Mass, M. L., et al. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Elsevier; North American Nursing Diagnosis Association - International. (2011). Nursing diagnoses, 2012–2014 Edition: Definitions & classification NANDA-I NURSING DIAGNOSIS. West Sussex, UK: John Wiley & Sons.

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1 Health Care Delivery and Nursing Practice Adapted by Pauline Paul

Learning Objectives On completion of this chapter, the learner will be able to: 1. Define health, wellness, and health promotion. 2. Recognize and define the principles of the Canada Health Act. 3. Identify common nursing care delivery models. 4. Define primary health care. 5. List the principles of primary health care. 6. Describe factors contributing to changes in the health care system and their impact on health care and the nursing profession. 7. Describe the care giver, leadership, and research roles of nurses. 8. Discuss advanced nursing practice roles.

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Organized nursing in Canada began in the 17th century with the settlement by France of the parts of North America that were then known as Acadia and New France. The provision of nursing care was one of the first services offered to settlers and Aboriginal people alike. For example, only 27 years after the foundation of Quebec City, the Augustinian Sisters founded the Hôtel-Dieu de Québec, the first hospital of New France. After the British North America Act of 1867, Roman Catholic nursing sisters continued to play an instrumental role in the development of nursing and health care in every region of the country. For example, during the late 1800s and early 1900s, the Grey Nuns of Montreal spearheaded the creation of an impressive network of hospitals across the Canadian Prairies. Although religious orders no longer play a predominant role in health care delivery in the 21st century, their legacy is alive and well through new generations of nurses and through the institutions they created and once managed. The nurses of today continue to be essential to the delivery and organization of health care services (Paul & Ross-Kerr, 2011).

THE HEALTH CARE SYSTEM 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 1859 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 International Council of Nurses (ICN) states: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of the ill, disabled and dying people. Advocacy, promotion of safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN, 2010)

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In Canada, there are three regulated nursing professions: registered nurses (includes also nurse practitioners); practical nurses, who use the designation “licensed practical nurse” in some provinces and the designation “registered practical nurse” in other provinces; and registered psychiatric nurses, who are unique to Western Canada. Registered nurses are by far the largest group, as they constitute approximately 75% of the regulated nursing workforce (Canadian Institute for Health Information [CIHI], 2012). Because the regulation of health care professionals is under provincial jurisdiction, the provincial nursing associations—or colleges, as they are most often called— regulate individual nurses. In some provinces, registration of all nurses is under one college, while in other provinces each group of nurses has its own regulating college. The cases of Ontario and Alberta are used to provide examples of these two types of systems. In Ontario, registered nurses and registered practical nurses are both regulated by the College of Nurses of Ontario. In Alberta, registered nurses, licensed practical nurses, and registered psychiatric nurses each have their own regulating college, the College and Association of Registered Nurses of Alberta, College of Licensed Practical Nurses of Alberta, and College of Registered Psychiatric Nurses of Alberta, respectively. Provincial regulatory bodies set standards of practice and expect ethical practice from their members. An example of a code of ethics is the CNA’s Code of Ethics for Registered Nurses (Canadian Nurses Association [CNA], 2008a), which is used by most registered nurse regulatory bodies in Canada.

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 a person who is a recipient of care. For some, this term has a connotation 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. However, for many, the term client has a mercantile connotation, which makes its use even more negative than the term patient. The term patient is used throughout this book, with the understanding that either term is acceptable.

Glossary British North American Act of 1867: legislation that lead to the creation of the Canadian Confederation, and made health care a matter of provincial jurisdiction Canada Health Act: a federal health legislation enacted in 1984 that includes five principles that must be respected across the country continuous quality improvement (CQI): the ongoing examination of processes used to provide care, with

the aim of improving quality by assessing and improving those processes that might improve patient care outcomes and patient satisfaction regulated health profession: a health profession whose members are regulated by a professional college which has the legislated mandate to protect the public

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The patient who seeks care for a health concern or concerns (increasing numbers of people have multiple health concerns) is also an individual person, a member of a family, and a member of the community. Patients’ needs vary depending on their health issues, associated circumstances, and past experiences. Among the nurse’s important functions in health care delivery are identifying the patient’s immediate needs and working in concert with the patient to address them.

The Patient’s Basic Needs Certain needs are basic to all people. Some of these needs are more important than others. Once an essential need is met, people often experience a need on a higher level of priority.

Maslow’s Hierarchy Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging 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 movement toward psychological health and well-being. Such a hierarchy of needs is a useful framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

Health Care in Transition Changes occurring in health care delivery and nursing are the result of societal, economic, technologic, scientific, and political forces that have evolved throughout the 20th and 21st centuries. 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; higher costs of health care and changes in health care financing; and other health care reform efforts. These changes have led to institutional restructuring, staff reduction and cross-training, increased outpatient care services, decreased lengths of hospital stay, and increased health care in community and home settings. Such changes have dramatically influenced where nurses practice. These changes have influenced society’s view of health and illness and affected the focus of nursing and health care. As the proportion of the population reaching age 65 years has increased, and with the shift from acute illnesses to chronic illnesses, the traditional disease management and care focus of the health care professions has expanded. There is increasing concern about emerging infectious diseases, trauma, obesity, diabetes, and bioterrorism. Thus, health care must focus more on disease prevention, health promotion, and management of chronic conditions and disability than in previous times. This shift in focus coincides with a nationwide emphasis on cost control and resource management directed toward

providing safe, cost-efficient, and cost-effective health care services to the population as a whole.

Organization and Financing of Health Care Services in Canada The passage of the British North American Act of 1867 made health care in Canada a matter of provincial jurisdiction, and the Constitutional Act of 1982 reconfirmed this division of power. In practice, it means that because provincial governments have this constitutional authority, it takes considerable efforts to obtain the provincial and federal consensus necessary to establish policies that have a national scope. However, because Canadians see health care and the provision of health care services as a key priority, the federal government has played an increasing role in fostering the development of national policies through cost-sharing initiatives. In 1955, the provincial and federal governments agreed to establish hospital insurance, which led to the Hospital Insurance and Diagnostic Act of 1957. In 1964, the Royal Commission on Health Services recommended that it would be important to also add the provision of medical services to the national program. This recommendation led to the passage of the Medical Care Act of 1968. Although all provincial governments entered into these partnerships, the development in the following decades of provincial variations, such as the introduction of extra-billing and users fees, concerned federal authorities and brought about the Canada Health Act of 1984 (Ross-Kerr, 2011).

The Canada Health Act The Canada Health Act stipulates that health care insurance plans must be publicly administered, universal, comprehensive, accessible, and portable. Providing an exhaustive definition of these principles is beyond the scope of this chapter, but in brief, the plan must be operated and administered on a nonprofit basis by a public authority responsible to the provincial government; 100% of the insured individuals in a province are entitled to the services that are provided under this plan; the plan must insure all services offered by hospitals and physicians and, where permitted, by other health care professionals; these services must be reasonably accessible; and when moving from one province to another, or when temporarily absent from their province (but within Canada), residents must continue to be covered (Health Canada, 2002). Current issues related to the financing of health care services are further addressed in the section of this chapter on economic pressures.

Models of Nursing Care Delivery Several organizational methods or models that vary greatly from one facility to another and from one set of patient circumstances to another may be used to carry out nursing care. These methods and models have changed over the years and have included functional nursing, team nursing, primary nursing, and patient-focused or patient-centred

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care. A review of these models is beyond the scope of this chapter. Of note, health care agencies may use elements of a variety of models in the actual delivery of care, and there is much variation across Canada.

HEALTH, WELLNESS, AND HEALTH PROMOTION Health How health is perceived depends on how health is defined. The World Health Organization (WHO) defines health in the preamble to its constitution as a “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” (WHO, 2006, p. 1). Although this definition of health does not allow for any variation in degrees of wellness or illness, 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 being neither completely healthy nor completely ill. 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. Use of the health–illness continuum makes it possible to regard a person as simultaneously possessing degrees of both health and illness. On the health–illness continuum, even people with a chronic illness or disability may 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 and health are related terms that nurses often use interchangeably. However, for some, wellness is a broader concept that is like a journey taken by people in their quest for well-being. Miller (2008) believes that wellness is a broad concept that includes four components: achieving balance through all phases of health; recognizing that body, mind, and spirit are connected; recognizing personal responsibility; and building relationships with self, others, and the environment. 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 wellbeing. 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 In Canada, the 1974 report A New Perspective on the Health of Canadians, a Working Document, also known as the Lalonde report, brought to the forefront the concept of health promotion. Prior to its publication, health education had been the main focus of policy makers (O’Neill, Pederson, Dupéré, et al., 2007). The Lalonde report suggested that medical care was not the most important determinant of health and changes in lifestyle and

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environment played the greatest role in improving the health of populations. The WHO and Canada played a central role in creating a new vision of health promotion that recognizes that social factors are paramount to the health of populations. In 1986, Canada hosted the first international conference on health promotion, at which was promulgated the Ottawa Charter for Health Promotion. In this charter, health promotion is defined as follows: [T]he process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being. (WHO, 1986, p. 1)

Jackson and Riley (2007) have provided a review of the development of health promotion in Canada from 1986 to 2006. According to the Public Health Agency of Canada (PHAC), the “new” health promotion recognizes that a series of factors, known as determinants of health, have a profound impact on the health of individuals and populations. These factors are income and social status, social support networks, employment and working conditions, education, physical environment, social environment, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender, and culture (PHAC, 2011). The Population Health Approach endorsed by the PHAC is concerned with addressing the determinants of health for the population as a whole (PHAC, 2012).

Primary Health Care The primary health care (PHC) model, first introduced by the Alma-Ata Declaration of 1978, is important in the Canadian context, especially because there is a renewed interest by governments, who see it as a way to sustain our publicly funded health care system (Reutter & Ogilvie, 2011). It is also congruent with the Principles of the Canada Health Act. Primary health care is defined as follows: Essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community. (WHO, 1978)

Primary health care is based on five principles that are seen as essential if a nation wishes to improve the health of its population: services must be accessible to the population, this population must be involved in the planning and operation of services, intersectoral and interdisciplinary collaboration are essential because determinants of health cannot be addressed by one type of provider alone and by only the health care sector, technologies must be adapted to the given context, and a focus on health

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promotion and prevention of illness and injury must be present (Reutter & Ogilvie, 2011).

INFLUENCES ON HEALTH CARE DELIVERY The health care delivery system is constantly adapting as the population shifts its health care needs and expectations change. The shifting demographics of the population, the increase in chronic illnesses and disability, the greater emphasis on health care costs, and technologic advances have resulted in changing emphases in health care delivery and in nursing.

Population Demographics Changes in the population in general are affecting the need for and the delivery of health care. The 2011 Canadian census indicated that there were 33,476,688 people in the country (Statistics Canada, 2012b). Population growth is attributed in part to improved public health services and improved nutrition. Not only is the population increasing, but also its composition is changing. The decline in birth rate and the increase in lifespan due to improved health care have resulted in fewer school-age children and more senior citizens, many of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of members of ethnic minorities to the inner cities and a migration of members of the middle class to suburban areas. The number of people who are homeless, 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 population changes, the health care needs of people of specific ages, of women, and of diverse groups of people in specific geographic locations is altering the effectiveness of traditional means of providing health care. As a result, far-reaching changes in the overall health care delivery system are necessary.

Aging Population The older population in the Canada has increased significantly and will continue to grow in future years. According to the 2011 census, 4,945,060 people, representing 14.8% of the Canadian population, were aged 65 years or older. Among these, there were 5,825 centenarians (Statistics Canada, 2012a). Many older Canadians live with multiple chronic conditions. As the Canadian population continues to age, it will become increasingly imperative to provide services that make it easier for older people to remain in their homes and continue to have fulfilling lives. See Chapter 13 for more details about the health care of the older adult.

Cultural Diversity An appreciation for the diverse characteristics and needs of people from varied ethnic and cultural backgrounds is important in health care and nursing.

The term “Aboriginal Peoples” includes First Nations, Inuit, and Métis populations in Canada (Royal Commission on Aboriginal Peoples, 1996). Is usually written as Aboriginal Peoples (First Nations, Inuit, and Métis). There are over 605 Aboriginal Communities in Canada and each one is unique in terms of history, language, cultural beliefs, and ceremonies (Commission on the Future of Health Care in Canada, 2002). About 4% of the Canadian population have identified themselves as Aboriginal and of these 60% are First Nations, 4% are Inuit, and 33% are Métis (Romanow). The Truth and Reconciliation Commission of Canada held meetings (2010 to 2014) across Canada to hear firsthand from some of the 150,000 Aboriginal men and women who as children were taken from their families and forced to attend Indian Residential Schools. Many of the children were physically, emotionally, and sexually abused (Woods, 2013). Smith, Varcoe, and Edwards (2005) have written about the intergenerational impact of the residential schools and the implications for health policy. In 2013, new information was released about federal research projects conducted on aboriginal children in residential schools, which included severely limited diets for the children between 1942 and 1952 (Editorial, 2013), and giving antibiotics inappropriately, which resulted in deafness. More than 200 ethnic origins were identified in the 2011 national household survey, and visible minorities now constitute 19.1% of the Canadian population (Statistics Canada, 2013). As the cultural composition of the population changes, it is increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups not only bring various health care beliefs, values, and practices to the health care setting, but also have a variety of risk factors for some disease conditions and unique reactions to treatment (Newbold, 2009). These factors significantly affect a person’s responses to health care issues or illnesses, to caregivers, and to the care itself. Unless these factors are assessed for, 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 behaviour, beliefs, and values that are shared by 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 behaviour, genderspecific 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 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 guides the person’s thinking, decisions, and actions. It provides direction for interpreting and responding to illness and disability and to health care. To promote an effective nurse–patient relationship and positive outcomes of care, nursing care must be culturally safe and competent, appropriate, and sensitive to cultural differences. All attempts should be made to help patients retain their unique cultural characteristics. Providing special foods that have significance and arranging for religious observances may enable patients to maintain a

CHAPTER 1

feeling of wholeness at a time when they 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 occurs when communication among the nurse, the patient, and the patient’s family is directed toward understanding the situation or the concern and respecting each other’s goals.

Changing Patterns of Disease During the past 50 years, the health issues of Canadians have changed significantly. Although many infectious diseases have been controlled or eradicated, others, such as tuberculosis, acquired immunodeficiency syndrome (AIDS), and sexually transmitted infections, are on the rise. An increasing number of infectious agents are becoming resistant to antibiotic therapy as a result of widespread and inappropriate use of antibiotics. Obesity has become a major health concern, and the multiple comorbidities that accompany it, such as hypertension, heart disease, diabetes, and cancer, add significantly to its associated mortality (See Chapter 6). Conditions that were once easily treated have become more complex and life-threatening. The prevalence of chronic illnesses and disability is increasing because of the lengthening lifespan of Canadians and the advances in care and treatment options for conditions such as cancer, human immunodeficiency virus (HIV) infection, and cystic fibrosis. In addition, improvements in care for trauma and other serious acute health problems have meant that many people with these conditions live decades longer than in the past. Because the majority of health issues seen today are chronic in nature, many people are learning to 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 health and wellness, has a prominent role in the current focus on management of chronic illness and disability.

Advances in Technology and Genetics Advances in technology and genetics have occurred more rapidly during the past several decades compared with other time periods. 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 have resulted in expanded screening, diagnostic testing, and treatments for a variety of conditions. The sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information, have stimu-

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lated brisk change as well as swift obsolescence in health care delivery strategies. Advances in genetics and technology have also resulted in many ethical issues for the health care system, health care providers, patients, families, and society.

Demand for Quality Health Care Nurses in acute care settings work with other health care team members to maintain quality care while facing pressures to discharge patients and decrease staffing costs. Nurses in hospitals now care for patients who are hospitalized for relatively few days. Nurses in the community care for patients who need high-technology acute care services as well as long-term care in the home. The importance of effective discharge planning and quality improvement cannot be overstated. Acute care nurses must also work with community-based nurses and others in community settings to ensure continuity of care. The general public has become increasingly interested in and knowledgeable about health care and health promotion through television, newspapers, magazines, the Internet, and other communications media. The public has also become very health conscious and subscribes to the belief that health and quality health care constitute a basic right, rather than a privilege for a chosen few.

Quality Improvement and Evidence-Based Practice 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 as well as by political debate. The public desires care that is both personalized and delivered in a timely manner. Over the last three decades, new systems of quality assurance (QA) and delivery have gradually emerged. Three of them—continuous quality improvement (CQI) and evidence-based practice, clinical pathways and care mapping, and case management—are discussed in more detail.

Continuous Quality Improvement and Evidence-Based Practice Seeking to ensure the quality of patient care, Canadian hospitals have adopted, over time, various methods aimed at improving quality. The adoption of these methods has also been linked with the aim of meeting accreditation standards. Since 1958, the Canadian Council on Health Services Accreditation, formerly known as the Canadian Council on Hospital Accreditation, has the mandate to provide accreditation programs. In the 1970s and the 1980s, the presence of a QA program was one of its standards of accreditation. Although well intentioned, QA programs were found to have limitations including, for example, their costeffectiveness and their department-specific focus, which limited opportunities for interdisciplinary involvement to

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solve problems needing the involvement of more than a single discipline. In light of this, in the early 1990s, attention shifted from achieving predetermined standards to using processes of CQI (Cummings & Wong, 2011). CQI emphasizes the importance of improving the care processes used by organizations, that improvement must be continuous, customers must be the focus, leaders must be committed, staff education is essential to ensure a motivated workforce, and that cultural transformation is a long-term proposition. In contrast with QA, which was department and disciplinary focused, CQI is systemwide and interdisciplinary. The principles of quality improvement are recognized in the current accreditation standards of the Canadian Council on Hospital Services Accreditation (Cummings & Wong, 2011). If care is to be of the best possible quality and continuously improve, it follows that practice must be based on evidence. In other words, health professionals must incorporate the latest research findings in their practice. However, it is increasingly recognized that health professionals face challenges in locating and using research findings. This is why research on knowledge utilization and knowledge transfer is such a growing field of research.

Clinical Pathways and Care Mapping First developed in the United States, the use of clinical pathways, or care mapping, is increasingly common in Canada. Clinical pathways are tools for tracking a patient’s progress toward achieving positive outcomes within specified time frames. Clinical pathways based on current literature and clinical expertise have been developed for patients with certain diagnosis-related groups (DRGs) (e.g., heart failure, ischemic stroke, fractured hip), for high-risk patients (e.g., those receiving chemotherapy), and for patients with certain common health problems (e.g., diabetes, chronic pain). The pathways indicate key events, such as diagnostic tests, treatments, activities, medications, consultation, and education, that must occur within specified times for patients to achieve the desired and timely outcomes. A case manager often facilitates and coordinates interventions to ensure that the patient progresses through the key events and achieves the desired outcomes. Nurses who provide 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. Examples of clinical pathways can be found on . Other EBP tools used for planning patient care are care mapping, clinical guidelines, and algorithms. These tools are used to move patients toward predetermined outcome markers. Algorithms are used more often in acute situations to determine a particular treatment based on patient information or response. Care maps and clinical guidelines help facilitate coordination of care and education throughout hospitalization and after discharge. Because care mapping and guidelines are used for conditions in which a patient’s progress often defies prediction, specific time frames for achieving outcomes are excluded. A patient with a highly complex condition or

multiple underlying illnesses may benefit more from care mapping or guidelines than from clinical pathways, because the use of outcome milestones (rather than specific time frames) is more realistic. 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 to home care and community settings. Continuity of care, effective utilization of services, and cost containment are the major benefits for society and for the health care system.

Case Management Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. The premise of case management is that the responsibility for meeting patient needs rests with one person or team whose goals are to provide the patient and family with access to required services, to ensure coordination of these services, and to evaluate how effectively these services are delivered. Since the 1980s, case management has become prominent in American hospitals. In Canada, case management is primarily used for care delivered in the community, such as home care services. Nurses or other members of the health care team (e.g., occupational therapists and social workers) serve as case managers. Case managers may carry out a variety of roles, depending on the way in which services are organized in a health region. They may be responsible for the care of individual clients or groups of clients and may also have responsibility at the level of program, organizations, or service-delivery systems. A case manager may serve as clinical expert, facilitator, coordinator, liaison, supporter, educator, researcher, negotiator, monitor, advocate, and manager (Smith, Smith, Newhook, et al., 2006).

ROLES OF THE NURSE The professional nurse in hospital/institutional, communitybased or public health, and home care settings has three major roles: the caregiver role, which includes teaching and collaborating; the leadership role; and the research role. Although each role carries specific responsibilities, these roles relate to one another and are found in all nursing positions. These roles are designed to meet the immediate and future health care and nursing needs of the population.

Caregiver Role The caregiver role involves those actions taken by nurses to meet the health care and nursing needs of individual patients, their families, and significant others. This role is a dominant one for nurses in primary, secondary, and tertiary health care settings and in home care and community nursing. It is achieved through use of critical thinking, clinical judgment, and the nursing process, all of which are key tools for nursing practice. Nurses help patients meet their needs by using direct intervention, by teaching patients and family members to perform care, and by

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coordinating and collaborating with other disciplines to provide needed services.

ADVANCED NURSING PRACTICE ROLES

Leadership Role

Professional nursing is adapting to meet changing health needs and expectations. One such adaptation is through advanced nursing practice, which has developed to better respond to the needs of the population (Donnely, 2007; Schober & Affara, 2006). As stated by the CNA (2008b, p. ii):

The leadership role is often viewed as a role assumed by nurses who have titles that suggest leadership and who are the leaders of large groups of nurses or related health care professionals. However, demonstrating leadership skills is required within all nursing positions. For example, when advocating for patients, staff nurses must be able to convince others and to do this they must possess attributes of leadership (Grossman & Valiga, 2013). Nursing leadership involves four components: decision making, relating, influencing, and facilitating. Each of these components promotes change and the ultimate outcome of goal achievement. Basic to the entire process is effective communication, which determines the success of the process and achievement of goals. The components of the leadership process are appropriate during all phases of the nursing process and in all settings.

Research Role The primary task of nursing research is to contribute to the scientific base of nursing practice. Studies are needed to determine the effectiveness of nursing interventions and nursing care. The science of nursing grows through research, leading to the generation of scientifically based rationale for nursing practice and patient care. This process is the basis of EBP, with a resultant increase in the quality of patient care. The research role is considered to be a responsibility of all nurses in clinical practice. Nurses are constantly alert for nursing problems and important issues related to patient care that can serve as a basis for the identification of researchable questions. Nurses with a background in research methods can use their research knowledge and skills to initiate and implement timely, relevant studies. Nurses directly involved in patient care are often in the best position to identify potential research questions, and their clinical insights are invaluable. Nurses also have a responsibility to become actively involved in ongoing research studies. This may involve facilitating the data collection process, or it may include actual collection of data. Explaining the study to patients and their families and to other health care professionals is often of invaluable assistance to the researcher who is conducting the study. Above all, nurses must use research findings in their nursing practice; the use, validation, replication, dissemination, and evaluation of research findings further the science of nursing. As stated previously, EBP requires the critique of the best evidence available in research-based studies and validating their saliency to nursing practice. Nurses need to continually be aware of studies that are directly related to their own area of clinical practice and critically analyze those studies to determine the applicability of their implications for specific patient populations. Relevant conclusions and implications can be used to improve patient care.

Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations. It involves analyzing and synthesizing knowledge: understanding, interpreting and applying nursing theory and research; and developing and advancing nursing knowledge and the profession as a whole.

Advanced practice nurses usually have a graduate degree in nursing. Two advanced nursing practice roles exist in Canada: the clinical nurse specialist (CNS) and the nurse practitioner (NP). The CNS has been present in Canada since the 1960s (CNA, 2009). A clinical nurse specialist is “a registered nurse who holds a master’s or doctoral degree in nursing with expertise in a clinical nursing specialty: uses in-depth knowledge and skills, advanced judgment and clinical experience in a nursing specialty to assist in providing solutions for complex health care issues” (CNA, 2008b, p. 40). A nurse practitioner is “a registered nurse with additional educational preparation and experience who possesses and demonstrates the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals, and perform specific procedures within the legislated scope of practice” (CNA, 2008b, p. 41). Nurse practitioners are not as common in Canada as they are in the United States. The role initially emerged in the late 1960s, but had almost disappeared by the 1980s. After renewed interest from employers and governments in the 1990s, legislation regulating NP practice has been enacted (Pringle, 2007). The number of NPs are on the rise in Canada, increasing from 1,334 NPs in 2007 to 2,777 NPs by 2011 (CIHI, 2012). In general, initial care, ambulatory health care, and anticipatory guidance are all becoming increasingly important in nursing practice. Advanced practice roles enable nurses to function interdependently with other health care professionals and to establish a more collegial relationship with physicians. As changes in health care continue, the role of advanced practice nurses, especially in primary care settings, is expected to increase in terms of scope, responsibility, and recognition.

Interprofessional Collaboration This chapter has explored the changing roles of nursing. Many references have been made to the significance of nurses as members of the health care team. As team members, nurses develop and maintain solid working relationships with other health care professionals in order to obtain the best possible outcomes for patients. As interprofessional collaboration is becoming increasingly

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critical, the Canadian Interprofessional Health Collaborative (CIHC) has developed a competency framework to assist educators in fostering the development of new practitioners who will be well prepared for this type of collaboration (CIHC, 2010).

Critical Thinking Exercises 1 Your clinical assignment is in a long-term care facility. Identify a patient care issue (e.g., nutritional status) that could be improved. Describe the mechanism that is available within a clinical facility to address such quality improvement issues. 2 You are planning the discharge of an older patient who has several chronic medical conditions. A case manager has been assigned to this patient. How would you explain the role of the case manager to the patient and her husband? 3

You are assigned to care for a hospitalized patient who is obese, with a history of diabetes, and a new diagnosis of stable angina. There is a clinical nurse specialist (CNS) assigned to provide consistent, quality care for this patient from hospital admission to discharge. Identify the evidence that supports the effectiveness of CNSs in supervising care of patients and promoting positive patient outcomes. What is the strength of the evidence? How might this specific patient’s care be affected?

REFERENCES AND SELECTED READINGS BOOKS **Double asterisks indicate classic reference. Cummings, G. G., & Wong, C. A. (2011). Quality of care: Quality assurance and improvement to culture of patient safety. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 210–227). Toronto, ON: Elsevier Mosby. Grossman, S. C., & Valiga, T. M. (2013). The new leadership challenge creating the future of nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. **Lalonde, M. (1974). A new perspective on the health of Canadians, a working document. Ottawa, ON: Department of National Health and Welfare. Miller, C. A. (2008). Nurse’s toolbook for promoting wellness. New York: McGraw-Hill Medical. O’Neill, M., Pederson, A., Dupéré, S., et al. (2007). Introduction: An evolution in perspectives. In M. O’Neill, A. Pederson, S. Dupéré, et al. (Eds.), Health promotion in Canada: Critical perspectives (2nd ed., pp. 1–15). Toronto, ON: Canadian Scholar’s Press Inc. Paul, P., & Ross-Kerr, J. C. (2011). Nursing in Canada, 1600 to the present: A brief account. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 17–41). Toronto, ON: Elsevier Mosby. Reutter, L., & Ogilvie, L. (2011). Primary health care: Challenges and opportunities for the nursing profession. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 185–207). Toronto, ON: Elsevier Mosby. Ross-Kerr, J. C. (2011). The Canadian health care system. In J. C. RossKerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 3–17). Toronto, ON: Elsevier Mosby. Schober, M., & Affara, F. (2006). Advanced nursing practice. Oxford, UK: Blackwell Publishing and International Council of Nursing.

Smith, D. L., Smith, J. E., Newhook, C., et al. (2006). Continuity of care, service integration, and case management. In J. M. Hibberd & D. L. Smith (Eds.), Nursing leadership and management in Canada (3rd ed., pp. 81–112). Toronto, ON: Elsevier Canada. **World Health Organization. (1978). Primary health care: Report of the international conference on primary health care: Alma-Ata. USSR. Geneva: Author. **World Health Organization. (1986). Ottawa charter for health promotion. Geneva: Author. World Health Organization. (2006). Constitution of the World Health Organization (45th ed.). New York: Author.

JOURNALS AND ELECTRONIC DOCUMENTS Canadian Institute for Health Information. (2012). Regulated nurses: Canadian trends, 2007 to 2011. Ottawa, ON: Author. Retrieved from https://secure.cihi.ca/free_products/Regulated_Nurses_EN.pdf. Canadian Interprofessional Health Collaborative (2010). A national interprofessional competency framework. Ottawa, ON: Queens’ Printer. Retrieved from http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210r.pdf. Canadian Nurses Association. (2008a). Code of ethics for registered nurses. Ottawa, ON: Author. Canadian Nurses Association. (2008b). Advanced nursing practice: A national framework. Ottawa, ON: Author. Retrieved from http://www.cna-aiic.ca. Canadian Nurses Association. (2009). Position statement: Clinical nurse specialist. Ottawa, ON: Author. Retrieved from http://www.cna-aiic.ca/ en/advocacy/policy-support-tools/cna-position-statements/. Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Saskatoon, SK: Author. Donnely, G. (2007). Clinical expertise in advanced practice nursing: A Canadian perspective. Nursing Education Today, 23(3), 168–173. Editorials (2013, July 24). The healing power of truth. The Edmonton Journal, p. A16. **Health Canada. (2002). Canada Health Act Overview. Ottawa, ON: Author. Retrieved from http://www.hc-sc.gc.ca. International Council of Nurses. (2010). The ICN definition of nursing. Retrieved July 4, 2013, from http://www.icn.ch/about-icn/ icn-definition-of-nursing/. Jackson, S. F., & Riley, B. L. (2007). Health promotion in Canada: 1986 to 2006. Promotion and Education, 14(4), 214–218. Newbold, K. B. (2009). The short term health of Canada’s new immigrant arrivals: Evidence from LSIC. Ethnicity & Health 14(3), 315–336. Pringle, D. (2007). Nurse practitioner role: Nursing needs it. Canadian Journal of Nursing Leadership, 20(2), 1–5. Public Health Agency of Canada. (2007). WHO Collaborating Centre on non communicable disease policy. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/cd-mc/index-eng.php. Public Health Agency of Canada. (2011). What determines health? Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/ ph-sp/determinants/index-eng.php. Public Health Agency of Canada. (2012). What is the Population Health Approach? Ottawa, ON: Author. Retrieved from http://www.phac-aspc. gc.ca/ph-sp/approach-approche/index-eng.php. **Royal Commission on Aboriginal Peoples (1996). Royal commission report on Aboriginal peoples. Retrieved from http://www.aadnc-aandc. gc.ca/eng/1307458586498/1307458751962. Smith, D., Varcoe, C., & Edwards, N. (2005). Turning around the intergenerational impact of residential schools on Aboriginal people: Implications for health policy and practice. Canadian Journal of Nursing Research, 37(4), 38–60. Statistics Canada. (2012a). The Canadian population in 2011: Age and Sex. 2011 census. Ottawa, ON: Author. Retrieved July 5, 2013, from http:// www12.statcan.ca/census-recensement/2011/as-sa/98–311-x/98-311x2011001-eng.cfm. Statistics Canada. (2012b). The Canadian population in 2011: Population counts and growth. Population and dwelling counts 2011 census. Ottawa, ON: Author. Retrieved July 5, 2013, from http://www12.statcan.gc.ca/ census-recensement/index-eng.cfm?HPA Statistics Canada. (2013). 2011 National Household Survey: Immigration, place of birth, citizenship, ethnic origin, visible minorities, language and religion. Ottawa, ON: Author. Retrieved from http://www. statcan.gc.ca/daily-quotidien/130508/dq130508b-eng.htm. Woods, M. (2013, June 11). We can’t lose another generation. The Edmonton Journal, p. A12.

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2 Community-Based Nursing Practice Adapted by Joanne K. Olson

Learning Objectives On completion of this chapter, the learner will be able to: 1. Discuss the changes in the health care system that have increased the need for medical-surgical nurses to practice in community-based settings. 2. Compare the differences and similarities between community-based and hospital nursing. 3. Describe the discharge planning process in relation to home care preparation. 4. Explain methods for identifying community resources and making referrals. 5. Discuss how to prepare for a home visit and how to conduct the visit. 6. Identify personal safety precautions a home care nurse takes when making home visits. 7. Describe the various types of nursing functions provided in ambulatory care facilities, in occupational health and school nursing programs, to people who are homeless, and to those with alcohol or drug addictions.

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The changes that have occurred in the health care system and society in the past two decades have increased the need for care in ambulatory settings and in the home. These changes have created a demand for highly skilled and wellprepared nurses to provide community-based care. The delivery of community health care occurs within the Canadian health care system, also known as Medicare. This system reflects the values that define Canadian culture: social justice, equity, and community. Guided by the Canada Health Act, passed in 1984, the system is based on the fundamental principle that all members of Canadian society, including the most vulnerable, are entitled to health care. Within the Canadian health care system, there has been a trend toward more health care being delivered within communities. This shift is partly due to ongoing implementation of a long-held Canadian belief that health promotion services are a critical component of the country’s health care system. The more recent factors contributing to this trend include advancements in scientific knowledge and technology leading to improved diagnostics and treatment, and thus earlier hospital discharge (Kozier, Erb, Berman, et al., 2010). As more health care delivery shifts into the community, more nurses are working in a variety of public health and community-based settings. These settings include public health departments, ambulatory health clinics, long-term care facilities, prenatal and well-baby clinics, hospice agencies, industrial settings (as occupational health nurses), shelters for people who are homeless, and clinics, nursing centres, home care agencies, urgent care centres, same-day surgical centres, short-stay correctional facilities, and patients’ homes. Nurses in these settings often deliver care without direct on-site supervision or the support of other health care personnel. They must be self-directed, flexible, adaptable, and tolerant of various lifestyles and living conditions. Expertise in independent decision making, critical thinking, assessment, and health education as well as competence in basic nursing care are essential to function effectively in the community-based setting (Stanhope, Lancaster, Jessup-Falcioni, et al., 2011).

COMMUNITY-BASED CARE Community-based nursing is a philosophy of care of individuals and families. The care is provided in a community as the individual or family move among various kinds of service providers outside of hospitals (Stanhope et al., 2011). Although the phrase “community-based nursing” is often interchanged with “community health nursing,” a distinction

FIGURE 2-1. Community-based nursing takes many forms and focuses.

Here, the school nurse performs screening for scoliosis.

should be made. The phrase “community health nursing” has generally been equated to “public health nursing.” Public health nursing is a specialty focused on total populations, although care may be given to individuals. Communitybased nursing is broader and may incorporate community health–public health nursing; it is focused on individuals and families rather than total populations. Community-based nursing also includes home care nursing, school health nursing, and a host of other nursing services provided to individuals and groups in the community (Fig. 2-1). Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although primary and secondary prevention are also addressed.

Glossary community-based nursing: nursing care of individuals and families that is designed to 1) promote and maintain health and 2) prevent disease. It is provided as patient’s transition through the health care system to health-related services outside of the hospital setting primary prevention: health care delivery focused on health promotion and prevention of illness or disease

secondary prevention: health care delivery centred on health maintenance and aimed at early detection of disease, with prompt intervention to prevent or minimize loss of function and independence tertiary prevention: health care delivery focused on minimizing deterioration associated with disease and improving quality of life through rehabilitation measures

CHAPTER 2

Nurses in community settings must be culturally competent and practice cultural safety, as culture plays a role in the delivery of care and there are many opportunities for culturally diverse interactions (Betancourt & Green, 2010; Canadian Association of Schools of Nursing, 2013; Harrowing, Mill, & Spiers, 2010; Starr & Wallace, 2009). Cross-cultural health encounters are especially common in Canada because of the diverse ethnic and Aboriginal peoples (First Nations, Inuit, and Métis) populations in the country (Kozier et al., 2010). Increasingly, health care providers in Canada are from diverse cultural backgrounds as well (Higginbottom, 2011). Community-based nursing practice focuses on promoting and maintaining the health of individuals and groups, preventing and minimizing the progression of disease, and improving quality of life (Stanhope et al., 2011). Although nursing interventions used by public health nurses may involve individuals, families, or small groups, the central focus remains promotion of health and prevention of disease in the entire community. The actions of community health nurses may include provision of direct care to patients and families as well as political advocacy to secure resources for aggregate populations (e.g., the aging population). The community health nurse may function as an epidemiologist, a case manager for a group of patients, a coordinator of services provided to an aggregate of patients, an occupational health nurse, a school nurse, a visiting nurse, or a parish nurse. (In parish nursing, the members of the religious community—the parish—are the recipients of care.) The commonality of these various roles is that the nurse maintains a focus on community needs as well as on the needs of the patient. Community-based care is generally focused on the individual or family; although efforts may be undertaken to improve the health of the whole community, the individual or family unit is the main focus. The primary concepts of community-based nursing care are self-care and preventive care within the context of culture and community. Two other important concepts are continuity of care and collaboration. Some community-based nursing fields have become specialties in their own right, such as school health nursing and home care nursing.

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provide palliative care in patients’ homes and within hospice centres, thus promoting comfort, peace, and dignity to patients who are dying. Clinic nurses may conduct home visits as part of patient follow-up. Public health, parish, and school nurses may make visits to provide anticipatory guidance to high-risk families and follow-up care to patients with communicable diseases. Many home care patients are acutely ill, and many have chronic health problems and disabilities, requiring nurses to provide more education and monitoring to the patients and families. Holistic care is provided in the home through the collaboration of an interdisciplinary team that includes professional nurses; home care aides; social workers; physical, speech, and occupational therapists; pharmacists; and physicians. An interdisciplinary approach is used to provide health and social services with oversight of the total health care plan by a case manager, clinical nurse specialist, or nurse practitioner. Basic home care services are provided to Canadians through programs operated by territorial or provincial governments. The basic services covered may vary from province to province or territory. Private payment or insurance coverage is therefore sometimes required to cover costs not publicly funded. Older adults are the most frequent users of home care services. To be eligible for service, the patient must be ill, homebound, and in need of skilled nursing services. Health care visits may be intermittent or periodic, and case management via telephone or via Internet may be used to promote communication with home care consumers. The nurse instructs the patient and family about skills and self-care strategies and about health maintenance and promotion activities (e.g., nutritional counselling, exercise programs, stress management). Nursing care includes skilled assessment of the patient’s physical, psychological, social, and environmental status (Fig. 2-2). Nursing interventions may include intravenous (IV) therapy and injections, parenteral nutrition, venipuncture, catheter insertion, pressure ulcer treatment, wound care, ostomy care, and patient and family teaching. Complex technical equipment, such as dialysis machines and ventilators, is often part of home health care (Stanhope et al., 2011).

HOME CARE Home care nursing is a unique aspect of community-based nursing. Home care visits are made by nurses who work for home care agencies, public health agencies, and visiting nurse associations; by nurses who are employed by hospitals; and by parish nurses who voluntarily work with the members of their religious communities to promote health. Such visits may also be part of the responsibilities of school nurses, clinic nurses, or occupational health nurses. Home health care agencies are continuing to employ more nurses. Because of the high acuity levels of patients, nurses with acute care and critical care experience are in demand in this field. The type of nursing services provided to patients in their homes varies from agency to agency. Nurses from home care or hospice agencies make home visits to provide skilled nursing care, follow-up care, and teaching to promote health and prevent complications. Hospice nursing has become a specialty area of nursing practice in which nurses

FIGURE 2-2. Assessment is an important part of any home health visit.

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Nurses have a role in evaluating the safety and effectiveness of technology in the home setting. In addition, “telehealth” is an emerging trend in home health care; this facilitates exchange of information via telephone lines between patients and nurses regarding health information such as blood glucose readings, vital signs, and cardiac parameters (Stanhope et al., 2011). Use of a broad spectrum of computer and Internet resources, such as Web cams, also facilitates exchange of information.

Nursing in the Home Setting The home care nurse is a guest in the patient’s home and must have permission to visit and give care. The nurse has minimal control over the lifestyle, living situation, and health practices of the patients he or she visits. This lack of full decision-making authority can create a conflict for the nurse and may lead to issues in the nurse–patient relationship. To work successfully with patients in any setting, the nurse must be nonjudgmental and convey respect for patients’ beliefs, even if they differ sharply from the nurse’s. This can be difficult when a patient’s lifestyle involves activities that a nurse considers harmful or unacceptable, such as smoking, use of alcohol, drug abuse, or overeating. The cleanliness of a patient’s home may not meet the standards of a hospital. Although the nurse can provide teaching points about maintaining clean surroundings, the patient and family decide whether they will implement the nurse’s suggestions. The nurse must accept their decisions and deliver the care required regardless of the conditions of the setting. The kind of equipment, supplies, and resources usually available in acute care settings are often unavailable in a patient’s home. The nurse has to learn to improvise when providing care, such as when changing a dressing or catheterizing a patient in a regular bed that is not adjustable and lacks a bedside table. At times, the nurse works closely with the patient and others to achieve a unique solution for each patient and family situation. Infection control is as important in the home as it is in the hospital, but it can be more challenging and requires creative approaches. As in any situation, it is important to cleanse one’s hands before and after giving direct patient care, even in a home that does not have running water. A waterless, alcoholbased hand cleanser is a useful product for hand decontamination. If aseptic technique is required, the nurse needs to have a plan for implementing this technique before going to the home. This applies also to Routine Practices and Additional Precautions (Health Canada, 1999) and disposal of bodily secretions and excretions. If injections are given, the nurse uses a closed container to dispose of syringes. Injectable and other medications must be kept out of the reach of children during visits and must be stored in a safe place if they are to remain in the house. Friends, neighbours, or family members may ask the nurse about the patient’s condition. A patient has a right to confidentiality, and information should be shared only with the patient’s permission. If the nurse carries the patient’s health record into the house, it must be put in a secure place to prevent it from being picked up by others or misplaced.

Discharge Planning for Home Care Discharge planning is an important part of making the transition from the acute care setting to the home care setting. Discharge planning begins with the patient’s admission to the hospital and must consider the possible need for follow-up home care. Several different personnel (e.g., social workers, home care nurses, and case managers) or agencies may be involved in the planning process. The development of a comprehensive discharge plan requires collaboration with professionals at both the referring agency and the home care agency, as well as the community agencies that provide specific resources upon discharge. The process involves identifying the patient’s needs and developing a thorough plan to meet them. It is essential to have open lines of communication with family members to ensure their understanding and cooperation.

COMMUNITY RESOURCES AND REFERRALS As case managers, community-based nurses may make referrals to other team members, such as home health aides and social workers. These nurses work collaboratively with the health team and the referring agency or person. Continuous coordinated care among all health care providers involved in a patient’s care is essential to avoid duplication of effort by the various personnel caring for the patient. A community health nurse is knowledgeable about community resources available to patients as well as services provided by local agencies, eligibility requirements, and any possible charges for the services. Most communities have directories of health and social service agencies that the nurse can consult. These directories are continually updated as resources change. If a community does not have a resource booklet, an agency may develop one for its staff. It should include the commonly used community resources that patients need as well as the costs of the services and eligibility requirements. The telephone book and Internet are often useful in helping patients identify the location and accessibility of grocery and drug stores, banks, health care facilities, ambulances, physicians, dentists, pharmacists, social service agencies, and senior citizens’ programs. In addition, a patient’s place of worship or parish may be an important resource for services. The community health nurse is responsible for informing the patient and family about the community resources available to meet their needs. During initial and subsequent home visits, the nurse helps the patient and family identify these community services and encourages them to contact the appropriate agencies. When appropriate, nurses may make the initial contact.

HOME VISITS Most agencies have a policy manual that states their philosophy and procedures and defines the services they provide. Becoming familiar with these policies is an essential

CHAPTER 2

step before initiating a home visit. It is also important to know the agency’s policies and the provincial/territorial law regarding what actions to take if the nurse finds a patient who has died, encounters an abusive situation in the family, determines that a patient cannot safely remain at home, or observes a situation that possibly indicates malicious harm to the community at large. Before making a home visit, the nurse reviews the patient’s referral form and other pertinent data concerning the patient. It may be necessary to contact the referring agency if the purpose for the referral is unclear or if important information is missing. The first step is to call the patient to obtain permission to visit, schedule a time for the visit, and verify the address. This initial phone conversation provides an opportunity to introduce oneself, identify the agency, and explain the reason for the visit. If a patient does not have a telephone, the nurse should see if the people who made the referral have a number where a phone message can be left for the patient. If an unannounced visit to a patient’s home must be made, the nurse should ask permission to come in before entering the house. Explaining the purpose of the referral at the outset and setting up the times for future visits before leaving are also recommended. Most agencies provide nurses with bags that contain standard supplies and equipment needed during home visits. It is important to keep the bag properly stocked and to bring any additional items that might be needed for the visit.

Personal Safety Precautions Community nurses pay particular attention to personal safety, because their practice settings are often in unknown environments. Based on the principle of due diligence, agencies are required to inform employees of at-risk working environments. Agencies have policies and procedures concerning the promotion of safety for clinical staff, and training is provided to facilitate personal safety. Environments are proactively assessed for safety by the individual nurse and agency. Whenever a nurse makes a home visit, the agency should know the nurse’s schedule and the locations of the visits. The nurse needs to learn about the neighbourhood and obtain directions to the destination. A plan of action should always be established in case of emergencies. If a dangerous situation is encountered during the visit, the nurse should return to the agency and contact his or her supervisor or law enforcement officials, or both. Suggested precautions to take when making a home visit are presented in Chart 2-1.

Initial Home Visit The first visit sets the tone for subsequent visits and is a crucial step in establishing the nurse–patient relationship. The situations encountered can vary depending on numerous factors. Patients may be in pain and unable to care for themselves. Families may be overwhelmed and doubt their ability to care for their loved one. They may not understand why the patient was sent home from the hospital before being totally rehabilitated. They may not comprehend what home care is or why they cannot have 24-hour

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CHART 2-1

Safety Precautions in Home Care • Learn, or preprogram a cellular phone with the telephone numbers of the agency, police, and emergency services.

• Let the agency know your daily schedule and the tele• • • • • •

• • • • • • •

phone numbers of your patients so that you can be located if you do not return when expected. Know where the patient lives before leaving to make the visit and carry a map or GPS for quick referral. Keep your car in good working order and have sufficient gas in the tank. Park the car near the patient’s home and lock it during the visit. Do not drive an expensive car or wear expensive jewellery when making visits. Know the regular bus schedule and know the routes when using public transportation or walking to the patient’s house. Carry agency identification and have enough change to make telephone calls in case you get lost or have problems. Most agencies provide cellular phones for their nurses so that the agency can contact the nurse, and so that the nurse can contact the agency in case of an emergency or unexpected situation. When making visits in high-crime areas, visit with another person rather than alone. Schedule visits only during daylight hours. Never enter a patient’s home uninvited. If you do not feel safe entering a patient’s home, leave the area. Become familiar with the layout of the house, including exits from the house. If a patient or family member is intoxicated, hostile, or obnoxious, reschedule the visit and leave. If a family member is having a serious argument or abusing the patient or anyone else in the household, reschedule the visit, contact your supervisor, and report the abuse to the appropriate authorities.

nursing services. It is critical that the nurse try to convey an understanding of what the patient and family are experiencing and how the illness is affecting their lives. During the initial home visit, which usually lasts up to an hour, the patient is evaluated and a plan of care is established to be followed or modified on subsequent visits. The nurse informs the patient of the agency’s practices, policies, and hours of operation. The initial assessment includes evaluating the individual patient, the home environment, the patient’s self-care abilities or the family’s ability to provide care, and the patient’s need for additional resources. Identification of possible hazards, such as cluttered walk areas, potential fire risks, air or water pollution, or inadequate sanitation facilities, is also part of the initial assessment. Documentation considerations for home visits follow fairly specific regulations. The patient’s needs and the nursing care given are documented accurately. The medical diagnosis and specific detailed information on the functional limitations of the patient are usually part of the documentation. The goals and the actions appropriate for attaining them need to be identified. Expected outcomes of the nursing interventions are stated in terms of patient behaviours and are to be realistic and measurable. They

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reflect the nursing diagnosis or the patient’s conditions and specify those actions that address the patient’s issues. Some agencies provide home care nurses with handheld computers for documenting the condition of the patient, and results of the visit (Stolee, Steeves, Glenny, et al., 2010; Tapper, Quinn, Kerry, et al., 2012).

Determining the Need for Future Visits

CHART 2-2

Assessing the Need for Home Visits Current Health Status • How well is the patient progressing? • How serious are the present signs and symptoms? • Has the patient shown signs of progressing as expected? Or does it seem that recovery will be delayed?

Home Environment

While conducting an assessment of the patient’s situation, the nurse evaluates the need for future visits and the frequency with which those visits may need to be made. To make these judgments, the nurse may find it helpful to consider the questions listed in Chart 2-2. With each subsequent visit, these same factors are evaluated to determine the continuing health needs of the patient. As progress is made and the patient, with or without the help of significant others, becomes more capable of self-care and more independent, the need for home visits may decline.

• Are worrisome safety factors apparent? • Are family or friends available to provide care? Or is the

Ending the Visit

• What level of nursing care does the patient require? • Does the care require basic skills or more complex inter-

As the visit comes to a close, it is important to summarize the main points of the visit for the patient and family and to identify expectations for future visits or patient achievements. The following points should be considered at the end of each visit: • What are the main points the patient or family should remember from the visit? • What positive attributes have been noted about the patient and the family that will give them a sense of accomplishment? • What were the main points of the teaching plan or the treatments needed to ensure that the patient and family understand what they must do? A written set of instructions should be left with the patient or family; provided they can read and see (alternative formats include video or audio recordings). Printed material should be in the patient’s primary language and in large print when indicated. • Whom should the patient or family call in case someone needs to be contacted immediately? Are current emergency telephone numbers readily available? Is telephone service available, or can an emergency cell phone service be provided? • What signs of complications should be reported immediately? • What is the date and time of the next visit? Will a different nurse make the visit? How frequently and for how long will visits be made (if determinable at this time)?

OTHER COMMUNITY-BASED HEALTH CARE SETTINGS Ambulatory Settings Ambulatory health care is provided for patients in community- or hospital-based settings. The types of agencies that provide ambulatory health care are medical clinics, ambulatory care units, urgent care centres, cardiac rehabilitation

patient alone?

Level of Self-Care Ability • • • •

Is the patient capable of self-care? What is the patient’s level of independence? Is the patient ambulatory? Or bedridden? Does the patient have sufficient energy? Or is he or she frail and easily fatigued? • Does the patient need and use assistive devices?

Level of Nursing Care Needed ventions?

Prognosis • What is the expectation for recovery in this particular instance?

• What are the chances that complications may develop if nursing care is not provided?

Educational Needs • How well has the patient or family grasped the teaching points made?

• Is there a need for further follow-up and retraining? • What level of proficiency does the patient or family show in carrying out the necessary care?

Mental Status • How alert is the patient? • Are there signs of confusion or thinking difficulties? • Does the patient tend to be forgetful or have a limited attention span?

Level of Adherence • Is the patient following the instructions provided? • Does the patient seem capable of following the instructions?

• Are the family members helpful, or are they unwilling or unable to assist in caring for the patient as expected?

programs, mental health centres, student health centres, community outreach programs, and nursing centres. Neighbourhood health centres provide services to patients who live in a geographically defined area. The centres may operate in freestanding buildings, storefronts, or mobile units. Agencies may provide ambulatory health care in addition to other services, such as offering an adult day care or health program. The kinds of services offered and the patients served depend on the agency’s mission. Nursing responsibilities in ambulatory health care settings include providing direct patient care, conducting patient intake screenings, treating patients with acute or chronic illnesses or emergency conditions, referring patients to other agencies for additional services, teaching

CHAPTER 2

patients self-care activities, and offering health education programs that promote health maintenance. Nurses also work as clinic managers, direct the operation of clinics, and supervise other health team members. Nurse practitioners, educated in primary care, often practice in ambulatory care settings with a focus on gerontology, pediatrics, family or adult health, or women’s health. Nurses can play an important part in facilitating the function of the ambulatory care facility.

Occupational Health Programs In Canada, health and safety standards in the workplace are legislated by provincial and territorial governments. The legislated standards are directed at creating safer and healthier work conditions. It is in an employer’s interest to provide as safe a working environment as possible, because the result is reduced costs associated with employee absenteeism, hospitalization, and disability. Occupational health nurses may work in solo units in industrial settings, or they may serve as consultants on a limited or part-time basis. They may be members of an interdisciplinary team composed of a variety of personnel such as nurses, physicians, exercise physiologists, health educators, counsellors, dietitians, safety engineers, and industrial hygienists. Occupational health nurses may: • Provide direct care to employees who become ill or injured • Conduct health education programs for company staff members • Set up health programs aimed at establishing specific health behaviours, such as eating properly and getting enough exercise • Monitor employees’ hearing, vision, blood pressure, or blood glucose • Track exposure to radiation, infectious diseases, and toxic substances, reporting results to government agencies as necessary Occupational health nurses must be knowledgeable about government regulations pertaining to occupational health and safety and be familiar with other pertinent legislations.

School Health Programs School health programs provide services to students and may also serve the school’s community. School-age children and adolescents with health conditions are at major risk for underachieving or failing in school. The leading health conditions of elementary school children are injuries, infections (including influenza and pneumonia), malnutrition, dental disease, and cancer. The leading health concerns of high school students are alcohol and drug abuse, injuries, homicide, pregnancy, eating disorders, sexually transmitted infections (STIs), sports injuries, dental disease, and mental and emotional issues. Contemporary school health issues that are being examined include school violence, which may affect students’ and teachers’ physical and emotional health, and the increasing numbers of children and adolescents who are overweight or obese. Ideally, school health programs have an interdisciplinary health team consisting of physicians, nurses, dentists, social workers, counsellors, school administrators,

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parents, and students. The school may serve as the site for a family health clinic that offers primary health and mental health services to children and adolescents as well as to all family members in the community. Nurse practitioners perform physical examinations and diagnose and treat students and families for acute and chronic illnesses within the scope of their practice. These clinics are costeffective and benefit students from low-income families who lack access to traditional health care. School nurses play a number of roles, including care provider, health educator, consultant, and counsellor. They collaborate with students, parents, administrators, and other health and social service professionals regarding student health issues. School nurses perform health screenings, provide basic care for minor injuries and concerns, administer medications, monitor the immunization status of students and families, identify children with health concerns, provide teaching related to health maintenance and safety, and monitor the weight of children in order to facilitate prevention and treatment of obesity. They need to be knowledgeable about provincial/territorial and local regulations affecting school-age children, such as ordinances for excluding students from school because of communicable diseases or parasites such as lice or scabies. School nurses are also health education consultants for teachers. In addition to providing information on health practices, teaching health classes, and participating in the development of the health education curriculum, school nurses educate teachers and classes when a student has a special issue, a disability, or a disease such as hemophilia, asthma, or human immunodeficiency virus (HIV) infection.

Care for People Who Are Homeless While exact figures are unknown, it is estimated that 157,000 people are homeless each year in Canada (Trypuc & Robinson, 2009). The homeless population includes increasing numbers of women with children (often victims of abuse) and older adults. People who are homeless are a heterogeneous group, including members of dysfunctional families, the unemployed, and those who cannot find affordable housing. A significant number of persons who are homeless are chronically mentally ill and/or abuse alcohol or other drugs (Trypuc & Robinson, 2009). People who are homeless often have difficulty gaining access to health care. Because of numerous obstacles, they seek health care late in the course of a disease and deteriorate more quickly than other patients. Many of the health problems they experience are related in large part to their living situations. Street life exposes people who are homeless to the extremes of hot and cold environments and a culture of drugs, alcohol, and violence, all of which compound their health risks. Persons who are homeless have high rates of trauma, tuberculosis, upper respiratory tract infections, poor nutrition and anemia, lice, scabies, peripheral vascular problems, STIs, dental issues, arthritis, hypothermia, skin disorders, and foot problems. Common chronic health conditions of people who are homeless include diabetes, hypertension, heart disease, AIDS, and mental illness. These health conditions are made more difficult by living on the

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street and by being discharged to a transitory, homeless situation in which follow-up is unlikely (Pennington, Coast, & Kroh, 2010). Shelters are frequently overcrowded and unventilated, promoting the spread of communicable diseases such as tuberculosis. Community health nurses who work with people who are homeless need to be nonjudgmental, patient, and understanding. They must be skilled in dealing with people who have a wide variety of health problems and needs and recognize that individualized treatment strategies are required in highly unpredictable environments (Loewenson & Hunt, 2011). Nursing interventions are aimed at assessing health care needs of people who live on the streets and in shelters, providing nursing care, and attempting to obtain other appropriate health care services for all people. Cities such as Edmonton, Alberta are committed to locating/ building appropriate housing and are making significant progress in reducing the number of people who are homeless. The Homeward Trust Edmonton found housing for 773 previously homeless individuals, of whom 76% were noted to be “chronically homeless.” Since 2008, there has been a decrease of 30% in the number of people who are homeless in Edmonton (Homeward Trust Edmonton 2012 Annual Report). At this time, Alberta is the only province with a definite plan to end homelessness in 10 years. In 2007, Cathy Crowe (a street nurse in Toronto for 15 years) and a group of 10 activists who were homeless co-wrote a book: Dying for a Home: Homeless Activists Speak Out. The message is a call for nurses to advocate for the right to housing as a necessary prerequisite to health.

Critical Thinking Exercises 1 Recall a difficult discharge planning situation in which you have been involved. Evaluate the effectiveness of the processes used to accomplish the goals. What changes could have been made that would have improved the processes and the outcomes? 2

An older adult man with diabetes is being referred for home care after discharge from the hospital, and he will need glucose monitoring and teaching. He has no family at home; his wife died 3 years ago, and his only daughter lives several hundred kilometers away. During the nurse’s initial visit to the man’s home, the nurse learns that he has difficulty seeing and therefore cannot read. What is the evidence for conducting a safety assessment of the home environment for older adult patients and for patients with visual limitations? Evaluate the strength of the evidence. What assessment criteria would you use to determine the needs of the patient’s home care situation?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Crowe, C. (2007). Dying for a home: Homeless activists speak out. Toronto, ON: Between the Lines.

Homeward Trust Edmonton. (2012). Homeward Trust Edmonton 2012 Annual Report. Retrieved from http://www.homewardtrust.ca/images/ files/2013-06-19-17-15HT%20Annual%20Report%202012%20WEB.pdf Kozier, B., Erb, G., Berman, A., et al. (2010). Fundamentals of Canadian nursing: Concepts, process, and practice (2nd ed.). Toronto, ON: Prentice Hall. Stanhope, M., Lancaster, J., Jessup-Falcioni, H., et al. (2011). Community health nursing in Canada. (2nd ed.). Toronto, ON: Elsevier Canada. Trypuc, B., & Robinson, J. (2009). Homeless in Canada: A funder’s primer in understanding the tragedy on Canada’s streets. King City, ON: Charity Intelligence.

JOURNALS Betancourt, J. R., & Green, A. R. (2010). Commentary: Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85, 583–585. Canadian Association of Schools of Nursing. (2013). Educating nurses to address socio-cultural, historical, and contextual determinants of health among Aboriginal peoples. Retrieved from www.casn.ca/vm/ newvisual/attachments/856/Media/2013WAHHRIKnowledgeProduct FINALforweb.pdf. *Harrowing, J., Mill, J., & Spiers, J. (2010). Critical ethnography, cultural safety, & international nursing research. Journal of Qualitative Methods, 9 (3), 240–251. *Higginbottom, G. (2011). The transitioning experiences of internationally-educated nurses into a Canadian health care system: A focused ethnography. BMC Nursing, 10, 14. Higginbottom, G., Caine, V., Salway, J., et al. (2013). Providing culturally safe and competent health care. A self-directed workbook and digital resource. Edmonton, AB: University of Alberta, Faculty of Nursing. Retrieved from www.nurs.ualberta.ca/higginbottom. Loewenson, K., & Hunt, R. (2011). Transforming attitudes of nursing students: Evaluating a service-learning experience. Journal of Nursing Education, 50(6), 345–349. Mahara, M., Duncan, S., & Whyte, N., et al. (2011). It takes a community to raise a nurse: Educating for culturally safe practice with Aboriginal peoples. International Journal of Nursing Education Scholarship, 8(1), 1–12. Pennington, K., Coast, M. J., & Kroh, M. (2010). Health care for the homeless: A partnership between a city and a school of nursing. Journal of Nursing Education, 49 (12), 700–703. Romonow, R. (2002). Building on values: The future of health care in Canada – Final Report. Royal Commission on Aboriginal Peoples (1996). Royal commission report on Aboriginal peoples. Retrieved from http://www.aadnc-aandc. gc.ca/eng/1307458586498/1307458751962. *Starr, S. & Wallace, D. (2009). Self-reported cultural competence of public health nurses in a Southeastern U.S. public health department. Public Health Nursing, 26 (1), 48–57. Stolee, P., Steeves, B., Glenny, C., et al. (2010). The use of electronic health information systems in home care. Home Health Care, 28(3), 167–181. Tapper, L., Quinn, H., Kerry, J., et al. (2012). Introducing handheld computers into home care. Canadian Nurse, 108(1), 28–32.

RESOURCES AND WEB SITES Aboriginal Nurses Association of Canada (A.N.A.C.); http://www.anac. on.ca Canadian Association for Parish Nursing Ministry (CAPNM); http:// www.capnm.ca Canadian Nurses Association; https://www.cna-aiic.ca/en Canadian Occupational Health Nurses Association (COHNA); http:// www.cohna-aciist.ca Canadian Public Health Association; http://www.cpha.ca Community Health Nurses Association of Canada (CHNAC); http:// www.chnac.ca Health Canada; http://www.hc-sc.gc.ca National Aboriginal Health Organization (NAHO); http://www.naho.ca National Advisory Committee on Immunization; http://www.phac-aspc. gc.ca/naci-ccni/index-eng.php Public Health Agency of Canada; http://www.phac-aspc.gc.ca Victorian Order of Nurses; http://www.von.ca/

CHAPTER

3 Critical Thinking, Ethical Decision Making, and the Nursing Process Adapted by Pauline Paul

Learning Objectives On completion of this chapter, the learner will be able to: 1. Define the characteristics of critical thinking and critical thinkers. 2. Describe the critical thinking process. 3. Define ethics and nursing ethics. 4. Identify several ethical dilemmas common to the medical-surgical area of nursing practice. 5. Specify strategies that can be helpful to nurses in ethical decision making. 6. Describe the components of the nursing process. 7. Develop a plan of nursing care for a patient using strategies of critical thinking.

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In today’s health care arena, nurses face increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in both hospital and community settings, an aging population, and complex disease processes, as well as ethical issues and cultural factors. The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking.

CRITICAL THINKING Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and alternatives that are most appropriate for the situation (Heffner & Rudy, 2008). Although many definitions of critical thinking have been offered in various disciplines, some consistent themes within those definitions are (1) a strong formal and informal foundation of knowledge; (2) willingness to pursue or ask questions; and (3) ability to develop solutions that are new, even those that do not fit the standard or current state of knowledge or attitudes. Willingness and openness to various viewpoints are inherent in critical thinking, and it is also important to reflect on the current situation (Chan, 2013). Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes, to help refine thinking skills. Independent judgments and decisions

evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society requires the use of high-level critical thinking skills. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. As previously stated, critical thinking is a conscious, outcome-oriented activity. It is not erratic but rather is systematic and organized. Critical thinkers are inquisitive truth seekers who are open to the alternative solutions that might surface. Alfaro-LeFevre (2013) identified critical thinkers as people who ideally are active thinkers, fair minded, open minded, persistent, empathic, independent in thought, good communicators, honest, organized and systematic, proactive, flexible, realistic, humble, cognizant of the rules of logic, curious and insightful, and creative and committed to excellence. The skills involved in critical thinking are developed over time through effort, practice, and experience.

Critical Thinking in Nursing Practice Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and the home and community. Regardless of the

Glossary assessment: the systematic collection of data to determine the patient’s health status and any actual or potential health problems collaborative problems: specific pathophysiologic manifestations that nurses monitor to detect onset or changes in status critical thinking: a process of insightful thinking that utilizes multiple dimensions of one’s cognition to develop conclusions, solutions, and alternatives that are appropriate for the given situation deontologic or formalist theory: an ethical theory maintaining that ethical standards or principles exist independently of the ends or consequences ethics: the formal, systematic study of moral beliefs evaluation: determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved implementation: actualization or carrying out of the plan of care through nursing interventions moral dilemma: situation in which a clear conflict exists between two or more moral principles or competing moral claims moral distress: conflict that arises within oneself when a person is aware of the correct course of action but institutional constraints stand in the way of pursuing the correct action

moral problem: competing moral claim or principle; one claim or principle is clearly dominant moral uncertainty: conflict that arises within a person when he or she cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling that something is not right morality: the adherence to informal personal values nursing diagnoses: actual or potential health problems that can be managed by independent nursing interventions nursing process: a deliberate problem-solving approach for meeting people’s health care and nursing needs; common components are assessment, diagnosis, planning, implementation, and evaluation planning: development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes teleologic theory or consequentialism: the theoretical basis of ethics, which focuses on the ends or consequences of actions, such as utilitarianism utilitarianism: a teleologic theory of ethics based on the concept of “the greatest good for the greatest number”

CHAPTER 3

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Critical Thinking, Ethical Decision Making, and the Nursing Process

setting, each patient situation is viewed as unique and dynamic. The unique factors that patients and nurses bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information then allows nurses to focus on those factors that are most relevant and most significant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action. Because developing the skill of critical thinking takes time and practice, critical thinking exercises are offered throughout this book as a means of honing one’s ability to think critically. Some of the exercises include questions that stimulate the reader to seek information about evidence-based practice relative to the clinical situation described. The questions listed in Chart 3-1 can serve as a guide in working through the exercises, although it is important to remember that each situation is unique and calls for an approach that fits the particular circumstances described. In addition, much emphasis is placed on nurses basing their clinical actions on research, using evidence-based practice. Critical thinking has been associated with the use of research findings (Profetto-McGrath, Hesketh, Lang, et al., 2003).

ETHICAL NURSING CARE In the complex modern world, we are surrounded by ethical issues in all facets of our lives. Consequently, there has been a heightened interest in the field of ethics in an attempt to gain a better understanding of how these issues influence us. Specifically, the focus on ethics in health care has intensified in response to controversial developments, including advances in technology and genetics, as well as diminished health care and financial resources. Today, sophisticated technology can prolong life well beyond the time when death would have occurred in the past. Expensive experimental procedures, medications, equipment, and devices are available for attempting to preserve life, even when such attempts are likely to fail. The development of technologic support has influenced the quality and delivery of nursing care at all stages of life and also has contributed to an increase in average life expectancy. For example, the prenatal period has been influenced by genetic screening, in vitro fertilization, the harvesting and freezing of embryos, and prenatal surgery. Premature infants who once would have died early in life now may survive because of advances in technology. Children and adults who would have died of organ failure are living longer because of organ transplantation. These advances in technology have been a mixed blessing. Questions have been raised about whether it is appropriate to use such technology, and if so, under what circumstances. Although many patients do achieve a better quality of life, others face extended suffering as a result of efforts to prolong life, usually at great expense. Ethical issues also surround those practices or policies that seem to allocate health care resources unjustly on the basis of age, race, gender, disability, or social mores. The ethical dilemmas nurses may encounter in the medical-surgical nursing arena are numerous and diverse and occur in all settings. An awareness of underlying

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CHART 3-1

The Inquiring Mind: Critical Thinking in Action Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate: • What relevant assessment information do I need, and how do I interpret this information? What does this information tell me? What contextual factors must be considered when gathering this information? • To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider? • Have I gathered all the information I need (signs and symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing? • Is there anything that needs to be reported immediately? Do I need to seek additional assistance? • Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks? • What possible complications must I anticipate? • What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems? • What are the desired outcomes for this patient? Which have the highest priority? Do the patient and I agree on these points? • What is going to be my first action in this situation? • How can I construct a plan of care to achieve the goals? • Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account? • How do the family dynamics affect this situation, and will they have an effect on my actions or the plan of care? • Are there cultural factors that I must address and consider? • Am I dealing with an ethical issue here? If so, how am I going to resolve it? • Has any nursing research been conducted on this subject? What are the nursing implications of this research for care of this patient?

philosophical concepts helps nurses use reason to work through these dilemmas. Basic concepts related to moral philosophy, such as ethics and its terminology, theories, and approaches, are included in this chapter. Understanding the role of the professional nurse in ethical decision making helps nurses articulate their ethical positions and develop the skills needed to make ethical decisions.

Ethics Versus Morality The terms ethics and morality are used to describe beliefs about right and wrong and to suggest appropriate

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Basic Concepts in Nursing

guidelines for action. In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values. Because the distinction between ethics and morality is slight, the two terms are often used interchangeably.

Ethics Theories One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends or consequences of actions. The best-known form of this theory, utilitarianism, is based on the concept of “the greatest good for the greatest number.” The choice of action is clear under this theory, because the action that maximizes good over bad is the correct one. The theory poses difficulty when one must judge intrinsic values and determine whose good is the greatest. In addition, it is important to ask whether good consequences can justify any amoral actions that might be used to achieve them. Another theory in ethics is the deontologic or formalist theory, which argues that ethical standards or principles exist independently of the ends or consequences. In a given situation, one or more ethical principles may apply. Nurses have a duty to act based on the one relevant principle, or the most relevant of several ethical principles. Problems arise with this theory when personal and cultural biases influence the choice of the most primary ethical principle.

Approaches to Ethics There are three approaches to ethics: meta-ethics, applied ethics, and relational ethics. An example of meta-ethics (understanding the concepts and linguistic terminology used in ethics) in the health care environment is analysis of the concept of informed consent. Nurses are aware that patients must give consent before surgery, but sometimes a question arises as to whether a patient is truly informed. Delving more deeply into the concept of informed consent would be a meta-ethical inquiry. An example of applied ethics is when a specific discipline identifies ethical problems within that discipline’s practice. Various disciplines use the frameworks of general ethical theories and principles and apply them to specific problems within their domain. Common ethical principles that apply in nursing include autonomy, beneficence, confidentiality, double effect, fidelity, justice, nonmaleficence, paternalism, respect for people, sanctity of life, and veracity. Brief definitions of these important principles can be found in Chart 3-2. Nursing ethics may be considered a form of applied ethics because it addresses moral situations that are specific to the nursing profession and patient care. Some ethical problems that affect nursing may also apply to the broader area of bioethics and health care ethics. Nursing has its own professional code of ethics. Relational ethics is a third approach to discussing ethics. According to Bergum and Dossetor (2005), “the focus of relational ethics is on people (whole persons) and the quality of the commitment between them. These commitments are experienced in a relational or ethical space which

stimulates a fundamental shift in how to think about health ethics” (pp. 8–9). The focus becomes asking the ethical question rather than trying to solve the ethical problem. Another way to look at relational ethics is about “nurturing of another person, the nurturing of the self, and the nurturing of the relationship” (Bergum & Dossetor, p. 16).

Moral Situations Many situations exist in which ethical analysis is needed. Some are moral dilemmas, situations in which a clear conflict exists between two or more moral principles or competing moral claims, and nurses must choose the lesser of two evils. Other situations represent moral problems, in which there may be competing moral claims or principles, but one claim or principle is clearly dominant. Some situations result in moral uncertainty, when one cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling that something is not right. Still other situations may result in moral distress, in which one is aware of the correct course of action but constraints stand in the way of pursuing the correct action. For example, a patient tells a nurse that if he is dying he wants all possible measures taken to save his life. However, the surgeon and family have made the decision not to tell the patient that he is terminally ill and not to resuscitate him if he stops breathing. From an ethical perspective, the patient should be told the truth about his diagnosis and should have the opportunity to make decisions about treatment. Ideally, this information should come from the physician, with the nurse present to assist the patient in understanding the terminology and to provide further support, if necessary. In this situation, a moral problem exists because of the competing moral claims of the family and physician, who wish to spare the patient distress, and the nurse, who wishes to be truthful with the patient. If the patient’s competency were questionable, a moral dilemma would exist because no dominant principle would be evident. The nurse could experience moral distress if the hospital threatened disciplinary action or job termination because the information is disclosed to the patient without the agreement of the physician or the family, or both. It is essential that nurses freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone involved. Improved interdisciplinary communication is supported when all members of the health care team can voice their concerns and come to an understanding of the moral situation. The use of an ethics consultant or consultation team could be helpful to assist the health care team, patient, and family to identify the moral dilemma and possible approaches to the dilemma. Nurses should be familiar with agency policy supporting patient self-determination and resolution of ethical issues.

Types of Ethical Problems in Nursing As a profession, nursing is accountable to society. Collectively, Canadian nursing has formally defined its standards of accountability through the Code of Ethics for Registered

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CHART 3-2

Common Ethical Principles The following common ethical principles may be used to validate moral claims.

Autonomy This word is derived from the Greek words autos (“self”) and nomos (“rule” or “law”), and therefore refers to self-rule. In contemporary discourse it has broad meanings, including individual rights, privacy, and choice. Autonomy entails the ability to make a choice free from external constraints.

Beneficence Beneficence is the duty to do good and the active promotion of benevolent acts (e.g., goodness, kindness, charity). It may also include the injunction not to inflict harm (see nonmaleficence).

Confidentiality Confidentiality relates to the concept of privacy. Information obtained from an individual will not be disclosed to another unless it will benefit the person or there is a direct threat to the social good.

Double Effect This is a principle that may morally justify some actions that produce both good and evil effects. All four of the following criteria must be fulfilled: 1. The action itself is good or morally neutral. 2. The agent sincerely intends the good and not the evil effect (the evil effect may be foreseen but is not intended). 3. The good effect is not achieved by means of the evil effect. 4. There is proportionate or favourable balance of good over evil.

Fidelity Fidelity is promise keeping; the duty to be faithful to one’s commitments. It includes both explicit and implicit promises to another person.

Justice From a broad perspective, justice states that like cases should be treated alike. A more restricted version of justice is distributive justice, which refers to the distribution of social

Nurses (Canadian Nurses Association [CNA], 2008a). This code is structured around values and responsibilities that are providing safe, compassionate, competent, and ethical care; promoting health and well-being; promoting and respecting informed decision making; preserving dignity; promoting justice; and being accountable (CNA, 2008a). The code offers an ideal framework for nurses to use in ethical decision making. Ethical issues have always affected the role of the professional nurse. The accepted definition of professional nursing has inspired a new advocacy role for nurses. The International Council of Nurses (2008, p. 1) states: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

benefits and burdens based on various criteria that may include the following: Equality Individual need Individual effort Societal contribution Individual merit Legal entitlement Retributive justice is concerned with the distribution of punishment.

Nonmaleficence This is the duty not to inflict harm as well as to prevent and remove harm. Nonmaleficence may be included within the principle of beneficence, in which case nonmaleficence would be more binding.

Paternalism Paternalism is the intentional limitation of another’s autonomy, justified by an appeal to beneficence or the welfare or needs of another. Under this principle, the prevention of evil or harm takes precedence over any potential evil caused by interference with the individual’s autonomy or liberty.

Respect for Persons Respect for persons is frequently used synonymously with autonomy. However, it goes beyond accepting the notion or attitude that people have autonomous choices, to treating others in such a way that enables them to make choices.

Sanctity of Life This is the perspective that life is the highest good. Therefore, all forms of life, including mere biologic existence, should take precedence over external criteria for judging quality of life.

Veracity Veracity is the obligation to tell the truth and not to lie or deceive others.

This definition supports the claim that nurses must be actively involved in the decision-making process regarding ethical concerns surrounding health care and human responses. Efforts to enact this standard may cause conflict in health care settings in which the traditional roles of the nurse are delineated within a bureaucratic structure. If, however, nurses learn to present ethical conflicts within a logical, systematic framework, struggles over jurisdictional boundaries may decrease. Health care settings in which nurses are valued members of the team promote interdisciplinary communication and may enhance patient care. To practice effectively in these settings, nurses must be aware of ethical issues and assist patients in voicing their moral concerns. Nursing theories that incorporate the biopsychosocial– spiritual dimensions emphasize a holistic viewpoint, with humanism or caring at the core. As the nursing profession strives to delineate its own theory of ethics, caring is often cited as the moral foundation. For nurses to embrace this

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professional ethos, they must be aware not only of major ethical dilemmas, but also of those daily interactions with health care consumers that frequently give rise to less easily identifiable ethical challenges. Although technologic advances and diminished resources have been instrumental in raising numerous ethical questions and controversies, including life-and-death issues, nurses should not ignore the many routine situations that involve ethical considerations. Some of the most common issues faced by nurses today include confidentiality, use of restraints, trust, refusing care, and end-of-life concerns.

Confidentiality All nurses should be aware of the confidential nature of information obtained in daily practice. If information is not pertinent, they should question whether it is prudent to document it in a patient’s record. In the practice setting, discussion of patients with other members of the health care team is often necessary. However, these discussions should occur in a private area where it is unlikely that the conversation will be overheard. Another threat to confidentiality is the widespread use of computer-based technologies and people’s easy access to them. The growing demand for tele-health innovations and the increasing use of this new method can result in unchecked access to health information. In addition, personal and health information is often made available to numerous individuals and corporate stakeholders, which may increase the potential for misuse of health care information. Because of these possibilities of maleficence (see Chart 3-2), sensitivity to the principle of confidentiality is essential.

Restraints The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones. It is important to weigh carefully the risks of limiting a person’s autonomy and increasing the risk of injury by using restraints against the risks of not using restraints; they have been documented as resulting in physical harm and death (Mohr, 2010). Before restraints are used, other strategies, such as asking family members to sit with the patient, should be tried. Professional nursing associations such as the College and Association of Registered Nurses of Alberta (CARNA, 2009) consider that registered nurses should “exhaust all possible alternative intervention before deciding to use a restraint” (p. 3). In situations where restraints are used, nurses have the moral responsibility to perform ongoing assessments and advocate for their clients (CARNA, 2009).

Trust Issues Telling the truth (veracity) is one of the basic principles of our culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a patient, and revealing a diagnosis to people other than the patient with the diagnosis. All involve the issue of trust, which is an essential element in the nurse–patient relationship (Carter, 2009).

Placebos may be used in experimental research, in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. However, the use of a placebo as a substitute for an active drug to show that a patient does not have actual symptoms of a disease is deceptive, and this practice may severely undermine the nurse–patient relationship. Informing a patient of his or her diagnosis when the family and physician have chosen to withhold information is a common ethical situation in nursing practice. The nursing staff may often use evasive comments with the patient as a means of maintaining professional relationships with other health practitioners. This area is indeed complex, because it challenges a nurse’s integrity. Strategies nurses could consider include the following: • Not lying to the patient • Providing all information related to nursing procedures and diagnoses • Communicating the patient’s requests for information to the family and physician. The family is often unaware of the patient’s repeated questions to the nurse. With a better understanding of the situation, the family members may change their perspective Although providing the information may be the morally appropriate behaviour, the manner in which the patient is told is important. Nurses must be compassionate and caring while informing patients; disclosure of information merely for the sake of patient autonomy does not convey respect for others.

Refusing to Provide Care Any nurse who feels compelled to refuse to provide care for a particular type of patient faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal injury. However, there is an ethical obligation to care for all patients, and nurses must be accountable. In the section on “Being Accountable,” the Code of Ethics for Registered Nurses includes the following statement: If nursing care is requested that is in conflict with the nurse’s moral beliefs and values but in keeping with professional practice, the nurse provides safe, compassionate, competent and ethical care until alternative care arrangements are in place to meet the person’s needs or desires. If nurses can anticipate a conflict with their conscience, they have an obligation to notify their employers (CNA, 2008a, p. 19).

To avoid facing these ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the patient population. If the applicant is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not an acceptable nursing practice.

End-of-Life Issues Dilemmas that centre on death and dying are prevalent in medical-surgical nursing practice and frequently initiate ethical discussion (CNA, 2008a). The dilemmas are

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Critical Thinking, Ethical Decision Making, and the Nursing Process

compounded by the fact that the idea of curing is paramount in health care. With advanced technology, it may be difficult to accept the fact that nothing more can be done or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult ethical situations. End-of-life issues are discussed in detail in Chapter 18.

Preventive Ethics When a nurse is faced with two conflicting alternatives, it is his or her moral decision to choose the lesser of the two evils. Various preventive strategies are available to help nurses anticipate or avoid certain kinds of ethical dilemmas. Frequently, dilemmas occur when health care practitioners are unsure of the patient’s wishes because the patient is unconscious or too cognitively impaired to communicate directly. Encouraging patients to prepare advanced directives serves in the prevention of these dilemmas.

Advance Directives An advance directive is a legal document that specifies a person’s wishes prior to illness (and before hospitalization) and provides valuable information that may assist health care providers in decision making (Health Canada, 2006). This directive is used only if the person is unable to speak for him or herself, and it is revoked if the person regains the ability to make decisions. Whereas one tends to think that the advance directive contains information about treatments that are not to be initiated or maintained, it can also provide the direction that active, potentially lifesaving treatment is to occur. An advance directive usually includes the name of a substitute decision maker who has agreed to make decisions that respect the instructions contained within the document. Each province and two of the three territories have advance directive legislation with information on what to include and how to ensure that the directive is legally binding (Nunavut only provides for power of attorney for property and financial matters) (Health Canada, 2006). All advance directives in Canada are about future health care decisions. There are fines or other penalties in place if an advance directive is not followed. The provinces and territories have laws that regulate how individuals can arrange for another person to manage their financial affairs if they become physically unable to do so themselves (power of attorney). This type of power of attorney ends if the signer becomes mentally incompetent. Of more importance is the durable power of attorney, in which an individual identifies another person to make health care decisions on his or her behalf. In this type of directive, the person may have clarified his or her wishes concerning a variety of medical situations. The benefit of a durable power of attorney is that it continues even if the signer becomes mentally incompetent. Institutional ethics committees, which exist in many hospitals to assist practitioners with ethical dilemmas, also aid in preventive ethics. The purpose of these multidisciplinary committees varies among institutions. In

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some hospitals, the committee exists solely for the purpose of developing policies; in others, it may have a strong educational or consultation focus. Because these committees usually comprise individuals with some advanced training in ethics, they are important resources to the health care team, patient, and family. Nurses with a particular interest or expertise in the area of ethics are valuable members of ethics committees and can serve as resources for staff nurses. The heightened interest in ethical decision making has resulted in many continuing education programs, ranging from seminars or workshops to full-semester courses offered by local colleges or professional organizations. In addition, nursing and medical journals contain articles on ethical issues, and numerous textbooks on clinical ethics or nursing ethics are available. These are valuable resources because they cover the ethical theory and dilemmas of practice in greater depth. The CNA also has publications available to assist nurses with ethical decision making.

Ethics Committees Institutional ethics committees exist in many hospitals to assist clinicians with ethical dilemmas. The purpose of these interdisciplinary committees varies among institutions. In some hospitals, the committees exist solely for the purpose of developing policies, whereas in others, they may have a strong educational or consultation focus. These committees usually are composed of people with some advanced training in ethics and are important resources for the health care team, patient, and family. Nurses with a particular interest or expertise in the area of ethics can serve as members of these committees, which are valuable resources for staff nurses.

Ethical Decision Making As noted in the preceding discussions, ethical dilemmas are common and diverse in nursing practice. Situations vary, and experience indicates that there are no clear solutions to these dilemmas. However, the fundamental philosophical principles are the same, and the process of moral reflection helps nurses justify their actions. The approach to ethical decision making can follow the steps of the nursing process. Chart 3-3 outlines the steps of an ethical analysis.

THE NURSING PROCESS Definition The nursing process is a deliberate problem-solving approach for meeting people’s health care and nursing needs. Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and evaluation. The traditional steps are defined as follows: 1. Assessment: The systematic collection of data to determine the patient’s health status and any actual or

Basic Concepts in Nursing

The following are guidelines to assist nurses in ethical decision making. These guidelines reflect an active process in decision making, similar to the nursing process detailed in this chapter.

Assessment 1. Assess the ethical/moral situations of the problem. This step entails recognition of the ethical, legal, and professional dimensions involved. a. Does the situation entail substantive moral problems (conflicts among ethical principles or professional obligations)? b. Are there procedural conflicts? (e.g., who should make the decisions? Any conflicts among the patient, health care providers, family, and guardians?) c. Identify the significant people involved and those affected by the decision.

Planning 2. Collect information. a. Include the following information: the medical facts, treatment options, nursing diagnoses, legal data, and the values, beliefs, and religious components. b. Make a distinction between the factual information and the values/beliefs. c. Validate the patient’s capacity, or lack of capacity, to make decisions. d. Identify any other relevant information that should be elicited. e. Identify the ethical/moral issues and the competing claims.

Implementation

Assessment data are gathered through the health history and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of changing patient needs and the effectiveness of nursing care. Outcome(s) Documentation

n of nursing care Pla

hy s

n ical me assess

DIAG

NOSIS

rative proble llabo ms

NURSING ASSESSMENT

achieved or rev mes ised tco Ou rative activiti es llabo Co ected outcomes

alth histor y He

P

4. Decide and evaluate the decision. a. What is the best or morally correct action? b. Give the ethical reasons for your decision. c. What are the ethical reasons against your decision? d. How do you respond to the reasons against your decision?

Assessment

E xp

Evaluation

Using the Nursing Process

Co

3. List the alternatives. Compare alternatives with applicable ethical principles and professional code of ethics. Choose either of the frameworks below, or other frameworks, and compare outcomes. a. Utilitarian approach: Predict the consequences of the alternatives; assign a positive or negative value to each consequence; choose the consequence that predicts the highest positive value or “the greatest good for the greatest number.” b. Deontologic approach: Identify the relevant moral principles; compare alternatives with moral principles; appeal to the “higher-level” moral principle if there is a conflict.

Dividing the nursing process into distinct steps serves to emphasize the essential nursing actions that must be taken to address the patient’s nursing diagnoses and manage any collaborative problems or complications. However, dividing the process into separate steps is artificial: The process functions as an integrated whole, with the steps being interrelated, interdependent, and recurrent (Fig. 3-1). Chart 3-4 presents an overview of the nursing activities involved in applying the nursing process.

t

Steps of an Ethical Analysis

• Collaborative problems: “Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize the complications of the events” (Carpenito-Moyet, 2012, p. 19). 3. Planning: Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes 4. Implementation: Actualization of the plan of care through nursing interventions. 5. Evaluation: Determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved

g diagnose s

CHART 3-3

sin Nur

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d als an priorities Go

UNIT 1

Interventions

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PLANNING

potential health problems. (Analysis of data is included as part of the assessment. Analysis may also be identified as a separate step of the nursing process.) 2. Diagnosis: Identification of the following two types of patient problems: • Nursing diagnoses: Actual or potential health problems that can be managed by independent nursing interventions

IMPL EMENTATION EVALUATION FIGURE 3-1. The nursing process is depicted schematically in this cir-

cle. Starting from the innermost circle, nursing assessment, the process moves outward through the formulation of nursing diagnoses and collaborative problems; planning, with setting of goals and priorities in the nursing plan of care; implementation and documentation; and, finally, the ongoing process of evaluation and outcomes.

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CHART 3-4

Steps of the Nursing Process Assessment 1. 2. 3. 4. 5.

Conduct the health history. Perform the physical assessment. Interview the patient’s family or significant others. Study the health record. Organize, analyze, synthesize, and summarize the collected data.

Diagnosis NURSING DIAGNOSIS 1. Identify the patient’s nursing problems. 2. Identify the defining characteristics of the nursing problems. 3. Identify the etiology of the nursing problems. 4. State nursing diagnoses concisely and precisely. COLLABORATIVE PROBLEMS 1. Identify potential problems or complications that require collaborative interventions. 2. Identify health team members with whom collaboration is essential.

Planning 1. Assign priority to the nursing diagnoses. 2. Specify the goals. a. Develop immediate, intermediate, and long-term goals. b. State the goals in realistic and measurable terms. 3. Identify nursing interventions appropriate for goal attainment. 4. Establish expected outcomes. a. Make sure that the outcomes are realistic and measurable. b. Identify critical times for the attainment of outcomes.

Health History The health history is conducted to determine a person’s state of wellness or illness and is best accomplished as part of a planned interview. The interview is a personal dialogue between a patient and a nurse that is conducted to obtain information. The nurse’s approach to the patient largely determines the amount and quality of the information that is received. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the patient. Examples of effective therapeutic communication techniques that can be used to achieve this goal are found in Table 3-1. The use of a health history guide may help in obtaining pertinent information and in directing the course of the interview. A variety of health history formats designed to guide the interview are available, but they must be adapted to the responses, problems, and needs of the person. See Chapter 5 for further information about the health history.

Physical Assessment A physical assessment may be carried out before, during, or after the health history, depending on a patient’s physical and emotional status and the immediate priorities of the situation. The purpose of the physical assessment is to identify those aspects of a patient’s physical, psychological, and emotional state that indicate a need for nursing care. It

5. Develop the written plan of nursing care. a. Include nursing diagnoses, goals, nursing interventions, expected outcomes, and critical times. b. Write all entries precisely, concisely, and systematically. c. Keep the plan current and flexible to meet the patient’s changing problems and needs. 6. Involve the patient, family or significant others, nursing team members, and other health team members in all aspects of planning.

Implementation 1. Put the plan of nursing care into action. 2. Coordinate the activities of the patient, family or significant others, nursing team members, and other health team members. 3. Record the patient’s responses to the nursing actions.

Evaluation 1. Collect data. 2. Compare the patient’s actual outcomes with the expected outcomes. Determine the extent to which the expected outcomes were achieved. 3. Include the patient, family or significant others, nursing team members, and other health care team members in the evaluation. 4. Identify alterations that need to be made in the nursing diagnoses, collaborative problems, goals, nursing interventions, and expected outcomes. 5. Continue all steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation.

requires the use of sight, hearing, touch, and smell, as well as appropriate interview skills and techniques. Physical examination techniques as well as techniques and strategies for assessing behaviours and role changes are presented in Chapters 5 and 8 and in each unit of this book.

Other Components of the Assessment Additional relevant information should be obtained from the patient’s family or significant others, from other members of the health team, and from the patient’s health record or chart. Depending on the patient’s immediate needs, this information may have been completed before the health history and the physical assessment were obtained. Whatever the sequence of events, it is important to use all available sources of pertinent data to complete the nursing assessment.

Recording the Data After the health history and physical assessment are completed, the information obtained is recorded in the patient’s permanent record. This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. The record fulfills other functions as well: • It serves as the legal and business record for a health care agency and for the professional staff members who

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Basic Concepts in Nursing

Therapeutic Communication Techniques

Technique

Definition

Therapeutic Value

Listening

Active process of receiving information and examining one’s reactions to the messages received Periods of no verbal communication among participants for therapeutic reasons

Nonverbally communicates nurse’s interest in patient

Restating

Repeating to the patient what the nurse believes is the main thought or idea expressed

Demonstrates that the nurse is listening and validates, reinforces, or calls attention to something important that has been said

Reflection

Directing back to the patient his or her feelings, ideas, questions, or content

Validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient

Clarification

Asking the patient to explain what he or she means or attempting to verbalize vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding

Helps to clarify the patient’s feelings, ideas, and perceptions and to provide an explicit correlation between them and the patient’s actions

Focusing

Questions or statements to help the patient develop or expand an idea

Allows the patient to discuss central issues and keeps communication goal directed

Broad openings

Encouraging the patient to select topics for discussion

Indicates acceptance by the nurse and the value of the patient’s initiative

Humour

Discharge of energy through the comic enjoyment of the imperfect

Promotes insight by bringing repressed material to consciousness, resolving paradoxes, tempering aggression, and revealing new options; a socially acceptable form of sublimation

Informing

Providing information

Helpful in health teaching or patient education about relevant aspects of patient’s well-being and self-care

Sharing perceptions

Asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling

Conveys the nurse’s understanding to the patient and has the potential to clarify confusing communication

Theme identification

Underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse–patient relationship

Allows the nurse to best promote the patient’s exploration and understanding of important problems

Suggesting

Presentation of alternative ideas for the patient’s consideration relative to problem solving

Increases the patient’s perceived options or choices

Silence

Gives patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance

Adapted from Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.). St Louis, MO: CV Mosby.

are responsible for the patient’s care. A variety of systems are used for documenting patient care, and each health care agency selects the system that best meets its needs. • It serves as a basis for evaluating the quality and appropriateness of care and for reviewing the effective use of patient care services. • It provides data that are useful in research, education, and short- and long-range planning.

lating nursing diagnoses acceptable for study. Approved nursing diagnoses are compiled and categorized by NANDA International in a taxonomy that is updated to maintain currency. The diagnostic labels identified by NANDA International (2012) have been generally accepted, but ongoing validation, refinement, and expansion based on clinical use and research are encouraged. They are not yet complete or mutually exclusive, and more research is needed to determine their validity and clinical applicability.

Diagnosis

Choosing a Nursing Diagnosis

The assessment component of the nursing process serves as the basis for identifying nursing diagnoses and collaborative problems. Soon after the completion of the health history and the physical assessment, nurses organize, analyze, synthesize, and summarize the data collected and determine the patient’s need for nursing care.

Nursing Diagnosis Nursing diagnoses, the first taxonomy created in nursing, have fostered autonomy and accountability in nursing and have helped delineate the scope of practice. North American Nursing Diagnosis Association (NANDA) International is the official organization responsible for developing the taxonomy of nursing diagnoses and formu-

When choosing the nursing diagnoses for a particular patient, nurses must first identify the commonalities among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The identified problems are then defined as specific nursing diagnoses. Nursing diagnoses represent actual or potential health problems that can be managed by independent nursing actions. It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician, and they are not diagnostic studies. Rather, they are succinct statements in terms of specific patient problems that guide nurses in the development of the nursing plan of care.

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To give additional meaning to the nursing diagnosis, the characteristics and etiology of the problem are identified and included as part of the diagnosis. For example, the nursing diagnoses and their defining characteristics and etiology for a patient who has anemia may include the following: • Activity intolerance related to weakness and fatigue • Ineffective tissue perfusion related to inadequate blood volume • Imbalanced nutrition: Less than body requirements related to fatigue and inadequate intake of essential nutrients

Collaborative Problems In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The term collaborative problem is used to identify these situations. Collaborative problems are certain physiologic complications that nurses monitor to detect changes in status or onset of complications. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize complications (CarpenitoMoyet, 2012). When treating collaborative problems, a primary nursing focus is monitoring patients for the onset of complications or changes in the status of existing complications. The complications are usually related to the disease process, treatments, medications, or diagnostic studies. The nurse recommends nursing interventions that are appropriate for managing the complications and implements the treatments prescribed by the physician. The algorithm in Figure 3-2 depicts the differences between nursing diagnoses and collaborative problems. After the nursing diagnoses and collaborative problems have been identified, they are recorded on the plan of nursing care.

Situation identified (health status, problem)

Can the nurse legally order the primary interventions to achieve a goal?

Yes

No

Nursing diagnosis

Are medical and nursing interventions needed to achieve the patient goal?

Prescribe and execute the interventions that are definitive for prevention, treatment, or health promotion

Yes

No

Discharged from nursing care

Collaborative problems

Monitor and evaluate condition

Prescribe and implement interventions that are in the domain of nursing

Implement the prescriptive orders

FIGURE 3-2. Differentiating nursing diagnoses and collaborative prob-

Planning Once the nursing diagnoses have been identified, the planning component of the nursing process begins. This phase involves the following steps: 1. Assigning priorities to the nursing diagnoses and collaborative problems 2. Specifying expected outcomes 3. Specifying the immediate, intermediate, and long-term goals of nursing action 4. Identifying specific nursing interventions appropriate for attaining the outcomes 5. Identifying interdependent interventions 6. Documenting the nursing diagnoses, collaborative problems, expected outcomes, nursing goals, and nursing interventions on the plan of nursing care 7. Communicating to appropriate personnel any assessment data that point to health care needs that can best be met by other members of the health care team

lems. (Redrawn from Carpenito-Moyet, L. J. (2012). Nursing diagnosis: Application to clinical practice (14th ed., p. 27). Philadelphia, PA: Lippincott Williams & Wilkins.)

Setting Priorities Assigning priorities to the nursing diagnoses and collaborative problems is a joint effort by the nurse and the patient or family members. Any disagreement about priorities is resolved in a way that is mutually acceptable. Consideration must be given to the urgency of the problems, with the most critical problems receiving the highest priority. The Maslow hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs; once those basic needs are met, higher-level needs can be addressed. See Chapter 1 for a further discussion of the Maslow hierarchy.

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CHART 3-5

Nursing-Sensitive Outcomes Classification (NOC) The NOC is a classification of patient outcomes sensitive to nursing interventions. Each outcome is a neutral statement about a variable patient condition, behaviour, or perception, coupled with a rating scale. The outcome statement and

scale can be used to identify baseline functioning, expected outcomes, and actual outcomes for individual patients. The following table is an example of a nursing-sensitive outcome.

Respiratory Status: Gas Exchange (0402) Domain—Physiologic Health (II) Class—Cardiopulmonary (E) Scale(s)—Severe deviation from normal range to No deviation from normal range (b) and Severe to None (n) Definition: Alveolar exchange of carbon dioxide and oxygen to maintain arterial blood gas concentrations. OUTCOME TARGET RATING

Maintain at ______

Respiratory Status: Gas Exchange Overall Rating Indicators 040208 Partial pressure of oxygen in arterial blood (PaO2) 040209 Partial pressure of carbon dioxide in arterial blood (PaCO2) 040210 Arterial pH 040211 Oxygen saturation 040212 End-tidal carbon dioxide 040213 Chest x-ray findings 040214 Ventilation–perfusion balance 040203 040204 040205 040206 040207 040216

Dyspnea at rest Dyspnea with mild exertion Restlessness Cyanosis Somnolence Impaired cognition

Increase to ______

Severe Deviation From Normal Range

Substantial Deviation From Normal Range

Moderate Deviation From Normal Range

Mild Deviation From Normal Range

No Deviation From Normal Range

1

2

3

4

5

1

2

3

4

5

NA

1

2

3

4

5

NA

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

NA NA NA NA NA

Severe

Substantial

Moderate

Mild

None

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5

NA NA NA NA NA NA

With permission from Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby-Elsevier.

Establishing Expected Outcomes Expected outcomes of the nursing interventions are expressed in terms of the patient’s behaviours and the time period in which the outcomes are to be achieved, as well as any special circumstances related to achieving the outcome (Smith-Temple & Johnson, 2013). These outcomes must be realistic and measurable. Resources for identifying appropriate expected outcomes include the NursingSensitive Outcomes Classification (NOC) (Chart 3-5) and standard outcome criteria established by health care agencies for people with specific health problems. These outcomes can be associated with nursing diagnoses and interventions and can be used when appropriate. However, the NOC may need to be adapted to establish realistic criteria for the specific patient involved. The expected outcomes that define the desired behaviour of the patient are used to measure the progress made

toward resolving the problem. The expected outcomes also serve as the basis for evaluating the effectiveness of the nursing interventions and for deciding whether additional nursing care is needed or whether the plan of care needs to be revised.

Establishing Goals After the priorities of the nursing diagnoses and expected outcomes have been established, goals (immediate, intermediate, and long term) and the nursing actions appropriate for attaining the goals are identified. The patient and family are included in establishing goals for the nursing actions. Immediate goals are those that can be attained within a short period. Intermediate and long-term goals require a longer time to be achieved and usually involve preventing complications and other health problems and promoting self-care and rehabilitation. For example, goals

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for a patient with a nursing diagnosis of impaired physical mobility related to pain and edema following total knee replacement may be stated as follows: • Immediate goal: Stands at bedside for 5 minutes 6 to 12 hours after surgery • Intermediate goal: Ambulates with walker or crutches in hospital and home • Long-term goal: Ambulates independently 1 to 2 miles each day

Determining Nursing Actions In planning appropriate nursing actions to achieve the desired goals and outcomes, the nurse, with input from the patient and significant others, identifies individualized interventions based on the patient’s circumstances and preferences that address each outcome. Interventions should identify the activities needed and who will implement them. Determination of interdisciplinary activities is made in collaboration with other health care providers as needed. The nurse identifies and plans patient teaching and demonstration as needed to assist the patient in learning certain self-care activities. Planned interventions should be ethical and appropriate to the patient’s culture, age, and gender. Standardized interventions, such as those found on institutional care plans or in the Nursing Interventions Classification (NIC) (Bulechek, Butcher, Dochterman, et al., 2013) can be used. Chart 3-6 describes the NIC system and provides an example of an NIC system intervention. It is important to individualize prewritten interventions to promote optimal effectiveness for each patient. Actions of nurses should be based on established standards.

Implementation The implementation phase of the nursing process involves carrying out the proposed plan of nursing care. The nurse assumes responsibility for the implementation and coordinates the activities of all those involved in implementation, including the patient and family, other members of the nursing team, and other members of the health care team, so that the schedule of activities facilitates the patient’s recovery. The plan of nursing care serves as the basis for implementation, as described below: • The immediate, intermediate, and long-term goals are used as a focus for the implementation of the designated nursing interventions. • While implementing nursing care, the nurse continually assesses the patient and his or her response to the nursing care. • Revisions are made in the plan of care as the patient’s condition, problems, and responses change and when reordering of priorities is required. Implementation includes direct or indirect execution of the planned interventions. It is focused on resolving the patient’s nursing diagnoses and collaborative problems and achieving expected outcomes, thus meeting the patient’s health needs. Examples of nursing interventions are assisting with hygiene care; promoting physical and psychological comfort; supporting respiratory and elimination functions; facilitating the ingestion of food, fluids, and nutrients; managing the patient’s immediate sur-

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CHART 3-6

Nursing Interventions Classification (NIC) The NIC is a standardized classification of nursing treatments (interventions) that includes independent and collaborative interventions. Intervention labels are terms such as hemorrhage control, medication administration, or pain management. Listed under each intervention are multiple discrete nursing actions that together constitute a comprehensive approach to the treatment of a particular condition. Not all actions are applicable to every patient; nursing judgment will determine which actions to implement. The following is an example of a nursing intervention:

Ventilation Assistance DEFINITION Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs ACTIVITIES Maintain a patent airway. Position to alleviate dyspnea. Position to facilitate ventilation–perfusion matching (“good lung down”), as appropriate. Assist with frequent position changes, as appropriate. Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table for patient to lean on). Monitor the effects of position change on oxygenation (e.g., arterial blood gases, SaO2, SvO2). Encourage slow deep breathing, turning, and coughing. Assist with incentive spirometer, as appropriate. Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. Monitor for respiratory muscle fatigue. Initiate and maintain supplemental oxygen, as prescribed. Administer appropriate pain medication to prevent hypoventilation. Ambulate three to four times per day, as appropriate. Monitor respiratory and oxygenation status. Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas exchange. Teach pursed lips breathing techniques, as appropriate. Teach breathing techniques, as appropriate. Initiate a program of respiratory muscle strength and/or endurance training, as appropriate. Initiate resuscitation efforts, as appropriate. Used with permission from Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby-Elsevier.

roundings; providing health teaching; promoting a therapeutic relationship; and carrying out a variety of therapeutic nursing activities. Judgment, critical thinking, and good decision-making skills are essential in the selection of appropriate evidence-based and ethical nursing interventions. All nursing interventions are patient focused and outcome directed and are implemented with compassion, confidence, and a willingness to accept and understand the patient’s responses. Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and

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collaborating with other health care team members to accomplish specific expected outcomes and to monitor and manage potential complications. Such interdependent functioning is just that—interdependent. Requests or orders from other health care team members should not be followed blindly but should be assessed critically and questioned when necessary. The implementation phase of the nursing process ends when the nursing interventions have been completed.

• Do priorities need to be reordered? • Have the patient’s nursing needs been met? • Should the nursing interventions be continued, revised, or discontinued? • Have new problems evolved for which nursing interventions have not been planned or implemented? • What factors influenced the achievement or lack of achievement of the objectives? • Should changes be made in the expected outcomes and outcome criteria?

Evaluation

Objective data that provide answers to these questions are collected from all available sources (e.g., patients, families, significant others, health care team members). These data are included in patients’ records and must be substantiated by direct patient observation before the outcomes are documented.

Evaluation, the final step of the nursing process, allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the objectives have been achieved. The plan of nursing care is the basis for evaluation. The nursing diagnoses, collaborative problems, priorities, nursing interventions, and expected outcomes provide the specific guidelines that dictate the focus of the evaluation. Through evaluation, the nurse can answer the following questions: • Were the nursing diagnoses and collaborative problems accurate? • Did the patient achieve the expected outcomes within the critical time periods? • Have the patient’s nursing diagnoses been resolved? • Have the collaborative problems been resolved?

Plan of Nursing Care

Documentation of Outcomes and Revision of Plan Outcomes are documented concisely and objectively. Documentation should relate outcomes to the nursing diagnoses and collaborative problems, describe the patient’s responses to the interventions, indicate whether the outcomes were met, and include any additional pertinent data. An example of an individualized plan of nursing care is given in Chart 3-7.

Chart 3-7. Example of an Individualized Plan of Nursing Care

Mrs. T.C., a 52-year-old elementary school teacher, was admitted to the nursing unit from the emergency department. She had had a gnawing pain on her right side radiating to her back for 3 days. She now describes her pain as “excruciating after eating or drinking.” In the past 48 hours she has been vomiting about 2 to 3 hours after she eats. She has not had anything to eat or drink for the past 12 hours. Mrs. T.C. stated that she had not been successful in adhering to the weight reduction diet that had been prescribed by her physician and that she had rapidly lost, then regained, weight several times in the past year and a half. She stated, “My life is just too busy—I work late hours planning lessons and have to buy my meals out a lot.” She indicated that in addition to her work, she and her husband share the responsibility for raising their three young children. Admission physical examination revealed BP 132/84, P 104, R 22, T 37.8°C, height 1.7m, weight 92 kg, skin warm, no jaundice. She stated that her urine has been “a strange gold colour” and her stools were “greyish.” She was admitted with the diagnosis of acute cholecystitis. The physician’s orders on admission included monitor vital signs every 4 hours; IV of D5 Ringer’s lactate 125 mL per hour; 1,500-calorie, low-fat liquid diet and progress to low-fat soft diet if no pain in 16 hours; morphine sulfate 2 mg IV every 2 hours as needed; notify physician for sudden increase in frequency or intensity of pain; promethazine 12.5 mg IV every 4 hours as needed for nausea or vomiting.

Nursing Diagnoses • Acute pain related to distended cystic duct and inflamed or infected gallbladder

• Risk for deficient fluid volume related to vomiting and decreased intake

• Ineffective coping related to role and responsibilities at work and home

• Imbalanced nutrition: More than body requirements, re-

lated to knowledge deficit about sedentary lifestyle, poor food choices and eating pattern

Collaborative Problems • Risk for cystic duct necrosis or perforation • Obesity

Goals Immediate • Relief of pain • Prevent fluid volume deficit and electrolyte imbalance • Promote rest • Early detection of any complications Intermediate • Initiation of lifestyle alterations to decrease stress and facilitate rest

Long Term • Alteration of lifestyle to reduce emotional and environmental stressors

• Compliance with dietary regimen • Weight reduction

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Critical Thinking, Ethical Decision Making, and the Nursing Process

Chart 3-7. Example of an Individualized Plan of Nursing Care, Continued

NURSING INTERVENTIONS

EXPECTED OUTCOMES

OUTCOMES

1. Monitor BP, pulse, temperature, and respirations every 4 hours.

1. Vital signs within normal limits

2. Monitor pain status with accompanying abdominal assessment every 2 hours, or more frequently, as needed. a. Assess pain characteristics every 2 hours or as needed. b. Assess abdomen every 2 hours or with pain assessment. c. Use nonpharmacologic measures (pillows, repositioning, etc.) as desired and tolerated by patient for pain relief. d. Administer analgesic at regular intervals as needed, and assess response. 3. Monitor and support fluid and electrolyte status: a. Monitor weight. b. I&O c. Monitor skin turgor and temperature. d. Monitor serum electrolytes. e. Monitor colour and consistency of urine and stool output. f. Encourage low-fat liquid intake if pain-free. g. Administer promethazine as prescribed to control or relieve vomiting. 4. Promote atmosphere conducive to physical and mental rest: a. Encourage alternation of rest and activity. b. Encourage limitation of visitors and interactions that are stress producing.

2. Experiences pain relief; abdominal assessment within normal limits

1. BP range 110/62–128/78 with pain relief measures; temperature 36.6°– 37.1°C; pulse range 74–88; respirations 18–22 2. Verbalized decrease in pain from severe (8) to low (2) intensity within 10 minutes after morphine administered; no pain radiation to back Abdomen soft and nontender

5. Assist patient to alter lifestyle to decrease stress: a. Discuss relationship between emotional stress and physiologic function. b. Encourage patient to identify stressproducing stimuli. c. Encourage patient to identify adjustments necessary to reduce stress relative to the home and work setting. 6. Encourage patient to identify sedentary lifestyle, obesity, and repetitive weight loss and gain as physiologic and emotional stressors; request consultation with dietitian and reinforce instructions given. 7. Teach importance of maintaining lowfat liquid diet and progression toward long-term low-fat diet. Teach food and menu choices low in fat.

5. Describes stress, sedentary lifestyle, and obesity as precursors to alteration in physiologic functioning Identifies lifestyle factors that produce stress

3. Fluid balance maintained; electrolytes within normal limits

3. Weight 92.9 kg on admission and 90.2 kg after 2-day period Urinary output adequate in relation to oral and IV intake Skin warm and supple, good recoil Electrolytes in normal range Urine dark amber in colour, no sediment; stools soft, formed, light brown No vomiting reported

4. Alternates periods of rest and activity Limits visitors to family in the evenings Avoids stress-producing interactions

4. Rested in bed 2 hours in morning and 2 hours in afternoon; disconnected phone during rest periods. 8 hours uninterrupted sleep at night; husband and children visit 2 hours in evening; patient calm and relaxed after visits Accurately described relationship between stress, sedentary lifestyle, and obesity 5. Identified the following stressors: Demands of job Excessive involvement in children’s school and recreational activities

6. Identifies lifestyle adjustments necessary to reduce stress Discusses lifestyle adjustments with family 7. Identifies harmful effects of obesity and high-fat foods Makes plans for losing weight Makes plans for preplanned meals Identifies foods/menu choices low in fat

6. Identified need to stop taking work home with her Consulted with husband and children; will alternate with husband in attending children’s activities; all family members supportive 7. Accurately described effects of obesity and intake of high-fat foods on overall physical health and well-being Plans to attend Weight Watchers; has had success with this program in the past Identified that preparing low-fat lunches at home the night before work is a good preplanning option

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CHART 3-8

Hierarchy of Taxonomy in Nursing Practice: A Unified Structure of Nursing Language I. The functional domain is defined as the diagnoses, outcomes, and interventions that promote basic needs and includes the following eight classes: Activity/exercise: physical activity, including energy conservation and expenditure Comfort: a sense of emotional, physical, and spiritual wellbeing and relative freedom from distress Growth and development: physical, emotional, and social growth and developmental milestones Nutrition: processes related to taking in, assimilating, and using nutrients Self-care: ability to accomplish basic and instrumental activities of daily living Sexuality: maintenance or modification of sexual identity and patterns Sleep/rest: the quantity and quality of sleep, rest, and relaxation patterns Values/beliefs: ideas, goals, perceptions, and spiritual and other beliefs that influence choices or decisions II. The physiologic domain is defined as the diagnoses, outcomes, and interventions to promote optimal biophysical health and includes the following 10 classes: Cardiac function: cardiac mechanisms used to maintain tissue perfusion Elimination: processes related to secretion and excretion of body wastes Fluid and electrolyte: regulation of fluid/electrolytes and acid–base balance Neurocognition: mechanisms related to the nervous system and neurocognitive functioning, including memory, thinking, and judgment Pharmacologic function: effects (therapeutic or adverse) of medications or drugs and other pharmacologically active products Physical regulation: body temperature, endocrine, and immune system responses to regulate cellular processes

Reproduction: processes related to human procreation and birth Respiratory function: ventilation adequate to maintain arterial blood gases within normal limits Sensation/perception: intake and interpretation of information through the senses, including seeing, hearing, touching, tasting, and smelling Tissue integrity: skin and mucous membrane protection to support secretion, excretion, and healing III. The psychosocial domain is defined as the diagnoses, outcomes, and interventions to promote optimal mental and emotional health and social functioning and includes the following seven classes: Behaviour: actions that promote, maintain, or restore health Communication: receiving, interpreting, and expressing spoken, written, and nonverbal messages Coping: adjusting or adapting to stressful events Emotional: a mental state of feeling that may influence perception of the world Knowledge: understanding and skill in applying information to promote, maintain, and restore health Roles/relationships: maintenance and/or modification of expected social behaviours and emotional connectedness with others Self-perception: awareness of one’s body and personal identity IV. The environmental domain is defined as the diagnoses, outcomes, and interventions that promote and protect the environmental health and safety of individuals, systems, and communities and includes the following three classes: Health care system: social, political, and economic structures and processes for delivery of health care services Populations: aggregates of individuals or communities having characteristics in common Risk management: avoidance or control of identifiable health threats

From: Herdman, T. H. (Ed.) (2013). NANDA International Nursing Diagnoses: Definitions & Classification 2012–2014 , Oxford, UK: Wiley-Blackwell.

The plan of care is subject to change as a patient’s needs change, as the priorities of needs shift, as needs are resolved, and as additional information about a patient’s state of health is collected. As the nursing interventions are implemented, the patient’s responses are evaluated and documented, and the plan of care is revised accordingly. A well-developed, continuously updated plan of care is the greatest assurance that the patient’s nursing diagnoses and collaborative problems are addressed and his or her basic needs are met.

Framework for a Common Nursing Language: Combining NANDA, NIC, and NOC Various frameworks or taxonomies can be used for determining nursing diagnoses (e.g., NANDA-I), establishing outcomes (e.g., NOC), and designing interventions (e.g.,

NIC). Ultimately, a framework that uses a language common to all aspects of nursing, regardless of the classification system, is desirable. Although still controversial and in its infancy, significant efforts have been made toward accomplishing this goal of unifying the language of nursing. In 2001, a taxonomy of nursing practice was developed for the harmonization of NANDA-I, NIC, and NOC. This three-part combination links nursing diagnoses, accompanying interventions, and outcomes, organizing them in the same way. Such organization of concepts in a common language may facilitate the process of critical thinking, because interventions and outcomes are more accurately matched with appropriately developed nursing diagnoses ( Johnson, Moorhead, Bulechek, et al., 2012). The final taxonomic scheme identifies four clinical domains (functional, physiologic, psychosocial, and environmental), which contain numerous classes of diagnoses, outcomes, and interventions. Chart 3-8 presents the taxonomy of nursing practice.

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Critical Thinking, Ethical Decision Making, and the Nursing Process

Critical Thinking Exercises 1 A 50-year-old, morbidly obese man is admitted to your unit with a severe asthma attack. He reports extreme shortness of breath and chest pain. What are the priorities for data collection for this patient’s current condition? How would these priorities change if the client is in no acute distress and not having chest pain? 2 You are at the bedside of a 93-year-old patient who has no advance directives. The patient has been comatose for 3 days and the physician has not prescribed any feedings. When you ask the physician about an enteral nutritional supplement (tube feeding), he responds, “No, I don’t think so.” What actions should be taken in this situation? What ethical and legal dilemmas exist? What other health professionals could be helpful in resolving any issues? 3

You are caring for a patient with another nursing student, and the student shares that he administered a wrong medication to the patient but is afraid to share this with the faculty and nurses. The patient was given an antihypertensive agent that was not due for another 12 hours. The patient appears to be “OK” at this time, and it is 2 hours after the medication was given. What actions should be taken? Should this information be communicated to your faculty supervisor? What is the care priority for the patient? What evidence supports or does not support disclosure of medication administration errors to patients? What steps would you take and in what order?

REFERENCES AND SELECTED READINGS BOOKS Alfaro-LeFevre, R. (2013). Critical thinking and clinical judgment: A practical approach to outcome focused thinking (5th ed.). Philadelphia, PA: Saunders. Bergum, V., & Dossetor, J. (2005). Relational ethics. The full measure of respect. Hagerstown, MD: University Publishing Group. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC). (6th ed.). St. Louis, MO: Mosby-Elsevier. Carpenito-Moyet, L. J. (2012). Nursing diagnosis: Application to clinical practice (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Herdman, T. H. (Ed.). (2012). NANDA International Nursing Diagnoses: Definitions & Classification, 2012–2014. Oxford, UK: Wiley-Blackwell.

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Johnson, M., Moorhead, S., Bulechek, G. M., et al. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care (3rd ed.). Maryland Heights, MO: Elsevier Mosby. Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds.). (2013). Nursing outcomes classification (NOC). Measurement of health outcomes (5th ed.). St. Louis, MO: Mosby-Elsevier. Smith-Temple, J., & Johnson, J. Y. (2013). Nurses’ guide to clinical procedures (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis, MO: Mosby.

JOURNALS AND ELECTRONIC DOCUMENTS *Asterisks indicate nursing research articles. Canadian Nurses Association. (2008a). Code of ethics for registered nurses. Ottawa, ON: Author. Retrieved from http://buydownload. cna-aiic.ca/shopexd.asp?id=4. Canadian Nurses Association. (2008b). Providing nursing care at the end of life. Ottawa, ON: Author. Retrieved from http://www.cna-aiic.ca/ sitecore%20modules/web/∼/media/cna/page%20content/pdf%20 en/2013/07/26/10/43/ps96_end_of_life_e.pdf#search=%22providing care at the end of life%22. Carter, M.A. (2009). Trust, power, and vulnerability: A discourse on Helping in Nursing. Nursing Clinics of North America, 44, 393–405. *Chan, Z. C. Y. (2013). A systematic review of critical thinking in nursing education. Nurse Education Today, 33, 236–240. College and Association of Registered Nurses of Alberta. (2009). Position statement on the use of restraints in client care settings. Edmonton, AB: Author. Retrieved from http://www.nurses.ab.ca/Carna-Admin/ Uploads/Use_of_Restraints.pdf. Health Canada. (2006). Advance care planning: The Glossary project: Final report. Ottawa, ON: Author. Retrieved from http://www.hc-sc.gc.ca/ hcs-sss/pubs/palliat/2006-proj-glos/index-eng.php. Heffner, S., & Rudy, S. (2008). Critical thinking: What does it mean in the care of elderly hospitalized patients? Critical Care Nursing Quarterly, 31(1), 73–78. International Council of Nurses. (2008). The ICN definition of nursing. Retrieved from http://www.icn.ch/definition.htm. Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3–14. *Profetto-McGrath, J., Hesketh, K. L., Lang, S., et al. (2003). A study of critical thinking and research utilization among nurses. Western Journal of Nursing Research, 25 (3), 322–337.

RESOURCES Canadian Nurses Association (CNA): http://www.cna-aiic.ca International Council of Nurses (ICN): http://www.icn.ch NANDA International: http://www.nanda.org/

CHAPTER

4 Health Education and Health Promotion Adapted by Beverly Williams

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the purposes and significance of health education. 2. Describe the concept of adherence to a therapeutic regimen. 3. Identify variables that affect learning readiness and adult learning abilities. 4. Describe the relationship of the teaching–learning process to the nursing process. 5. Develop a teaching plan for a patient. 6. Identify modifications indicated when teaching patients with disabilities. 7. Define the concepts of health, wellness, and health promotion. 8. Discuss major health promotion theories. 9. Describe the components of health promotion: self-responsibility, nutritional awareness, stress reduction and management, and physical fitness. 10. Specify the variables that affect health promotion activities for adolescents, young and middle-aged adults, and older adults. 11. Describe the role of the nurse in health promotion.

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CHAPTER 4

Effective health education lays a solid foundation for individual and community wellness. Teaching is an integral tool that all nurses use to assist patients and families in developing effective health behaviours and altering lifestyle patterns that predispose people to health risks. Health education is an influential factor directly related to positive patient care outcomes.

HEALTH EDUCATION TODAY Today’s health care environment mandates the use of an organized approach to health education so that patients can meet their specific health care needs. Significant factors for nurses to consider when planning patient education include the availability of health care outside the hospital setting, the use of diverse health care providers to accomplish care management goals, and the increased use of complementary and alternative strategies rather than traditional approaches to care. Careful consideration of these factors can provide patients with the comprehensive information that is essential for making informed decisions about health care. Demands from consumers for comprehensive information about their health issues throughout the life cycle accentuate the need for holistic health education to occur in every patient–nurse encounter. Teaching, as a function of nursing, is included in provincial standards of practice. For example, see the College and Association of Registered Nurses of Alberta (CARNA, 2013) and the Code of Ethics of the Canadian Nurses Association (CNA, 2008). Health education is an independent function of nursing practice and is a primary nursing responsibility. All nursing care is directed toward promoting, maintaining, and restoring health; preventing illness; and helping people adapt to the residual effects of illness. Many of these nursing activities are accomplished through health education or patient teaching. Nurses who serve as teachers are challenged to focus on the educational needs of communities and to provide specific patient and family education. Health education is important to nursing care because it affects the abilities of people and families to perform important self-care activities.

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Every contact an individual nurse has with a patient, whether or not that person is ill or has a disability, should be considered an opportunity for health teaching. Although people have a right to decide whether or not to learn, nurses have the responsibility to present information that motivates people to recognize the need to learn. Therefore, nurses use opportunities in all health care settings to promote wellness. Educational environments may include homes, hospitals, community health centres, schools, places of business, service agencies, shelters, correctional facilities, and consumer action or support groups.

Purpose of Health Education This emphasis on health education stems in part from the public’s right to comprehensive health care, which includes up-to-date health information. It also reflects the emergence of an informed public that is asking more significant questions about health and health care. Because of the importance Canadian society places on health and the responsibility each person has to maintain and promote his or her own health, members of the health care team, specifically nurses, are obligated to make health education available. Without adequate knowledge and education in self-care skills, consumers cannot make informed decisions about their health. As the lifespan of the population increases, the number of people with chronic illnesses and disabilities also increases. People with chronic illness may need health care information to participate actively in and assume responsibility for self-care. Health education can help those with chronic illness adapt to their illness, prevent complications, carry out prescribed therapy, and solve issues when confronted with new situations. It can also help prevent crisis situations and reduce the potential for rehospitalization resulting from inadequate information about self-care. The goal of health education is to teach people to live life to their healthiest—that is, to strive toward achieving their maximum health potential. In addition to the public’s right to and desire for health education, patient education is also a strategy for promoting

Glossary adherence: the process of faithfully following guidelines or directions community: an interacting population of individuals living together within a larger society feedback: the return of information about the results of input given to a person or a system health education: a variety of learning experiences designed to promote behaviours that facilitate health health promotion: the art and science of assisting people to change their lifestyle toward a higher state of wellness learning: the act of gaining knowledge and skill learning readiness: the optimum time for learning to occur; usually corresponds to the learner’s perceived need and desire to obtain specific knowledge nutrition: the science that deals with food and nourishment in humans

physical fitness: the condition of being physically healthy as a result of appropriate exercise and nutrition reinforcement: the process of strengthening a given response or behaviour to increase the likelihood that the behaviour will continue self-responsibility: personal accountability for one’s actions or behaviours stress management: behaviours and techniques used to strengthen a person’s resources against stress teaching: the imparting of knowledge therapeutic regimen: a routine that promotes health and healing wellness: a condition of good physical and emotional health sustained by a healthy lifestyle

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self-care at home and in the community, reducing health care costs by preventing illness, effectively managing necessary therapies, avoiding expensive medical interventions, decreasing hospital lengths of stay, and facilitating earlier discharge. For health care agencies, offering community wellness programs is a public relations tool for increasing patient knowledge and satisfaction and for developing a positive image of the institution.

Adherence to the Therapeutic Regimen One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. Adherence to treatment usually requires that a person make one or more lifestyle changes to carry out specific activities that promote and maintain health. Common examples of behaviours facilitating health include taking prescribed medications, maintaining a healthy diet, increasing daily activities and exercise, self-monitoring for signs and symptoms of illness, practicing specific hygiene measures, seeking recommended health evaluations and screening, and performing other therapeutic and preventive measures. Many people do not adhere to their prescribed regimens; rates of adherence are generally low, especially when the regimens are complex or of long duration (e.g., therapy for tuberculosis, multiple sclerosis, and human immunodeficiency virus [HIV] disease and hemodialysis). Nonadherence to prescribed therapy has been the subject of many studies (Belguzar, Kayser, & Selim (2007); Brown & Bussell, 2011; Law, Cheng, Dhalla, et al., 2012; Loke, Hinz, Wang, et al., 2012; Ho, Bryson, & Rumsfeld, 2009). For the most part, findings have been inconclusive, and no one predominant causative factor has been identified. Instead, a wide range of variables appears to influence the degree of adherence, including the following: • Demographic variables, such as age, gender, race, socioeconomic status, level of education, and health literacy • Illness variables, such as the severity of the illness and the relief of symptoms afforded by the therapy • Therapeutic regimen variables, such as the complexity of the regimen and uncomfortable side effects • Psychosocial variables, such as intelligence, motivation, availability of significant and supportive people (especially family members), attitudes toward health professionals, acceptance or denial of illness, substance abuse, and religious or cultural beliefs • Financial variables, especially the direct and indirect costs associated with a prescribed regimen Nurses’ success with health education is determined by ongoing assessment of the variables that affect patients’ ability to adopt specific behaviours, to obtain resources, and to maintain a healthy social environment (Edelman & Mandle, 2010). Teaching programs are more likely to succeed if the variables affecting patient adherence are identified and considered in the teaching plan. The problem of nonadherence to therapeutic regimens is a substantial one that must be addressed before patients

can achieve their maximum health potential. Surprisingly, patients’ need for knowledge has not been found to be a sufficient stimulus for acquiring knowledge and thereby enabling complete adherence to a health regimen. Teaching directed toward stimulating patient motivation results in varying degrees of adherence. The variables of choice, establishment of mutual goals, and quality of the patient–provider relationship directly influence the behavioural changes that can result from patient education. These factors are directly linked to motivation for learning. Using a learning contract or agreement can also be a motivator for learning. Such a contract is based on assessment of patient needs; health care data; and specific, measurable goals (Redman, 2007). A well-designed learning contract is realistic and positive; it includes measurable goals, with a specific time frame and reward system for goal achievement. The learning contract is recorded in writing and contains methods for ongoing evaluation. The value of the contract lies in its clarity, its specific description of what is to be accomplished, and its usefulness for evaluating behavioural change. In a typical learning contract, a series of goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals. Frequent, positive reinforcement is provided as the person moves from one goal to the next. For example, incremental goals such as weight loss of 0.5 to 1 kg per week are more appropriate in a weight reduction program than a general goal such as a 14 kg weight loss.

Gerontologic Considerations Nonadherence to therapeutic regimens is a significant concern for older adults, leading to increased morbidity, mortality, and cost of treatment (Latif & McNicoll, 2009). Many admissions to nursing homes and hospitals are associated with nonadherence. Older adults frequently have one or more chronic illnesses that are managed with numerous medications, and complicated by periodic acute episodes. Older adults may also have other issues that affect adherence to therapeutic regimens, such as increased sensitivity to medications and their side effects, difficulty in adjusting to change and stress, financial constraints, forgetfulness, inadequate support systems, lifetime habits of self-treatment with over-the-counter medications, visual and hearing impairments, and mobility limitations. To promote adherence among older adults, all variables that may affect health behaviour should be assessed (Fig. 4-1). Nurses also consider that cognitive impairment may be manifested by the older person’s inability to draw inferences, apply information, or understand the major teaching points (Ebersole, Touhy, Hess, et al., 2008). The person’s strengths and limitations must be assessed to encourage use of existing strengths to compensate for limitations. Above all, health care professionals need to work together to provide continuous, coordinated care; otherwise, the efforts of one health care professional may be negated by those of another.

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In general, there is no definitive theory about how learning occurs and how it is affected by teaching. However, learning can be affected by factors such as readiness to learn, the learning environment, and the teaching techniques used (Bastable, 2008).

Learning Readiness

FIGURE 4-1. Taking time to teach patients about their medication and treatment program promotes interest and cooperation. Older adults who are actively involved in learning about their medication and treatment program and the expected effects may be more likely to adhere to the therapeutic regimen.

THE NATURE OF TEACHING AND LEARNING Learning can be defined as acquiring knowledge, attitudes, or skills. Teaching is defined as helping another person learn. These definitions indicate that the teaching– learning process is an active one, requiring the involvement of both teacher and learner in the effort to reach the desired outcome, a change in behaviour. The teacher does not simply give knowledge to the learner but instead serves as a facilitator of learning.

One of the most significant factors influencing learning is a person’s learning readiness. For adults, readiness is based on culture, personal values, physical and emotional status, and past experiences in learning. The “teachable moment” occurs when the content and skills being taught are congruent with the task to be accomplished (Redman, 2007). Culture encompasses values, ideals, and behaviours, and the traditions within each culture provide the framework for solving the issues and concerns of daily living. Because people with different cultural backgrounds have different values and lifestyles, choices about health care vary. Culture is a major variable influencing readiness to learn because it affects how people learn and what information can be learned. Sometimes people do not accept health teaching because it conflicts with culturally mediated values. Before beginning health teaching, nurses conduct an individual cultural assessment instead of relying only on generalized assumptions about a particular culture. A patient’s social and cultural patterns are appropriately incorporated into the teaching–learning interaction. Chapter 9 (Chart 9-3) describes cultural assessment components to consider when formulating a teaching plan. Chart 4-1 summarizes a research study exploring sexual behaviour of Canadian Aboriginal young people (Devries, Free, Morison, et al., 2009).

NURSING RESEARCH PROFILE

Chart 4-1. Factors Associated With the Sexual Behaviour of Canadian Aboriginal Young People and Their Implications for Health Promotion Devries, K., Free, C., Morison, L., et al. (2009). Factors associated with the sexual behaviour of Canadian Aboriginal young people and their implications for health promotion. American Journal of Public Health, 99(5), 855–862. Purpose The purpose of this study was to examine factors that might be associated with having ever had sex, having more than one lifetime sexual partner, and condom nonuse in the last incidence of sexual intercourse among Canadian aboriginal young people. Design The study was a secondary analysis of a cross sectional survey (2003 British Columbia Adolescent Survey) conducted with young people in grades 7–12. Findings Of the 1,140 young aboriginal males 34% had had sex with 63% having had more than one sexual partner and 21% had

not used a condom during their last incidence of intercourse. Of the 1,336 young aboriginal women, 34% had had sex with 56% having had more than one sexual partner and 41% had not used a condom during their last incidence of intercourse. Several factors were strongly associated with sexual behaviour outcomes including frequent substance abuse, having been sexually abused, and having lived on a land reservation. Strong family connections were associated with more frequent condom use. Nursing Implications Young people on land reserves require particular attention. Encouraging changes in sexual behaviour of Aboriginal young people must move beyond the individual and incorporate interpersonal and structural dimensions of the family. Interventions to assist with reduction of substance use and sexual abuse while promoting feelings of individual worth and family connectedness should be considered.

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A person’s values include beliefs about behaviours that are desirable and undesirable. The nurse needs to know what value the patient places on health and health care. In clinical situations, patients express their values through their actions and the level of knowledge pursued (Andrews & Boyle, 2012). When the nurse is unaware of the patient’s cultural values, misunderstanding, lack of cooperation, and negative health outcomes may occur (Leininger & McFarland, 2006). A person’s values and behaviours can be either an asset or a deterrent to readiness to learn. Therefore, patients are unlikely to accept health education unless their values and beliefs about health and illness are respected (Giger & Davidhizar, 2013). Physical readiness is of vital importance, because until the person is physically capable of learning, attempts at teaching and learning may be both futile and frustrating. For example, a person in acute pain is unable to focus attention away from the pain long enough to concentrate on learning. Likewise, a person who is short of breath concentrates on breathing rather than on learning. Emotional readiness also affects the motivation to learn. A person who has not accepted an existing illness or the threat of illness is not motivated to learn. A person who does not accept a therapeutic regimen, or who views it as conflicting with his or her present lifestyle, may consciously avoid learning about it. Until the person recognizes the need to learn and demonstrates an ability to learn, teaching efforts may be thwarted. However, it is not always wise to wait for the person to become emotionally ready to learn, because that time may never come unless the nurse makes an effort to stimulate the person’s motivation. Illness and the threat of illness are usually accompanied by anxiety and stress. Nurses who recognize such reactions can use simple explanations and instructions to alleviate these anxieties and provide further motivation to learn. Because learning involves behaviour change, it often produces mild anxiety, which can be a useful motivating factor. Emotional readiness can be promoted by creating a warm, accepting, positive atmosphere and by establishing realistic learning goals. When learners achieve success and a feeling of accomplishment, they are often motivated to participate in additional learning opportunities. Feedback about progress also motivates learning. Such feedback is presented in the form of positive reinforcement when the learner is successful, and in the form of constructive suggestions for improvement when the learner is unsuccessful. Experiential readiness refers to past experiences that influence a person’s ability to learn. Previous educational experiences and life experiences in general are significant determinants of a person’s approach to learning. People with little or no formal education may not be able to understand the instructional materials presented. People who have had difficulty learning in the past may be hesitant to try again. Many behaviours required for reaching maximum health potential require knowledge, physical skills, and positive attitudes. In their absence, learning may be very difficult and very slow. For example, a person who does not understand the basics of adequate nutrition may not be able to understand the restrictions of a specific diet. A person who does not view the desired learning as personally meaningful may reject teaching efforts. A per-

son who is not future oriented may be unable to appreciate many aspects of preventive health teaching. Experiential readiness is closely related to emotional readiness, because motivation tends to be stimulated by an appreciation for the need to learn and by those learning tasks that are familiar, interesting, and meaningful.

The Learning Environment Although learning can take place without teachers, most people who are attempting to learn new or altered health behaviours benefit from contact with a nurse. The interpersonal interaction between the person and the nurse who is attempting to meet the person’s learning needs may be formal or informal, depending on the method and techniques of teaching. Learning may be optimized by minimizing factors that interfere with the learning process. For example, the room temperature, lighting, noise levels, and other environmental conditions should be appropriate to the learning situation. In addition, the time selected for teaching should be suited to the needs of the individual person. Scheduling a teaching session at a time of day when a patient is fatigued, uncomfortable, or anxious about a pending diagnostic or therapeutic procedure, or when visitors are present, is not conducive to learning. However, if the family is to participate in providing care, the sessions should be scheduled when family members are present so that they can learn any necessary skills or techniques.

Teaching Techniques Teaching techniques and methods enhance learning if they are appropriate to the patient’s needs. Numerous techniques are available, including lectures, group teaching, and demonstrations, all of which can be enhanced with specially prepared teaching materials. The lecture or explanation method of teaching is commonly used but should be accompanied by discussion. Discussion is important because it affords learners opportunities to express their feelings and concerns, to ask questions, and to receive clarification. Group teaching is appropriate for some people because it allows them not only to receive needed information, but also to feel secure as members of a group. People with similar health issues or learning needs have the opportunity to identify with each other and gain moral support and encouragement. However, not everyone relates or learns well in groups or benefits from such experiences. Also, if group teaching is used, assessment and follow-up are necessary to ensure that each person has gained sufficient knowledge and skills. Demonstration and practice are essential ingredients of a teaching program, especially when teaching skills. It is best to demonstrate the skill and then give the learner ample opportunity for practice. When special equipment is involved, such as syringes, colostomy bags, dialysis equipment, dressings, or suction apparatus, it is important to teach with the same equipment that will be used in the home setting. Learning to perform a skill with one kind of equipment and then having to change to a different kind may lead to confusion, frustration, and mistakes.

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Teaching aids used to enhance learning include books, pamphlets, pictures, films, slides, audio tapes, models, programmed instruction, other visual aids (e.g., charts), and computer-assisted learning modules. These are made available as needed for home, clinic, or hospital use, and they allow review and reinforcement of content and enhanced visual and auditory learning. Such teaching aids are invaluable when used appropriately and can save a significant amount of personnel time and related cost. However, all such aids should be reviewed before use to ensure that they meet the person’s learning needs, are up to date, and are free of advertisements that may confuse the patient. Human interaction and discussion cannot be replaced by teaching technologies but may be enhanced by them. Reinforcement and follow-up are important because learning takes time. Allowing ample time to learn and reinforcing what is learned are important teaching strategies; a single teaching session is rarely adequate. Followup sessions are required to promote the learner’s confidence in his or her abilities and to plan for additional teaching sessions. For hospitalized patients who may not be able to transfer what they have learned in the hospital to the

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home setting, follow-up after discharge is essential to ensure that they have realized the full benefits of a teaching program.

Teaching Special Populations People With Disabilities When providing health information to people with disabilities, the individual needs of each person must be assessed and incorporated into the teaching plan. Teaching techniques and the imparting of information may need to be altered. The nurse needs to be aware of the health promotion needs when teaching specific groups of people with physical disabilities; emotional, psychiatric, or mental health disabilities; hearing, visual, or sensory impairments; learning disabilities; and developmental disabilities. It may be necessary to institute new or modified approaches to teach people with disabilities about their health. Table 4-1 outlines some of the teaching strategies to use when teaching people with disabilities.

TABLE 4-1

Teaching People With Disabilities

Type of Disability

Teaching Strategy

Physical, Emotional, or Cognitive Disability

Adapt information to accommodate the person’s cognitive, perceptual, and behavioural disabilities. Give clear written and oral information. Highlight significant information for easy reference. Avoid medical terminology or “jargon.”

Hearing Impairment

Use slow, directed, deliberate speech. Use sign language or interpreter services if appropriate. Position yourself so that the person can see your mouth if speech reading. Use telecommunication devices (TTY or TDD) for the person with hearing impairment. Use written materials and visual aids, such as models and diagrams. Use captioned videos, films, and computer-generated materials. Teach on the side of the “good ear” if unilateral deafness is present.

Visual Impairment

Use optical devices such as magnifying lens. Use proper lighting and proper contrast of colours on materials and equipment. Use large-print materials. Use Braille materials if appropriate. Convert information to auditory and tactile formats. Obtain audiotapes and talking books. Explain noises associated with procedures, equipment, and treatments. Arrange materials in clockwise pattern.

Learning Disabilities Input disability

Output disability

Developmental disability

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If visual perceptual disorder: • Explain information verbally, repeat, and reinforce frequently. • Use audiotapes. • Encourage learner to verbalize information received. If auditory perceptual disorder: • Speak slowly with as few words as possible, repeat, and reinforce frequently. • Use direct eye contact to focus person on task. • Use demonstration and return demonstration such as modelling, role playing, and hands-on experiences. • Use visual tools, written materials, and computers. Use all senses as appropriate. Use written, audiotape, and computer information. Review information and give time to interact and ask questions. Use hand gestures and motions. Base information and teaching on developmental stage, not chronologic age. Use nonverbal cues, gestures, signing, and symbols as needed. Use simple explanations and concrete examples with repetition. Encourage active participation. Demonstrate information and have the person perform return demonstrations.

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Older Adults Nurses caring for older people need to be aware of how the usual changes that occur with aging may affect learning abilities and how they can help older people age well. Above all, it is important to recognize that just because a person is older does not mean that he or she cannot learn. Older adults can learn and remember if information is paced appropriately, is relevant, and is followed by the appropriate feedback strategies that apply to all learners (Miller, 2009). Because changes associated with aging vary significantly among older people, the nurse conducts a thorough assessment of each person’s level of physiologic and psychological functioning before beginning teaching. More information on the physiologic effects of aging can be found in Chapter 13. Changes in cognition with age may include slowed mental functioning; decreased short-term memory, abstract thinking, and concentration; and slowed reaction time. These changes are often accentuated by the health concerns that cause the older person to seek health care in the first place. Effective teaching strategies include slowpaced presentation of small amounts of material at a time; frequent repetition of information; and the use of reinforcement techniques, such as audiovisual and written materials, and repeated practice sessions. Distracting stimuli should be minimized as much as possible in the teaching environment. Sensory changes associated with aging also affect teaching and learning. Teaching strategies to accommodate decreased visual acuity include large-print and easy-to-read materials printed on nonglare paper. Because colour discrimination is often impaired, the use of colour-coded or highlighted materials may not be effective. To maximize hearing, teachers speak distinctly with a normal or lowered pitch, facing the person so that speech reading can occur as needed. Visual cues often help reinforce verbal teaching. Family members should be involved in teaching sessions when possible and appropriate. They provide another source for reinforcement of material and can help the older person recall instructions later. Family members can also provide valuable assessment information about the person’s living situation and related learning needs. The chance of success is maximized when nurses, families, and other health care professionals work collaboratively to facilitate the older person’s learning. Successful learning should result in improved self-care management skills, enhanced self-esteem, confidence, and a willingness to learn in the future.

THE NURSING PROCESS IN PATIENT TEACHING The steps of the nursing process are used when constructing a teaching plan to meet people’s teaching and learning needs (Chart 4-2).

Assessment Assessment in the teaching–learning process is directed toward the systematic collection of data about the person

and family’s learning needs and readiness to learn. All internal and external variables that affect the patient’s readiness to learn are identified. A learning assessment guide may be used for this purpose. Some of the available guides are directed toward the collection of general health information (e.g., smoking cessation), whereas others are specific to medication regimens or disease processes (e.g., stroke risk assessments). Such guides facilitate assessment but must be adapted to the responses, issues, and needs of each person. The nurse organizes, analyzes, synthesizes, and summarizes the assessment data collected and determines the patient’s need for teaching.

Nursing Diagnosis The process of formulating nursing diagnoses makes educational goals and evaluations of progress more specific and meaningful. Teaching is an integral intervention implied by all nursing diagnoses, and for some diagnoses, education is the primary intervention. Examples of nursing diagnoses that help in planning for educational needs are ineffective therapeutic regimen management, impaired or ineffective home maintenance, health-seeking behaviours (specify), and decisional conflict (specify). The diagnosis “deficient knowledge” should be used cautiously, because knowledge deficit is not a human response but a factor relating to or causing the diagnosis. For example, “ineffective therapeutic regimen management related to a lack of information about wound care” is a more appropriate nursing diagnosis than “deficient knowledge” (Carpenito-Moyet, 2013; Herdman, 2012). A nursing diagnosis that relates specifically to a patient’s and family’s learning needs serves as a guide in the development of the teaching plan.

Planning Once the nursing diagnoses have been identified, the planning component of the teaching–learning process is established in accordance with the steps of the nursing process: 1. Assigning priorities to the diagnoses 2. Specifying the immediate, intermediate, and long-term goals of learning 3. Identifying specific teaching strategies appropriate for attaining goals 4. Specifying the expected outcomes 5. Documenting the diagnoses, goals, teaching strategies, and expected outcomes of the teaching plan The assignment of priorities to the diagnoses should be a collaborative effort by the nurse, the patient, and family members. Consideration is given to the urgency of the patient’s learning needs; the most critical needs should receive the highest priority. After the diagnostic priorities have been mutually established, it is important to identify the immediate and longterm goals and the teaching strategies appropriate for attaining the goals. Teaching is most effective when the objectives of both the patient and nurse are in agreement

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CHART 4-2

A Guide to Patient Education Assessment 1. Assess the person’s readiness for health education. a. What are the person’s health beliefs and behaviours? b. What physical and psychosocial adaptations does the person need to make? c. Is the learner ready to learn? d. Is the person able to learn these behaviours? e. What additional information about the person is needed? f. Are there any variables (e.g., hearing or visual impairment, cognitive issues, literacy issues) that will affect the choice of teaching strategy or approach? g. What are the person’s expectations? h. What does the person want to learn? 2. Organize, analyze, synthesize, and summarize the collected data.

Nursing Diagnosis 1. Formulate the nursing diagnoses that relate to the person’s learning needs. 2. Identify the learning needs, their characteristics, and their etiology. 3. State nursing diagnoses concisely and precisely.

Planning and Goals 1. Assign priority to the nursing diagnoses that relate to the individual’s learning needs. 2. Specify the immediate, intermediate, and long-term learning goals established by teacher and learner together. 3. Identify teaching strategies appropriate for goal attainment. 4. Establish expected outcomes. 5. Develop the written teaching plan. a. Include diagnoses, goals, teaching strategies, and expected outcomes. b. Put the information to be taught in logical sequence. c. Write down the key points.

(Bastable, 2008). Learning begins with the establishment of goals that are appropriate to the situation and realistic in terms of the patient’s ability and desire to achieve them. Involving the patient and family in establishing goals and in planning teaching strategies promotes their cooperation in the implementation of the teaching plan. Outcomes of teaching strategies can be stated in terms of expected behaviours of patients, families, or both. Outcomes are to be realistic and measurable, and the critical time periods for attaining them are also identified. The desired outcomes and the critical time periods serve as a basis for evaluating the effectiveness of the teaching strategies. During the planning phase, the nurse considers the sequence in which the subject matter is presented. Critical information (e.g., survival skills for a patient with diabetes) and material that the person or family identifies to be of particular importance receives high priority. An outline is often helpful for arranging the subject matter and for ensuring that all necessary information is included. In addition, appropriate teaching aids to be used in imple-

d. Select appropriate teaching aids. e. Keep the plan current and flexible to meet the person’s changing learning needs. 6. Involve the learner, family or significant others, nursing team members, and other health care team members in all aspects of planning.

Implementation 1. Put the teaching plan into action. 2. Use language the person can understand. 3. Use appropriate teaching aids and provide Internet resources if appropriate. 4. Use the same equipment that the person will use after discharge. 5. Encourage the person to participate actively in learning. 6. Record the learner’s responses to the teaching actions. 7. Provide feedback.

Evaluation 1. Collect objective data. a. Observe the person. b. Ask questions to determine whether the person understands. c. Use rating scales, checklists, anecdotal notes, and written tests when appropriate. 2. Compare the person’s behavioural responses with the expected outcomes. Determine the extent to which the goals were achieved. 3. Include the person, family or significant others, nursing team members, and other health care team members in the evaluation. 4. Identify alterations that need to be made in the teaching plan. 5. Make referrals to appropriate sources or agencies for reinforcement of learning after discharge. 6. Continue all steps of the teaching process: assessment, diagnosis, planning, implementation, and evaluation.

menting teaching strategies are prepared or selected at this time. The entire planning phase concludes with the formulation of the teaching plan. This teaching plan communicates the following information to all members of the nursing team: • The nursing diagnoses that specifically relate to the patient’s learning needs and the priorities of these diagnoses • The goals of the teaching strategies • The teaching strategies that are appropriate for goal attainment • The expected outcomes, which identify the desired behavioural responses of the learner • The critical time period within which each outcome is expected to be met • The patient’s behavioural responses (which are documented on the teaching plan) The same rules that apply to writing and revising the plan of nursing care apply to the teaching plan.

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Implementation In the implementation phase of the teaching–learning process, the patient, the family, and other members of the nursing and health care team carry out the activities outlined in the teaching plan. The nurse coordinates these activities. Flexibility during the implementation phase of the teaching–learning process and ongoing assessment of patient responses to the teaching strategies support modification of the teaching plan as necessary. Creativity in promoting and sustaining the patient’s motivation to learn is essential. New learning needs that may arise after discharge from the hospital or after home care visits have ended should also be taken into account. The implementation phase ends when the teaching strategies have been completed and when the patient’s responses to the actions have been recorded. This serves as the basis for evaluating how well the defined goals and expected outcomes have been achieved.

Evaluation Evaluation of the teaching–learning process determines how effectively the patient has responded to teaching and to what extent the goals have been achieved. An evaluation is made to determine what was effective and what needs to be changed or reinforced. It cannot be assumed that patients have learned just because teaching has occurred; learning does not automatically follow teaching. An important part of the evaluation phase addresses the question, “What can be done to improve teaching and enhance learning?” Answers to this question direct the changes to be made in the teaching plan. A variety of measurement techniques can be used to identify changes in patient behaviour as evidence that learning has taken place. These techniques include directly observing the behaviour; using rating scales, checklists, or anecdotal notes to document the behaviour; and indirectly measuring results using oral questioning and written tests. All direct measurements are supplemented with indirect measurements whenever possible. Using more than one measuring technique enhances the reliability of the resulting data and decreases the potential for error from a measurement strategy. In many situations, measurement of actual behaviour is the most accurate and appropriate evaluation technique. Nurses often perform comparative analyses using patient admission data as the baseline. Selected data points observed when nursing care is given and self-care is initiated are compared with the patient’s baseline data. In other cases, indirect measurement may be used. Some examples of indirect measurement are patient satisfaction surveys, attitude surveys, and instruments that evaluate specific health status variables. Measurement is only the beginning of evaluation, which must be followed by data interpretation and value judgments about learning and teaching. These aspects of evaluation are conducted periodically throughout the teaching–learning program, at its conclusion, and at varying periods after the teaching has ended.

Evaluation of learning after teaching that occurs in any setting (e.g., clinics, offices, and hospitals) is essential, because the analysis of teaching outcomes must extend into aftercare. With shortened hospital lengths of stay and with short-stay and same-day surgical procedures, followup evaluation is especially important. Coordination of efforts and sharing of information between hospital-based and community-based nursing personnel facilitate postdischarge teaching and home care evaluation. Evaluation is not the final step in the teaching–learning process but is the beginning of a new patient assessment. The information gathered during evaluation is used to redirect teaching actions, with the goal of improving the patient’s responses and outcomes.

HEALTH PROMOTION Health teaching and health promotion are linked by a common goal—to encourage people to achieve as high a level of wellness as possible so that they can live maximally healthy lives and avoid preventable illnesses. The call for health promotion has become a cornerstone in health policy because of the need to control costs and reduce unnecessary sickness and death (Chart 4-3). Health goals for the nation were originally established in the Ottawa Charter for Health Promotion (1986) with the intent of achieving Health for All by the year 2000 and beyond. The priorities from this initiative were identified as building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The original goals continue to be relevant today. Every few years countries meet to reaffirm the original goals.

Definition Health promotion may be defined as those activities that assist people in developing resources that maintain or enhance well-being and improve their quality of life.

CHART 4-3

Leading Health Indicators to be Used to Measure the Health of the Nation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Physical activity Diet Body mass index Tobacco use Substance abuse Responsible sexual behaviour Mental health Injury and violence Environmental quality Immunization Access to health care

From Health Quality Council of Canada. (2011). A Citizen’s Guide to Health Indicators. Health Quality Council of Canada, Toronto, ON.

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These activities involve people’s efforts to remain healthy in the absence of symptoms and do not require the assistance of a health care team member. The purpose of health promotion is to focus on the person’s potential for wellness and to encourage appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and wellbeing. Health promotion is an active process; that is, it is not something that can be prescribed or dictated. It is up to each person to decide whether to make changes to promote a higher level of wellness. Only the individual can make these choices. Following the catastrophic public event of SARS, the Public Health Agency of Canada (PHAC) was created in 2003, with Dr. Butler-Jones as the first Chief Public Health Officer of Canada. The focus of the PHAC is on “five essential public health functions: health promotion, health protection, health surveillance, disease and injury prevention, and population health assessment” (Reutter & Kushner, 2010). The Federal Government’s “Health Canada”, also has a role in delivery of health promotion programs. Examples of two of these programs are “Federal Tobacco Control Strategy” and the “Canadian Diabetes Strategy” (Reutter & Kushner, 2012).

Health and Wellness The concept of health promotion has evolved because of a changing definition of health and an awareness that wellness exists at many levels of functioning. Health is viewed as a dynamic, ever-changing condition that enables people to function at an optimal potential at any given time. The ideal health status is one in which people are successful in achieving their full potential, regardless of any limitations they might have. Wellness, a reflection of health, involves a conscious and deliberate attempt to maximize one’s health. Wellness does not just happen; it requires planning and conscious commitment and is the result of adopting lifestyle behaviours for the purpose of attaining one’s highest potential for well-being. Wellness is not the same for every person. The person with a chronic illness or disability may still be able to achieve a desirable level of wellness. The key to wellness is to function at the highest potential within the limitations over which there is no control, such as a lifelong disability or genetic disorders (Chart 4-4). A significant amount of research has shown that people, by virtue of what they do or fail to do, influence their own

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health. Today, many of the major causes of illness are chronic diseases that have been closely related to lifestyle behaviours (e.g., type 2 diabetes mellitus, heart disease, lung and colon cancer, chronic obstructive pulmonary diseases, hypertension, cirrhosis, traumatic injury, and HIV disease). To a large extent, a person’s health status may be reflective of his or her lifestyle.

Health Promotion Models Several health promotion models identify health-protecting behaviours and seek to explain what makes people engage in preventive behaviours. A health-protecting behaviour is defined as any behaviour performed by people, regardless of their actual or perceived health condition, for the purpose of promoting or maintaining their health, whether or not the behaviour produces the desired outcome (Keleher, MacDougall, & Murphy, 2011). One model, the Health Belief Model, was designed to foster understanding of why some healthy people choose actions to prevent illness while others do not. Another model, the resource model of preventive health behaviour, addresses the ways in which people use resources to promote health (Keleher, et al., 2011). Nurse educators can use this model to assess how demographic variables, health behaviours, and social and health resources influence health promotion. The Canadian health promotion initiative, Achieving Health for All, builds on the work of Lalonde (1977), in which four determinants of health—human biology, environment, lifestyle, and the health care delivery system— were identified. Determinants of health were defined as factors and conditions that have an influence on the health of individuals and communities. Since the 1970s, a total of 12 health determinants have been identified, and this number will continue to increase as population health research progresses. Determinants of health provide a framework for assessing and evaluating the population’s health. The Health Belief Model developed by Becker (1974) is based on the premise that four variables influence the selection and use of health promotion behaviours. Demographic and disease factors, the first variable, include patient characteristics such as age, gender, education, employment, severity of illness or disability, and length of illness. Barriers, the second variable, are defined as factors leading to unavailability or difficulty in gaining access to a specific health promotion alternative. Resources, the third variable, encompass such factors as

GENETICS IN NURSING PRACTICE

Chart 4-4. Genetics Aspects of Health Education and Promotion Nurses in all settings should be prepared to incorporate genetics into health education and promotion by: • Inquiring about patients’ and families’ desired health outcomes with regard to genetics-related conditions or risk factors

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• Referring patients for genetics services when indicated • Identifying barriers to accessing genetics-related health services

• Offering appropriate genetics information and resources

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financial and social support. Perceptual factors, the fourth variable, consist of how the person views his or her health status, self-efficacy, and the perceived demands of the illness. Becker demonstrated that these four variables have a positive correlation with a person’s quality of life. The health promotion model described by Pender, Murdaugh and Parsons (2011) is based on social learning theory and emphasizes the importance of motivational factors in acquiring and sustaining health promotion behaviours. This model explores how cognitive-perceptual factors affect the person’s view of the importance of health. It also examines perceived control of health, self-efficacy, health status, and the benefits and barriers to healthpromoting behaviours. The Transtheoretical Model of Change, also known as the Stages of Change Model, is a framework that focuses on the motivation of a person to make decisions that promote healthy behaviour change (Miller, 2009; DiClemente, 2007). Table 4-2 shows the six stages of the model. Research indicates that people seeking assistance from professionals or self-help groups progress through these stages of change (Kim, 2007). Any of the models can serve as an organizing framework for clinical work and research that support the enhancement of health. Research and other literature that support health promotion concepts and frameworks increase the nurse’s understanding of the health promotion behaviours of families and communities (Betz, 2007; Chen, Shiao & Gau, 2007; Reutter & Kushner, 2010; Rowley, Dixon, & Palk, 2007; Seals, 2007).

Components of Health Promotion There are several components of health promotion as an active process: self-responsibility, nutritional awareness, stress reduction and management, and physical fitness.

TABLE 4-2 Stage

Stages in the Transtheoretical Model of Change Description

1. Precontemplative The person is not thinking about making a change. 2. Contemplative The person is only thinking about change in the near future. 3. Decision making The person constructs a plan to change behaviour. 4. Action The person takes steps to operationalize the plan of action. 5. Maintenance The person works to prevent relapse and to sustain the gains made from the actions taken. 6. Termination The person has the ability to resist relapse back to unhealthy behavior(s). Adapted from DiClemente, C. (2007). The transtheoretical model of intentional behavior change. Drugs & Alcohol Today, 7(1), 29–33 and Miller, C. A. (2009). Nursing wellness in older adults (5th ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Self-Responsibility Taking responsibility for oneself is the key to successful health promotion. The concept of self-responsibility is based on the understanding that the individual controls his or her life. Each person alone must make the choices that determine how healthy his or her lifestyle is. As more people recognize that lifestyle and behaviour significantly affect health, they may assume responsibility for avoiding highrisk behaviours such as smoking, alcohol and drug abuse, overeating, driving while intoxicated, risky sexual practices, and other unhealthy habits. They may also assume responsibility for adopting routines that have been found to have a positive influence on health, such as engaging in regular exercise, wearing seat belts, and eating a healthy diet. A variety of techniques have been used to encourage people to accept responsibility for their health, ranging from extensive educational programs to reward systems. No one technique has been found to be superior to any other. Instead, self-responsibility for health promotion is individualized and depends on a person’s desires and inner motivations. Health promotion programs are important tools for encouraging people to assume responsibility for their health and to develop behaviours that improve health.

Nutritional Awareness Nutrition, as a component of health promotion, has become the focus of considerable attention and publicity with the growing epidemic of obesity in Canada. A vast array of books and magazine articles address the topics of special diets; natural foods; and the hazards associated with certain substances, such as sugar, salt, cholesterol, trans fats, carbohydrates, artificial colours, and food additives. It has been suggested that good nutrition is the single most significant factor in determining health status, longevity, and weight control. Nutritional awareness involves an understanding of the importance of a healthy diet that supplies all of the essential nutrients. Understanding the relationship between diet and disease is an important facet of a person’s selfcare. Many clinicians believe that a healthy diet is one that substitutes “natural” foods for processed and refined ones and reduces the intake of sugar, salt, fat, cholesterol, caffeine, alcohol, food additives, and preservatives. Chapter 5 contains further information about the assessment of a person’s nutritional status. It describes the physical signs indicating nutritional status, assessment of food intake (food record, 24-hour recall), the dietary guidelines presented in the Canada Food Guide, and calculation of ideal body weight.

Stress Management and Stress Reduction Stress management and stress reduction are important aspects of health promotion. Studies have shown the negative effects of stress on health and a cause-and-effect relationship between stress and infectious diseases, traumatic injuries (e.g., motor vehicle crashes), and some chronic illnesses. Stress has become inevitable in contemporary societies in which demands for productivity have become excessive. More and more emphasis is placed on encouraging

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people to manage stress appropriately and to reduce the pressures that are counterproductive. Techniques such as relaxation training, exercise, and modification of stressful situations are often included in health promotion programs dealing with stress. Further information on stress management, including health risk appraisal and stress reduction methods such as biofeedback and the relaxation response, can be found in Chapter 6.

Physical Fitness Physical fitness is another important component of health promotion. Clinicians and researchers (Perry, Rosenfeld, Bennett, et al., 2007; Chao, Lian, Yu, et al., 2007) who have examined the relationship between health and physical fitness have found that a regular exercise program can promote health in the following ways: • Improve the function of the circulatory system and the lungs • Decrease cholesterol and low-density lipoprotein levels • Decrease body weight by increasing calorie expenditure • Delay degenerative changes such as osteoporosis • Improve flexibility and overall muscle strength and endurance An appropriate exercise program can have a positive effect on a person’s performance capacity, appearance, and level of stress and fatigue, as well as his or her general state of physical, mental, and emotional health. An exercise program is designed specifically for a given person, with consideration given to age, physical condition, and any known cardiovascular or other risk factors. Exercise can be harmful if it is not started gradually and increased slowly in accordance with a person’s response.

HEALTH PROMOTION THROUGHOUT THE LIFESPAN Health promotion is a concept and a process that extends throughout the lifespan. The health of a child can be affected either positively or negatively by the health practices of the mother during the prenatal period. Therefore, health promotion starts before birth and extends through childhood, adolescence, adulthood, and old age. Health promotion includes health screening. The College of Family Physicians of Canada has developed recommendations for periodic health examinations for both adults (Iglar, Katyal, Matthew, et al., 2008) and children (Greig, Constantin, Carsley, et al., 2010) that identify when specific screening interventions are appropriate. Table 4-3 presents general population guidelines.

Adolescents Health screening has traditionally been an important aspect of adolescent health care. The goal has been to detect health problems at an early age so that they can be treated at this time. Today, health promotion goes beyond the mere screening for disabilities and includes extensive efforts to promote positive health practices at an early age. Because health

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habits and practices are formed early in life, adolescents should be encouraged to develop positive health attitudes. For this reason, more and more programs are being offered to adolescents to help them develop good health habits. Although the negative results of practices such as smoking, risky sexual activities, alcohol and drug abuse, and poor nutrition are explained in these educational programs, emphasis is also placed on values training, self-esteem, and healthy lifestyle practices. The projects are designed to appeal to a particular age group, with emphasis on learning experiences that are fun, interesting, and relevant.

Young and Middle-Aged Adults Young and middle-aged adults represent an age group that not only expresses an interest in health and health promotion, but also responds enthusiastically to suggestions that show how lifestyle practices can improve health. Adults are frequently motivated to change their lifestyles in ways that are believed to enhance their health and wellness. Many adults who wish to improve their health turn to health promotion programs to help them make the desired changes in their lifestyles. Many have responded to programs that focus on topics such as general wellness, smoking cessation, exercise, physical conditioning, weight control, conflict resolution, and stress management. Because of the nationwide emphasis on health during the reproductive years, young adults actively seek programs that address prenatal health, parenting, family planning, and women’s health issues. Programs that provide health screening, such as those that screen for cancer, high cholesterol, hypertension, diabetes, abdominal aneurysm, and visual and hearing impairments, are quite popular with young and middle-aged adults. Programs that involve health promotion for people with specific chronic illnesses such as cancer, diabetes, heart disease, and pulmonary disease are also popular. Chronic disease and disability do not preclude health and wellness; rather, positive health attitudes and practices can promote optimal health for people who must live with the limitations imposed by their chronic illnesses and disabilities. Health promotion programs can be offered almost anywhere in the community. Common sites include local clinics, schools, colleges, recreation centres, churches, and even private homes. Health fairs are frequently held in civic centres and shopping malls. The outreach idea for health promotion programs has served to meet the needs of many adults who otherwise would not avail themselves of opportunities to strive toward a healthier lifestyle. The workplace has become a centre for health promotion activity for several reasons. Employers have become increasingly concerned about the rising costs of health care insurance to treat illnesses related to lifestyle behaviours, and they are also concerned about increased absenteeism and lost productivity. Some employers use health promotion specialists to develop and implement these programs, and others purchase packaged programs that have already been developed by health care agencies or private health promotion corporations. Programs offered at the workplace usually include employee health screening and counselling, physical fitness, nutritional awareness, work safety, and stress

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TABLE 4-3

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Routine Health Promotion Screening for Adults

Type of Screening

Suggested Time Frame

Routine health examination

Yearly

Blood chemistry profile

Baseline at age 20, then as mutually determined by patient and clinician

Complete blood count

Baseline at age 20, then as mutually determined by patient and clinician

Lipid profile

Baseline at age 20, then as mutually determined by patient and clinician

Hemoccult screening (fecal occult blood)

Yearly after age 50. If positive, follow-up with colonoscopy

Electrocardiogram

Baseline at age 40, then as mutually determined by patient and clinician

Blood pressure

Yearly, then as mutually determined by patient and clinician

Chest x-ray film

Baseline and as needed

Breast self-examination

Optional. However, it is important for both women and men to “be breast aware”—to know how their breasts look and feel, & what changes to look for (Canadian Breast Cancer Foundation, 2013).

Mammogram

Every 2 years for women 50 to 69 years and then as determined by patient and clinician. For women at increased risk due to family history of breast cancer, begin mammograms 10 years before date of onset in woman’s relative.

Clinical breast examination (CBE)

Yearly examination by a physician or nurse practitioner is questioned. “There is no direct scientific evidence that CBE reduces breast cancer death rates.” (Canadian Breast Cancer Foundation, 2013, p. 1). CBE and mammogram together slightly reduces breast cancer deaths but results in many false positives (Canadian Breast Cancer Foundation).

Gynecologic examination

Yearly

Pap smear

Every 1 to 3 years for sexually active women to age 70 years

Bone density screening

Based on identification of primary and secondary risk factors (prior to onset of menopause, if indicated)

Nutritional screening

As mutually determined by patient and clinician. (Includes weight, waist measurement, body mass index [BMI], if meeting the requirements of Canada’s Food Guide, and amount of sodium, fats, fibre, calcium, vitamin D taken daily.)

Digital rectal examination

Yearly for men after age 50

Colonoscopy

Every 5 years after age 50 or as mutually determined by patient and clinician

Prostate examination

Yearly

Prostate-specific antigen

Every 1 to 2 years after age 50

Testicular examination

Monthly self-examination

Skin examination

Yearly or as mutually determined by patient and clinician

Vision screening glaucoma

Every 2 to 3 years Baseline at age 40, then every 2 to 3 years until age 70, then yearly

Dental screening

Every 6 months

Hearing screening

As needed

Health risk appraisal

As needed

Adult Immunizations Hepatitis A & B (if not received as a child)

Series of three doses (now, 1 month later, then 5 months after the second date)—for lifetime

Influenza vaccine

Yearly

Pneumococcus

Once at age 60 years (earlier if have respiratory conditions)

Diphtheria, Pertussis, Tetanus

Every 10 years

Note: Any of these screenings may be performed more frequently if deemed necessary by the patient or recommended by the health care provider.

management and stress reduction. In addition, efforts are made to promote a safe and healthy work environment. Many large businesses provide exercise facilities for their employees and offer their health promotion programs to retirees.

Gerontologic Considerations Health promotion is as important for older people as it is for others. Although 80% of people older than 65 years have one or more chronic illnesses and many are

limited in their activity, older adults as a group experience significant gains from health promotion. Older adults are very health conscious, and most view their health positively and are willing to adopt practices that will improve their health and well-being. Although their chronic illnesses and disabilities cannot be eliminated, these adults can benefit from activities that help them maintain independence and achieve an optimal level of health. Various health promotion programs have been developed to meet the needs of older Canadians. Both public and private organizations continue to be responsive to

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nurse in assessing the student’s situation? What is the evidence base for offering information and health programs to help this young adult make appropriate health decisions and establish positive health behaviours? Identify the criteria used to evaluate the strength of the evidence for this practice. 2 After falling from a piece of machinery at a construction site, a 40-year-old man is recuperating at home after being in the hospital. A home care nurse visits three times a week to perform abdominal wound care. During a visit, the man reports that he misses his daily exercise routine and asks when he will be able to resume exercising. Determine the factors that influence his ability to engage in exercise. What factors support the overall relationship between fitness and health? Develop a plan to assist the man to maintain muscle tone and promote well-being. 3

FIGURE 4-2. Health promotion for the older adults includes physical

fitness. Here, a nurse teaches exercises at a seniors’ centre.

health promotion, and more programs that serve older adults are emerging. Many of these programs are offered by health care agencies, churches, community centres, senior citizen residences, and a variety of other organizations. The activities directed toward health promotion for the older adult are the same as those for other age groups: physical fitness and exercise, nutrition, safety, and stress management (Fig. 4-2).

A 74-year-old woman is volunteering at a local health fair being held at her granddaughter’s high school. When the nurse coordinator asks the woman if she would like to participate in the screening events and other informational activities, she replies, “No, thank you. I’m too old to think about health promotion. I just need to take care of the health problems that I already have.” What evidence supports the importance of health promotion strategies for the older adult? What information should you include in a discussion with this woman about promoting health in older adults? What type of information, available at various booths at the health fair, would be appropriate for this woman to obtain?

REFERENCES AND SELECTED READINGS

NURSING IMPLICATIONS By virtue of their expertise in health and health care and their long-established credibility with consumers, nurses play a vital role in health promotion. In many instances, they have initiated health promotion and health screening programs or have participated with other health care personnel in developing and providing wellness services in a variety of settings. As health care professionals, nurses have a responsibility to promote activities that foster well-being, self-actualization, and personal fulfillment. Every interaction with consumers of health care must be viewed as an opportunity to promote positive health attitudes and behaviours.

Critical Thinking Exercises 1 A female college student with a 2-year history of irritable bowel syndrome makes an appointment to speak with the nurse practitioner at the college health centre to discuss her increased use of antidiarrheal medication. The student states, “I’ve been very busy with my studies and several activities this semester, and I haven’t been eating right.” What health promotion components guide the

*Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Andrews, M. M., & Boyle, J. S. (2012). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Bastable, S. B. (2008). Nurse as educator: Principles of teaching and learning (3rd ed.). Sudbury, MA: Jones & Bartlett. **Becker, M. H. (Ed.). (1974). The health belief model and personal health behavior. Thorofare, NJ: Charles B. Slack. Carpenito-Moyet, L. J. (2013). Handbook of nursing diagnosis (14th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Chenoweth, K. H. (2011). Worksite health promotion (3rd ed.). Champaign, IL: Human Kinetics. Ebersole, P. & Touhy, T. A. (2006). Geriatric nursing: Growth of a specialty. New York, NY: Springer Publishing. Ebersole, P., Touhy, T. A., Hess, P., et al. (2008). Toward healthy aging: Human needs and nursing responses (7th ed.). St. Louis, MO: Mosby. Edelman, C. L., & Mandle, C. L. (2010). Health promotion throughout the life span (7th ed.). St. Louis, MO: Mosby. Giger, J. N., & Davidhizar, R. E. (2013). Transcultural nursing: Assessment and intervention (6th ed.). St. Louis, MO: Elsevier/Mosby. Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions & classifications, 2012–2014. Oxford, UK: Wiley-Blackwell. Keleher, H., MacDougall, C., & Murphy, B. (2011). Understanding health promotion. New York: Oxford University Press. **Lalonde, M. (1977). New perspectives on the health of Canadians: A working document. Ottawa, Canada: Minister of Supply and Services.

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Leininger, M. M., & McFarland, M. (2006). Culture care diversity and universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett. Miller, C. A. (2009). Nursing wellness in older adults (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pender, N. J., Murdaugh, C., & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson. Redman, B. K. (2007). The practice of patient education (10th ed.). Philadelphia, PA: Elsevier Health Sciences. Reutter, L., & Kushner, K. E. (2010). The broad scope of health promotion in health assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 3–25). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Reutter, L., & Kushner, K. E. (2012). The nurse’s role in health assessment. Jensen’s nursing health assessment. A best practice approach (1st ed., pp. 3–19). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Touhy, T. A. (2005). Ebersole & Hess’ Geriatric nursing and healthy aging (1st Canadian ed.). Toronto, ON: Elsevier Canada.

JOURNALS AND ELECTRONIC DOCUMENTS *Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceeding, 86(4), 304–314. Canadian Nurses Association (CNA). (2008). Code of Ethics for Registered Nurses. Ottawa, ON: Author. College and Association of Registered Nurse of Alberta (CARNA). (2013). Nursing Practice Standards. Edmonton, AB: Author. *Devries, K., Free, C., & Morison, L., et al. (2009). Factors associated with sexual behavior of Canadian Aboriginal young people and their implications for health promotion. American Journal of Public Health, 99(5), 855–862. **Becker, H. A., Stuifbergen, A. K., Oh, H., et al. (1993). The self-rated abilities for health practices scale: A health self-efficacy measure. Health Values, 17, 42–50. *Belguzar, K., Kayser, C., & Selim, K. (2007). Nonadherence with diet and fluid restriction and the level of perceived social support in patients receiving hemodialysis. Journal of Nursing Scholarship, 39(3), 243–248. Betz, C. (2007). Health literacy: The missing link in the provision of health care for children and their families. Journal of Pediatric Nursing, 22(4), 257–260. *Chao, M., Lian, L., Yu, C., et al. (2007). The effect of aerobic exercise training on blood indicators and physical fitness in middle-aged and older people with type 2 diabetes mellitus. Journal of Evidence-Based Nursing, 3(1), 34–43. *Chen, M., Shiao, Y., & Gau, Y. (2007). Comparison of adolescent health-related behavior in different family structures. Journal of Nursing Research, 15(1), 1–9. *de Jong, J., Lemmink, K., Stevens, M., et al. (2006). Six-month effects of the Groningen active living model (GALM) on physical activity, health and fitness outcomes in sedentary and underactive older adults aged 55–65. Patient Education & Counseling, 62(1), 132–141. *DiClemente, C. (2007). The transtheoretical model of intentional behavior change. Drugs & Alcohol Today, 7(1), 29–33. Doherty, W., & Mendenhall, T. (2006). Citizen health care: A model for engaging patients, families, and communities as coproducers of health. Families, Systems & Health: The Journal of Collaborative Family HealthCare, 24(3), 251–263. Greig, A., Constantin, E., Carsley, S., et al. (2010). Preventative health care visits for children and adolescents aged six to seventeen years: The Greig Health Record. Pediatric Child Health, 15(3), 157– 159.

*Guruge, S., & Collins, E. (2008). Working with immigrant women: Issues and strategies for mental health professionals. Toronto, ON: Canadian Center for Addiction and Mental Health. *Haines, D. J., Davis, L., Rancour, P., et al. (2007). A pilot intervention to promote walking and wellness and to improve the health of college faculty and staff. Journal of American College Health, 55(4), 219–225. *Harrington, K., Franklin, F., Davies, S., et al. (2005). Implementation of a family intervention to increase fruit and vegetable intake: The Hi5+ experience. Health Promotion Practice, 6(2), 180–189. Health Quality Council of Alberta. (2011). A citizen’s guide to health indicators. Toronto, ON: Author. Ho, P., Bryson, C., & Rumsfeld, J. (2009). Medication adherence: Its importance in cardiovascular outcomes. Circulation, 119, 3028–3035. *Hoffman-Goetz, L. & Donelle, L. (2007). Chat room computer-mediated support on health issues for Aboriginal women. Health Care for Women International, 28(4), 397–418. Iglar, K., Katyal, S., Matthew, R., et al. (2008). Complete health checkup for adults: Update on the Preventive Care Checklist Form. Canadian Family Physician, 54(1), 84–88 *Kim, Y. (2007). Application of the transtheoretical model to identify psychological constructs influencing exercise behavior: A questionnaire survey. International Journal of Nursing Studies, 44(6), 936–944. *Kushner, K. (2007). Meaning and action in employed mothers’ health work. Journal of Family Nursing, 13(1), 33–55. Latif, S., & McNicoll, L. (2009). Medication and non-adherence in the older adult. Geriatirics for the Practicing Physician, 92(12), 418–419. Law, M., Cheng, L., Dhalla, I., et al. (2012). The effect of cost adherence to prescription medications in Canada. Canadian Medical Association, doi:10.1503/cmaj.111270. Loke, Y., Hinz, I., Wang, X., et al. (2012). Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults. Annals of Pharmacotheraputics, 46(6), 863–872. London, F. (2007). Patient education: Teaching patients about wound care. Home Healthcare Nurse, 25(8), 497–500. Nakasato, Y. R., & Carnes, B. A. (2006). Health promotion in older adults: Promoting successful aging in primary care settings. Geriatrics, 61(4), 27–31. *Perry, C., Rosenfeld, A., Bennett, J., et al. (2007). Heart-to-Heart: Promoting walking in rural women through motivational interviewing and group support. Journal of Cardiovascular Nursing, 22(4), 304–312. *Rovniak, L., Hovell, M., Wojcik, J., et al. (2005). Enhancing theoretical fidelity: An e-mail-based walking program demonstration. American Journal of Health Promotion, 20(2), 85–95. *Rowley, C., Dixon, L., & Palk, R. (2007). Promoting physical activity: Walking programs for mothers and children. Community Practitioner, 80(3), 28–32. Seals, J. (2007). Integrating the transtheoretical model into the management of overweight and obese adults. Journal of the American Academy of Nurse Practitioners, 19(2), 63–71. Vik, S., Hogan, D., Patten, S., et al. (2006). Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults. Drugs and Aging, 23(4), 345–356.

RESOURCES Canadian Nurses Association: https://www.cna-aiic.ca Canadian Task Force on Preventative Health Care: http://www.ctfphc.org College of Family Physicians of Canada: http://cfpc.ca Health Canada: http://www.hc-sc.gc.ca Public Health Agency of Canada: http://www.phac-aspc.gc.ca/ Centers for Disease Control and Prevention: www.cdc.gov Health Promotion for Women with Disabilities, Villanova University College of Nursing: www.nurseweb.villanova.edu/WomenWith Disabilities/welcome.htm World Health Organization, http://www.who.int/en/

CHAPTER

5 Adult Health and Nutritional Assessment Adapted by Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify ethical considerations necessary for protecting a person’s rights related to data collected in the health history and physical assessment. 2. Describe the components of the health history. 3. Apply culturally competent and culturally safe interviewing skills and techniques to conduct a successful health history, physical examination, and nutritional assessment. 4. Identify genetic aspects nurses incorporate into the health history and physical assessment. 5. Identify modifications needed to obtain a health history and conduct a physical assessment for a person with a disability. 6. Describe the techniques of inspection, palpation, percussion, and auscultation to perform a basic physical assessment. 7. Discuss the techniques of measurement of body mass index, biochemical assessment, clinical examination, and assessment of food intake to assess a person’s nutritional status. 8. Describe factors that may contribute to altered nutritional status in high-risk groups such as adolescents and older adults. 9. Conduct a health history and physical and nutritional assessment of a person at home.

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The ability to assess patients is a skill integral to nursing, regardless of the practice setting. In all settings in which nurses interact with patients and provide care, eliciting a complete health history and using appropriate assessment skills are critical to identifying physical and psychological issues and concerns experienced by the patient. As the first step in the nursing process, patient assessment is necessary to obtain data that enable the nurse to make an accurate nursing diagnosis, identify and implement appropriate interventions, and assess their effectiveness. This chapter includes the complete health history and basic assessment techniques. Because a patient’s nutritional status is an important factor in overall health and well-being, a section on nutritional assessment is also addressed.

CONSIDERATIONS FOR CONDUCTING A HEALTH HISTORY AND PHYSICAL ASSESSMENT The Role of the Nurse All members of the health care team use their unique skills and knowledge to contribute to the resolution of patient problems by first obtaining some level of history and assessment (Skillen, 2012a). Because the focus of each member of the health care team is unique, a variety of health history and physical examination formats have been developed. Regardless of the format, the information obtained by the nurse complements the data obtained by other members of the health care team and focuses on nursing’s unique concerns for the patient. In health assessment, the nurse obtains the patient’s health history and performs a physical assessment, which can be carried out in a variety of settings, including acute care, clinic or outpatient office, schools, long-term care, correctional facility, or home. Nurses use a growing list of nursing diagnoses to identify and categorize patient issues that nurses have the knowledge, skills, and responsibility to treat independently (Herdman, 2012).

Communicating Effectively People who seek health care for a specific concern are often anxious. Their anxiety may be increased by fear about potential diagnoses, possible disruption of lifestyle, and other concerns. With this in mind, the nurse attempts

FIGURE 5-1. A comfortable, relaxed atmosphere and an attentive interviewer are essential for a successful clinical interview.

to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient’s responses to questions about health issues (Fig. 5-1). When obtaining a health history or performing a physical examination, the nurse is aware of his or her own nonverbal communication, as well as that of the patient. The nurse takes into consideration the patient’s educational and cultural background as well as language proficiency. Questions and instructions to the patient are phrased in a way that is easily understandable. Technical terms and medical jargon are avoided. In addition, the nurse considers the patient’s disabilities or impairments such as hearing, vision, cognitive, and physical limitations. At the end of the assessment, the nurse may summarize and clarify the information obtained and ask the patient if he or she has any questions; this gives the nurse and the patient the opportunity to correct misinformation and add facts that may have been omitted.

Ethical Use of History or Physical Examination Data Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used (Stephen, 2012a). It is also important that the person be

Glossary auscultation: listening to sounds produced within different body structures created by the movement of air or fluid body mass index (BMI): a calculation done to estimate the amount of body fat of a person health history: a series of questions that provides an overview of the patient’s current health status

inspection: visual assessment of different aspects of the patient palpation: examination of different organs of the body using the sense of touch percussion: the use of sound to examine different organs of the body

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aware that the decision to participate is voluntary. A private setting for the history interview and physical examination promotes trust and encourages open, honest communication. After the history and examination are completed, the nurse selectively records the data pertinent to the patient’s health status (Stephen, 2012b). This written record of the patient’s history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. This protects confidentiality and promotes professional conduct.

Increasing Use of Technology The use of technology to augment the information-gathering process has become an increasingly important aspect of obtaining a health history and physical examination. Computerization of health records is becoming more common. Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs; therefore, their implementation is moving forward on a global scale (Stephen, 2012b).

HEALTH HISTORY The health history is a series of questions used to provide an overview of the current health status of the patient. When obtaining the health history, attention is focused on the impact of psychosocial, ethnic, and cultural background on a person’s health, illness, and health promotion behaviours. The interpersonal and physical environments, as well as the person’s lifestyle and activities of daily living, are explored in depth. Many nurses are responsible for obtaining a detailed history of the person’s current health problems, past medical history, and family history and a review of the person’s functional status. This results in a total health profile that focuses on health as well as illness. The format of the health history traditionally combines the medical history and the nursing assessment, although formats based on nursing frameworks, such as functional health patterns, have also become standard. Both the review of systems and the patient profile are expanded to include individual and family relationships, lifestyle patterns, health practices, and coping strategies. These components of the health history are the basis of nursing assessment and can be easily adapted to address the needs of any patient population in any setting, institution, or agency (Stephen, 2012a). Combining the information obtained by the physician and the nurse into one health history prevents duplication of information and minimizes efforts on the part of the patient to provide this information repeatedly. This also encourages collaboration among members of the health care team who share in the collection and interpretation of the data.

The Informant The informant, or the person providing the health history, may not always be the patient, as in the case of a

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developmentally delayed, mentally impaired, disoriented, confused, unconscious, or comatose patient. The interviewer assesses the reliability of the informant and the usefulness of the information provided. For example, a patient who is disoriented is often unable to provide reliable information; people who use alcohol and illicit drugs often deny using these substances. The interviewer must make a clinical judgment about the reliability of the information (based on the context of the entire interview) and include this assessment in the record. Chart 5-1 provides special considerations for obtaining a health history from an older adult.

Components of the Health History When a patient is seen for the first time by a member of the health care team, the first requirement is that baseline information be obtained (except in emergency situations). The sequence and format of obtaining data about a patient may vary, but the content, regardless of format, usually addresses the same general topics. A traditional approach includes the following: biographical data, chief concern, present health concern (or present illness), past history, family history, review of systems, and patient profile.

CHART 5-1

Health Assessment in the Older Adult A health history is obtained from older patients in a calm, unrushed manner. Because of the increased incidence of impaired vision and hearing in the older adult, lighting needs to be adequate but not glaring, and distracting noises need to be kept to a minimum. The interviewer assumes a position that enables the person to read lips and facial expressions. People who usually use a hearing aid are asked to use it during the interview. The interviewer also recognizes that there is wide diversity among older adults and that differences exist in health practices, gender, income, and functional status (Skillen, 2012a). Older people often assume that new physical problems are a result of age rather than a treatable illness. In addition, the signs and symptoms of illness in older adults are often more subtle than those in younger people and may go unreported. Therefore, a question such as, “What interferes most in your daily activities?” may be useful in focusing the clinical evaluation (Soriano, Fernandes, Cassel, et al., 2007). Special care is taken in obtaining a complete history of medications used, because many older people take many different kinds of prescription and over-the-counter (OTC) medications. Although older people may experience a decline in mental function, it should not be assumed that they are unable to provide an adequate history (Anderson, Hunter, & Bickley, 2010). Nevertheless, including a member of the family in the interview process (e.g., spouse, adult child, sibling, caretaker) may validate information and provide missing details. However, this should be done after obtaining the patient’s permission. Further details about assessment of the older adult are provided in Chapter 13.

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Biographical Data Biographical information puts the patient’s health history into context. This information includes the person’s name, address, age, gender, marital status, occupation, and ethnic origins. Most interviewers prefer to wait to ask more personal questions later in the interview, when more trust and confidence have been established or until a patient’s immediate or urgent needs have been addressed. A patient who is in severe pain or has another urgent condition is unlikely to have a great deal of patience for an interviewer who is more concerned about marital or occupational status than with quickly addressing the issue at hand.

Chief Concern The chief concern is the issue that brings a person to the attention of the health care professional. Questions such as, “Why have you come to the health centre today?” or “Why were you admitted to the hospital?” usually elicit the chief concern. In the home setting, the initial question might be, “What is bothering you most today?” When an issue is identified, the person’s exact words are usually recorded in quotation marks. However, a statement such as, “My doctor sent me,” should be followed up with a question that identifies the probable reason why the person is seeking health care; this reason is then identified as the chief concern (Stephen, 2012a).

Present Health Concern or Illness The history of the present health concern or illness is the single most important factor in helping the health care team arrive at a diagnosis or determine the person’s needs. The physical examination is helpful but often only validates the information obtained from the history. A careful history assists in correct selection of appropriate diagnostic tests. Although diagnostic test results can be helpful, they often support rather than establish the diagnosis. If the present illness is only one episode in a series of episodes, the entire sequence of events is recorded. For example, a history from a patient whose chief concern is an episode of insulin shock describes the entire course of the diabetes to put the current episode in context. The details of the health concern or present illness are described from onset until the time of contact with the health care team. These facts are recorded in chronologic order, beginning with, for example, “The patient was in good health until . . . ” or “The patient first experienced abdominal pain 2 months prior to seeking help.” The history of the present illness or health concern includes such information as the date and manner (sudden or gradual) in which the problem occurred, the setting in which the concern occurred (at home, at work, after an argument, after exercise), manifestations of the problem, and the course of the illness or concern. This includes self-treatment (including complementary and alternative therapies), medical interventions, progress and effects of treatment, and the patient’s perceptions of the cause or meaning of the problem. Specific symptoms (pain, headache, fever, change in bowel habits) are described in detail, along with the location and radiation (if pain), quality, severity, and duration.

The interviewer also asks whether the concern is persistent or intermittent, what factors aggravate or alleviate it, and whether any associated manifestations exist. Associated manifestations are symptoms that occur simultaneously with the chief concern. The presence or absence of such symptoms may shed light on the origin or extent of the concern, as well as on the diagnosis. These symptoms are referred to as significant positive or negative findings and are obtained from a review of systems directly related to the chief concern. For example, if a patient reports a vague symptom such as fatigue or weight loss, all body systems are reviewed and included in this section of the history. If, on the other hand, a patient’s chief concern is chest pain, only the cardiopulmonary and gastrointestinal systems may be included in the history of the present illness. In either situation, both positive and negative findings are recorded to define the concern further.

Past Health History A detailed summary of a person’s past health is an important part of the health history (Stephen, 2012a). After determining the general health status, the nurse inquires about the immunization status according to the recommendations of the adult immunization schedule and records the dates of immunization (if known) (Public Health Agency of Canada [PHAC], 2012a,b). The nurse also inquires about any known allergies to medications or other substances, along with the type of allergy and adverse reactions. Other relevant material includes information, if known, about the patient’s last physical examination, chest x-ray, electrocardiogram, eye examination, hearing test, dental checkup (Chart 5-2), Papanicolaou (Pap) smear and mammogram (if female), digital rectal examination of the prostate gland (if male), bone density testing, colon cancer screening, and any other pertinent tests. The nurse then discusses previous illnesses and records negative as well as positive responses to a list of specific diseases. Dates of illness or the age of the patient at the time, as well as the names of the primary health care professional and hospital, the diagnosis, and the treatment are noted. The nurse elicits a history of the following areas: • Childhood illnesses—rubeola, rubella, polio, whooping cough, mumps, measles, chickenpox, scarlet fever, rheumatic fever, strep throat, meningitis • Adult illnesses • Psychiatric illnesses • Injuries—burns, fractures, head injuries • Hospitalizations • Surgical and diagnostic procedures • Current medications—prescription, over-the-counter (OTC), home remedies, complementary, and alternative therapies • Use of alcohol and other drugs • Smoking If a particular hospitalization or major medical intervention is related to the present illness, the account of it is not repeated; rather, the report refers to the appropriate part of the record, such as “See history of present illness” on the data sheet.

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NURSING RESEARCH PROFILE

Chart 5-2. Oral Health Assessment Chen, C. C. H., Chyun, D. A., Li, C., et al. (2007). A singleitem approach to screening elders for oral health assessment. Nursing Research, 56 (5), 332–338. Purpose When performing health assessments for older patients, nurses are aware that oral health is an important indicator of overall health. The main purpose of this study was to evaluate the usefulness of asking the question, “Do you have regular dental checkups?” as a means of determining whether an oral health assessment or further referral is indicated for older adults. Design The study was a secondary analysis using a nutritional survey of 240 older participants who were living in the community. A gerontologic nurse practitioner was trained to rate each participant on three oral indices: the Kayser-Jones Brief Oral Health Status Examination, the self-reported General Oral Health Assessment Index, and the number of remaining teeth. During an assessment in their home, the participants were also asked about their pattern of dental checkups (regular vs. irregular).

Findings Approximately half (55%) of participants reported a dental visit within the past year for any reason, but only 81 (33.8%) reported having regular dental checkups. For participants with teeth (n = 147), an irregular dental checkup was associated with lower educational level, Protestant faith, and black race. Participants with a pattern of irregular dental checkups scored lower on all three oral indices. The question, “Do you have regular dental checkups?” was found to be valid for identifying those with teeth and good oral health; it was less effective for those participants without teeth. Nursing Implications During the general health assessment for older adults, the nurse is aware that a single question, “Do you have regular dental checkups?” can be used effectively to identify those with teeth and good oral health and not in need of further oral health assessment or referral. This one question was less effective in identifying those in need of further oral health assessment or referral.

Family History To identify diseases that may be genetic, communicable, or possibly environmental in origin, the nurse asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). In general, the following conditions are included: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. One of the easiest methods of recording such data is by using the family tree, or genogram (Fig. 5-2). The results of genetic testing or screening, if known, are recorded. Chart 5-3 provides genetic considerations related to health assessment; see also Chapter 9 for a detailed discussion of genetics.

75 Lung cancer Alzheimer dementia

52 Unknown cause

52 Brain tumour

45 Breast cancer

Review of Systems The review of systems includes an overview of general health as well as symptoms related to each body system. Questions are asked about each of the major body systems for information about past and present symptoms. Reviewing each body system helps reveal relevant data. Negative as well as positive answers are recorded. If a patient responds positively to questions about a particular system, further questioning is used and the information is analyzed carefully. If any illnesses were previously mentioned or recorded, it is not necessary to repeat them in this part of the history. Instead, reference is made to the appropriate place in the health history where the information can be found.

88 Heart disease Osteoporosis

78 Breast cancer

68 Breast cancer Diabetes

43 A+W

47

48 Multiple sclerosis

Key: Male Female Deceased

3 mos 12 15 17 SIDS A + W A + W A + W

A + W Alive and well Patient FIGURE 5-2. Diagram (called a genogram) used to record history of

family members, including their age and cause of death or, if living, their current health status.

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GENETICS IN NURSING PRACTICE

Chart 5-3. Genetics Aspects of Health Assessment Nurses incorporate a genetics focus into the following health assessments: • Family history—assess for genetics-related risk factors. • Cultural, social, and spiritual assessment—assess for individual and family perceptions and beliefs around genetics topics.

A review of systems can be organized in a formal checklist, which becomes a part of the health history. One advantage of a checklist is that it can be easily audited and is less subject to error than a system that relies heavily on the interviewer’s memory.

Patient Profile In the patient profile, more biographical information is gathered. A complete composite, or profile, of the patient is critical to analysis of the chief concern and of the

• Physical assessment—assess for clinical features that may

suggest a genetic condition is present (e.g., unusually tall stature—Marfan syndrome). • Ethnic background—since many conditions are more common in specific ethnic populations, the nurse gathers information about ethnic background (e.g., Tay–Sachs disease in Ashkenazi Jewish populations or thalassemia in Southeast Asian populations).

person’s ability to deal with the concern. A complete patient profile is summarized in Chart 5-4. At this point in the interview, the information elicited is highly personal and subjective. People are encouraged to express feelings honestly and to discuss personal experiences. It is best to begin with general, open-ended questions and to move to direct questioning when specific facts are needed. Interviews that progress from information that is less personal (birthplace, occupation, education) to information that is more personal (sexuality, body image, coping abilities) often reduce anxiety.

CHART 5-4

Patient Profile Past Events Related to Health Place of birth Places lived Significant childhood/adolescent experiences

Education and Occupation Jobs held in past Current position/job Length of time at position Educational preparation Work satisfaction and career goals

Financial Resources Income Coverage for prescription medications, dental care, treatments (massage, physical therapy, acupuncture, etc.)

Environment Physical—living arrangements (type of housing, neighbourhood, presence of hazards) Spiritual—extent to which religion is a part of individual’s life; religious beliefs related to perception of health and illness; religious practices Interpersonal—ethnic background (language spoken, customs and values held, practices used to maintain health or to cure illness); family relationships (family structure, roles, communication patterns, support system); friendships (quality of relationship)

Lifestyle Patterns Sleep (time person retires, hours per night, comfort measures, awakens rested) Exercise (type, frequency, time spent) Nutrition (24-hour diet recall, idiosyncrasies, restrictions) Recreation (type of activity, time spent)

Caffeine (coffee, tea, cola, chocolate–kind), amount Smoking (cigarette, pipe, cigar, marijuana–kind), amount per day, number of years, desire to quit Alcohol–kind, amount, pattern over past year Drugs-kind, amount, route of administration

Physical or Mental Disability Presence of a disability (physical or mental) Effect of disability on function and health access Accommodations needed to support functioning

Self-Concept View of self in present View of self in future Body image (level of satisfaction, concerns)

Sexuality Perception of self as a man or woman Quality of sexual relationships Concerns related to sexuality or sexual functioning

Risk for Abuse Physical injury in past Afraid of partner, caregiver, or family member Refusal of caregiver to provide necessary equipment or assistance

Stress and Coping Response Major concerns or problems at present Daily “hassles” Past experiences with similar problems Past coping patterns and outcomes Present coping strategies and anticipated outcomes Individual’s expectations of family/friends and health care team in problem resolution

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A general patient profile consists of the following content areas: past life events related to health, education and occupation, environment (physical, spiritual, cultural), lifestyle (patterns and habits), presence of a physical or mental disability, self-concept, sexuality, risk for abuse, and stress and coping response.

Past Life Events Related to Health The patient profile begins with a brief life history. Questions about place of birth and past places of residence help focus attention on the earlier years of life. Personal experiences during childhood or adolescence that have special significance may be elicited by asking a question such as, “Was there anything that you experienced as a child or adolescent that would be helpful for me to know about?” The interviewer’s intent is to encourage the patient to make a quick review of his or her earlier life, highlighting information of particular significance. Although many patients may not recall anything significant, others may share information such as a personal achievement, a failure, a developmental crisis, or an instance of physical, emotional, or sexual abuse. The life history includes a brief medication history as appropriate for the patient.

Education and Occupation Inquiring about current occupation can reveal much about a person’s economic status and educational preparation. A statement such as, “Tell me about your job,” often elicits information about role, job tasks, and satisfaction with the position. Direct questions about past employment and career goals may be asked if the person does not provide this information. It is important to learn about a person’s educational background. Asking a person what kind of educational requirements were necessary to attain his or her present job is a more sensitive approach than asking whether he or she graduated from high school. Information about the patient’s general financial status may be obtained by questions such as, “Do you have any financial concerns at this time?” or “Sometimes there just doesn’t seem to be enough money to make ends meet. Are you finding this to be true?”

Environment The concept of environment includes a person’s physical environment and its potential hazards, spiritual awareness, cultural background, interpersonal relationships, and support system. PHYSICAL ENVIRONMENT. Information is elicited about the type of housing (apartment, duplex, singlefamily) in which the person lives, its location, the level of safety and comfort within the home and neighbourhood, and the presence of environmental hazards (e.g., isolation, potential fire risks, inadequate sanitation). If the patient has a disability, the nurse asks questions about the patient’s home environment. If the patient is homeless or living in a shelter the patient’s environment assumes special importance (Crowe, 2007). SPIRITUAL ENVIRONMENT. The term spiritual environment refers to the degree to which a person thinks about

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or contemplates his or her existence, accepts challenges in life, and seeks and finds answers to personal questions. Spirituality may be expressed through identification with a particular religion. Spiritual values and beliefs often direct a person’s behaviour and approach to health issues and can influence responses to sickness (Skillen, 2012b). Illness may create a spiritual crisis and can place considerable stress on a person’s internal resources and beliefs. Inquiring about spirituality can identify possible support systems as well as beliefs and customs that need to be considered in planning care. Information is gathered about the extent to which religion is a part of the person’s life as well as religious beliefs and practices related to health and illness. A spiritual assessment may involve asking the following questions: • • • •

Is religion or God or a higher power important to you? If yes, in what way? If no, what is the most important thing in your life? Are there any religious practices that are important to you? • Do you have any spiritual concerns because of your present health condition? CULTURAL ENVIRONMENT. When obtaining the health history, the person’s cultural and religious backgrounds are taken into account. Cultural attitudes and beliefs about health, illness, health care, hospitalization, the use of medications, and use of complementary and alternative therapies, which are derived from personal experiences, vary according to ethnic, cultural, and religious background. A person from another culture may have different views of personal health practices from those of the health care professional (Skillen, 2012c). See Chapter 9 for more cultural considerations. The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. They are expressed through language, dress, dietary choices, and role behaviours; in perceptions of health and illness; and in health-related behaviours. The influence of these beliefs and customs on how a person reacts to health issues and interacts with health care providers cannot be underestimated. The following questions may assist in obtaining relevant information:

• Where did your parents or ancestors come from? When? • What language do you speak at home? • Are there certain customs or values that are important to you? • Is there anything special you do to keep in good health? • Do you have any specific practices for treating illness? FAMILY RELATIONSHIPS AND SUPPORT SYSTEM. An assessment of family structure (members, ages, and roles), patterns of communication, and the presence or absence of a support system is an integral part of the patient profile. Although the traditional family is recognized as a mother, a father, and children, many different types of living arrangements exist within our society. “Family” may mean two or more people bound by emotional ties or commitments. Live-in companions, roommates, and close friends can all play a significant role in a person’s support system.

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Lifestyle The lifestyle section of the patient profile provides information about health-related behaviours. These behaviours include patterns of sleep, exercise, nutrition, and recreation, as well as personal habits such as smoking, use of alcohol, caffeine, and the use of illicit drugs. Although most people readily describe their exercise patterns or recreational activities, many are unwilling to report their smoking, alcohol use, and illicit drug use, and many deny or understate the degree to which they use such substances. Questions such as, “What kind of alcohol do you enjoy drinking at a party?” may elicit more accurate information than, “Do you drink?” The specific type of alcohol (e.g., wine, liquor, beer) and the amount ingested per day or per week (e.g., 500 mL of whiskey daily for 2 years) should be described (Stephen, 2012a). If alcohol abuse is suspected, additional information may be obtained by using common alcohol screening questionnaires such as the CAGE (Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers) (Ewing, 1984), AUDIT (Alcohol Use Disorders Identification Test), TWEAK (Tolerance, Worry, Eye-opener, Amnesia, Kut down) (Chan, Pristach, Welte, et al., 1993), or SMAST (Short Michigan Alcohol Screening Test). Chart 5-5 shows the CAGE Questions Adapted to Include Drugs (CAGEAID). The MAST (Michigan Alcohol Screening Test) has been updated to include drug use and has a geriatric version (The New York State Office of Alcoholism and Substance Abuse Services [OASAS], 2007). Similar questions can be used to elicit information about smoking and caffeine consumption. Questions about illicit drug use follow naturally after questions about smoking, caffeine consumption, and alcohol use. A nonjudgmental approach makes it easier for a person to respond truthfully and factually. If street names or unfaCHART 5-5

Assessing for Alcohol or Drug Use CAGE Questions Adapted to Include Drugs (CAGEAID)* Have you felt you ought to cut down on your drinking (or drug use)? _____Yes _____No Have people annoyed you by criticizing your drinking (or drug use)? _____Yes _____No Have you felt bad or guilty about your drinking (or drug use)? _____Yes _____No Have you ever had a drink (or used drugs) first thing in the morning to steady your nerves or get rid of a hangover (or to get the day started)? _____Yes _____No *Boldface text shows the original CAGE questions; boldface italic text shows modifications of the CAGE questions used to screen for drug disorders. In a general population, two or more positive answers indicate a need for more in-depth assessment. From Fleming, M. F., & Barry, K. L. (1992). Addictive disorders. St. Louis, MO: Mosby; and Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252(14), 1905–1907.

miliar terms are used to describe drugs, the person is asked to define the terms used. Investigation of lifestyle also includes questions about complementary and alternative therapies. According to the Public Health Agency of Canada (PHAC), 70% of Canadians use complementary or alternative therapies (PHAC, 2008). Other types of therapies include: special diets, prayer, visualization or guided imagery, massage, acupuncture, meditation, herbal products, and many others. Marijuana is used for management of symptoms, especially pain, in a number of chronic conditions.

Disability The general patient profile contains questions about any hearing, vision, or other type of physical disability. Mental, sensory, or cognitive disabilities are inquired about as well. The presence of an obvious physical limitation (e.g., using crutches to walk or using a wheelchair to get around) necessitates further investigation. The etiology of the disability should be elicited, and the length of time the patient has had the disability, the impact on function, and health access are important to assess (Smeltzer, ShartsHopko, Ott, et al., 2007). Chart 5-6 presents specific issues that the nurse considers when obtaining health histories and conducting physical assessments of patients with disabilities. See Chapter 12.

Self-Concept Self-concept refers to a person’s view of himself or herself, an image that has developed over many years. To assess self-concept, the interviewer might ask how a person views life, using a question such as, “How do you feel about your life in general?” A person’s self-concept can be threatened very easily by changes in physical function or appearance or other threats to health. The impact of certain medical conditions or surgical interventions, such as a colostomy or a mastectomy, can threaten body image. The question, “Do you have any particular concerns about your body?” may elicit useful information about self-image.

Sexuality No area of assessment is more personal than the sexual history. Health care professionals are frequently uncomfortable with such questions and ignore this area of the patient profile or conduct a very cursory interview about this subject. Lack of knowledge about sexuality, preconceived notions (e.g., assuming all people are heterosexual), and anxiety about one’s own sexuality may hamper the interviewer’s effectiveness in dealing with this subject (Stephen, 2012a). Sexual assessment can be approached at the end of the interview, at the time interpersonal or lifestyle factors are assessed, or it may be easier to discuss sexuality as a part of the genitourinary history within the Review of Systems. In female patients, a discussion of sexuality would follow questions about menstruation. In male patients, a similar discussion would follow questions about the urinary system. Obtaining the sexual history provides an opportunity to discuss sexual matters openly and gives the person

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CHART 5-6

Health Assessment of People With Disabilities Overview People with disabilities are entitled to the same level of health assessment and physical examination as people without disabilities. The nurse needs to be aware of the patient’s disabilities or impairments (hearing, vision, cognitive, and physical limitations) and take these into consideration when obtaining a health history and conducting a physical assessment. It is appropriate to ask the patient what assistance he or she needs rather than assuming that help is needed for all activities or that, if assistance is needed, the patient will ask for it.

Health History Communication between the nurse and the patient is essential. To ensure that the patient is able to respond to assessment questions and provide needed information, interpreters, assistive listening devices, or other alternative formats (e.g., Braille, large-print forms) may be required. When interpreters are needed, interpretation services should be arranged. Health care facilities have a responsibility to provide these services without charge to the patient. Family members (especially children) should not be used as interpreters, because doing so violates the patient’s right to privacy and confidentiality. The nurse speaks directly to the patient and not to family members or others who have accompanied the patient. If the patient has vision or hearing loss, usual tone and volume of the voice should be used when conducting the assessment. The patient should be able to see the nurse’s face clearly during the health history, so that speech reading and nonverbal clues can be used to aid communication. The health history addresses general health issues that are important to all patients, including sexual history and risk for abuse. It also addresses the impact of the patient’s disability on health issues and access to care and the effect of the patient’s current health concern on his or her disability. The nurse should verify what the patient has said; if the patient has difficulty communicating verbally, the nurse should ask for clarification rather than assume that it is too difficult for the patient to do so. Most people would rather be asked to explain again than run the risk of being misunderstood (Smeltzer et al., 2007).

Physical Examination Inaccessible facilities remain a major barrier to health care for people with disabilities. Barriers include lack of ramps and grab bars, inaccessible restrooms, small examination rooms, and examination tables that cannot be lowered to allow the patient to move himself or herself onto, or be transferred easily and safely to, the examination table. The patient may need

permission to express sexual concerns to an informed professional. The interviewer is nonjudgmental and uses language appropriate to the patient’s age and background (Stephen, 2012a). Determining whether a person is sexually active should precede any attempts to explore issues related to sexuality and sexual function. The assessment begins with an orienting sentence such as, “Next, I would like to ask about your sexual health and practices.” Such an opening may lead to a discussion of concerns related to sexual expression or the quality of a relationship, or to questions about contraception, risky sexual behaviours,

help getting undressed for the physical examination (and dressed again), moving on and off the examination table, and maintaining positions usually required during physical examination manoeuvres. It is important to ask the patient what assistance is needed. If the patient has impaired sensory function (e.g., lack of sensation, hearing or vision loss), it is important to inform the patient that you will be touching him or her. Furthermore, it is important to explain all procedures and manoeuvres. Gynecologic examinations should not be deferred because a patient has a disability or is assumed to be sexually inactive. Explanations of the examination are important for all women, and even more so for women with disabilities, because they may have had previous negative experiences. Slow, gentle moving and positioning of the patient for the gynecologic examination and warming the speculum before attempting insertion often minimize spasticity in women with neurologically related disabilities.

Health Screening and Testing Many people with disabilities report that they have not been weighed for years or even decades because they are unable to stand for this measurement. Alternative methods (e.g., use of wheelchair scales) are needed to monitor weight and body mass index. This is particularly important because of the increased incidence of obesity and its effects on health status and transfer of persons with disabilities. Patients with disabilities may require special assistance if urine specimens are to be obtained as part of the visit. They are often able to suggest strategies to obtain urine specimens based on previous experience. If it is necessary for the nurse to wear a mask during a procedure or if the patient is unable to see the face of the nurse during a procedure, it is important to explain the procedure and the expected role of the patient ahead of time. If the patient is unable to hear or is unable to communicate with the nurse or other health care provider verbally during an examination or diagnostic test, a method of communication (e.g., signaling the patient by tapping his or her arm, signaling the nurse by using a bell) is established beforehand. Inaccessible facilities have resulted in decreased participation of people with disabilities in recommended preventive screening, including gynecologic examinations, mammograms, and bone density testing (Smeltzer, Zimmerman, & Capriotti, 2005). Therefore, it is important to ask about health screening and recommendations for screening. In addition, people with disabilities should be asked about their participation in health promotion activities, because inaccessible environments may limit their participation in exercise, health programs, and other health promotion efforts.

and safer sex practices. Examples of other questions are, “How many sexual partners have you had?” and “Are you satisfied with your sexual relationships?” Care should be taken to initiate conversations about sexuality with older patients and patients with disabilities and not to treat them as asexual people. Questions are worded in such a way that the person feels free to discuss his or her sexuality regardless of marital status or sexual preference. Direct questions are usually less threatening when prefaced with such statements as, “Most people feel that . . .” or “Many people worry about. . . .”

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This suggests the normalcy of such feelings or behaviour and encourages the person to share information that might otherwise be omitted because of fear of seeming “different.” If a person answers abruptly or does not wish to carry the discussion any further, then the nurse moves to the next topic. However, introducing the subject of sexuality indicates to the person that a discussion of sexual concerns is acceptable and can be approached again in the future if so desired. Further discussion of the sexual history is presented in Chapters 47 and 50.

Risk for Abuse Physical, sexual, and psychological abuse is a topic of growing importance in today’s society (Stephen, 2012c). Such abuse occurs to people of both genders, of all ages, and from all socioeconomic, ethnic, and cultural groups. Patients rarely discuss this topic unless specifically asked about it. In fact, research shows that the majority of women currently in an abusive relationship have never told a health care professional. Therefore, it is important to ask direct questions, such as: • Is anyone physically hurting you? Or forcing you to have sexual activities? • Has anyone ever hurt you physically? Or threatened to do so? • Are you ever afraid of anyone close to you (your partner, caregiver, or other family members)? Patients who are older or have disabilities are at increased risk for abuse and should be asked about it as a routine part of assessment. However, when older patients are questioned directly, they rarely admit to abuse. Health care professionals should assess for risk factors, such as high levels of stress or alcoholism in caregivers, evidence of violence, and emotional outbursts, as well as financial, emotional, or physical dependency. Two additional questions have been found to be effective in uncovering specific types of abuse that may occur only in people with disabilities: • Does anyone prevent you from using a wheelchair? Cane? Respirator? Other assistive device? • Does anyone you depend on refuse to help you with an important personal need, such as taking your medicine? Getting to the bathroom? Getting in or out of bed? Bathing? Dressing? Getting food or drink? If a person’s response indicates that abuse is a risk, further assessment is warranted, and efforts are made to ensure the patient’s safety and provide access to appropriate community and professional resources and support systems. Further discussion of domestic violence and abuse is presented in Chapter 47.

Stress and Coping Responses Each person handles stress differently. How well people adapt depends on their ability to cope. During a health history, past coping patterns and perceptions of current stresses and anticipated outcomes are explored to identify the person’s overall ability to handle stress. It is especially important to identify expectations that a person may have of family, friends, and caregivers in providing emotional,

physical, or financial support. Further discussion of stress and coping is presented in Chapter 7.

Other Health History Formats The health history format discussed in this chapter is only one possible approach that is useful in obtaining and organizing information about a person’s health status. Some experts consider this traditional format to be inappropriate for nurses, because it does not focus exclusively on the assessment of human responses to actual or potential health problems. Several attempts have been made to develop an assessment format and database with this focus in mind. One example is a nursing database based on the North American Nursing Diagnosis Association International and its 13 domains: health promotion, nutrition, elimination/exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development (Herdman, 2012). Although there is support in nursing for using this approach, no consensus for its use has been reached. Other examples include electronic systems specific to home care and perioperative nursing. Groups from the public and private sectors have focused on assessing not only biologic health, but also other dimensions of health. These dimensions include physical, functional, emotional, mental, and social health. Efforts to assess health status have focused on the manner in which disease or disability affects a patient’s functional status— that is, the ability of the person to function and perform his or her usual physical, mental, and social activities. An emphasis on functional assessment is viewed as more holistic than the traditional health or medical history. Instruments to assess health status in these ways may be used by nurses along with their own clinical assessment skills to determine the impact of illness, disease, disability, and health concerns on functional status. Health concerns that are not complex (e.g., earache, sinusitis) and can be resolved in a short period usually do not require the depth or detail that is necessary when a person is experiencing a major illness or health concern. Additional assessments that go beyond the general patient profile may be used if the patient’s health concerns are acute and complex or if the illness is chronic. The person is asked about continuing health promotion and screening practices. If the person has not been involved in these practices in the past, information can be given about their importance and referred to appropriate health care professionals. Research has shown that health promotion is beneficial even for frail older home care clients. One study found that proactively providing older people with health promotion compared to providing standard nursing home care services resulted in better mental health functioning, decreased depression, and enhanced perceptions of social support with no increase in costs (Markle-Reid, Weir, Browne, et al., 2006). Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. However, the nursing focus complements these other approaches and encourages collaboration among the health care professionals, with each

CHAPTER 5

member bringing his or her own expertise and focus to the situation.

PHYSICAL ASSESSMENT Physical assessment, or the physical examination, is an integral part of nursing assessment. The basic techniques and tools used in performing a physical examination are described in general in this chapter. The examinations of specific systems, including special manoeuvres, are described in the appropriate chapters throughout the book.

Examination Considerations The physical examination is usually performed after the health history is obtained. It is carried out in a welllighted, warm area. The patient is asked to (or helped to) undress and is draped appropriately so that only the area to be examined is exposed. The person’s physical and psychological comfort are considered at all times. It is necessary to describe procedures to the patient and explain what sensations to expect before each part of the examination. The examiner’s hands are washed before and immediately after the examination. Fingernails are kept short to avoid injuring the patient. If there is a possibility of coming into contact with blood or other body secretions during the physical examination, gloves should be worn. An organized and systematic examination is the key to obtaining appropriate data in the shortest time. Such an approach encourages cooperation and trust on the part of the patient. The person’s health history provides the examiner with a health profile that guides all aspects of the physical examination. A “complete” physical examination is not routine. Many of the body systems are selectively assessed on the basis of the presenting concern. For example, if a healthy 20-year-old college student requires a physical examination to study abroad and reports no history of neurologic abnormality, the neurologic assessment is brief. Conversely, a history of transient numbness and diplopia (double vision) usually necessitates a complete neurologic investigation. Similarly, a patient with chest pain receives a much more intensive examination of the chest and heart than one with an earache. In general, the health history guides the examiner in obtaining additional data for a complete picture of the patient’s health. The process of learning to perform a physical examination requires repetition and reinforcement in a clinical setting. Only after basic physical assessment techniques are mastered can the examiner tailor the routine screening examination to include thorough assessments of particular systems, including special manoeuvres (Skillen, 2012d).

Components of the Physical Examination The components of a physical examination include general observations and then a more focused assessment of the pertinent body systems. The tools of the physical

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examination are the human senses of vision, hearing, touch, and smell. These may be augmented by special tools (e.g., stethoscope, ophthalmoscope, reflex hammer) that are extensions of the human senses; they are tools that anyone can learn to use well. Expertise comes with practice, and sophistication comes with the interpretation of what is seen and heard.

Initial Observations General inspection begins with the first contact with the patient. Introducing oneself and shaking hands provide opportunities for making initial observations: Is the person old? Or young? How old? How young? Does the person appear to be his or her stated age? Is the person thin? Or obese? Does the person appear anxious? Or depressed? Is the person’s body structure as expected? Or not? In what way, and how different from the expected? It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. Consider the following examples: • “The person appears sick.” In what way does he or she appear sick? Is the skin pale, jaundiced, or cyanotic? Is the person grimacing in pain? Or having difficulty breathing? Does he or she have edema? What specific physical features or behavioural manifestations indicate that the person is “sick”? • “The person appears chronically ill.” In what way does he or she appear chronically ill? Does the person appear to have lost weight? People who lose weight secondary to muscle-wasting diseases (e.g., acquired immunodeficiency syndrome [AIDS], malignancy) have a different appearance than those who are merely thin, and weight loss may be accompanied by loss of muscle mass or atrophy. Does the skin have the appearance of chronic illness (i.e., is it pale? Or does it give the appearance of dehydration? Or loss of subcutaneous tissue)? These important specific observations are documented in the patient’s chart or health record. Among general observations that are noted in the initial examination of the patient are posture and stature, body movements, gait, nutritional status, speech pattern, and vital signs.

Posture The posture that a person assumes often provides valuable information. Patients who have breathing difficulties (dyspnea) secondary to cardiac disease prefer to sit and may report feeling short of breath when lying flat for even a brief time. Patients with abdominal pain due to peritonitis prefer to lie perfectly still; even slight jarring of the bed causes agonizing pain. In contrast, patients with abdominal pain due to renal or biliary colic are often restless and may pace the room.

Body Movements Abnormalities of body movement are of two kinds: generalized disruption of voluntary or involuntary movement and asymmetry of movement. The first category includes tremors of a wide variety; some tremors may occur at rest (Parkinson’s disease), whereas others occur only on

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voluntary movement (cerebellar ataxia). Other tremors may exist during both rest and activity (alcohol withdrawal syndrome, thyrotoxicosis). Some voluntary or involuntary movements are described as “fine,” and others are “quite coarse.” At the extreme are the convulsive movements of epilepsy or tetanus and the choreiform (involuntary and irregular) movements of patients with rheumatic fever or Huntington disease. Asymmetry of movement, in which only one side of the body is affected, may occur with disorders of the central nervous system (CNS), primarily in those patients who have had a cerebrovascular accident (stroke). Patients may have drooping of one side of the face, weakness or paralysis of the extremities on one side of the body, and a foot-dragging gait. Spasticity (increased muscle tone) may also be present, particularly in patients with multiple sclerosis.

Nutritional Status Nutritional status is important to note. Obesity may be generalized as a result of excessive intake of calories, or it may be specifically localized to the trunk in patients who have an endocrine disorder (Cushing disease) or who have been taking corticosteroids for long periods. Loss of weight may be generalized as a result of inadequate caloric intake, or it may be seen in loss of muscle mass with disorders that affect protein synthesis. Nutritional assessment is discussed in more detail later in this chapter.

Speech Pattern Speech may be slurred because of CNS disease or because of damage to cranial nerves. Recurrent damage to the laryngeal nerve results in hoarseness, as do disorders that produce edema or swelling of the vocal cords. Speech may be halting, slurred, or interrupted in flow in patients with some CNS disorders (e.g., multiple sclerosis, stroke).

Vital Signs The recording of vital signs is a part of every physical examination (Skillen, 2012e). Blood pressure, pulse rate, respiratory rate, and body temperature measurements are obtained and recorded. Acute changes and trends over time are documented and unexpected changes and values that deviate significantly from a patient’s usual values are brought to the attention of the patient’s primary health care professional. The “fifth vital sign,” pain, is also assessed and documented, if indicated. A usual oral temperature for most people is 37°C; however, some variation is expected. Some people’s usual temperatures can be at 36.6° or 37.3°C. There is an expected diurnal variation of a degree or two in body temperature throughout the day; temperature is usually lowest in the morning and increases during the day to between 37.3° and 37.5°C (99° to 99.5°F), and it then decreases during the night (Skillen, 2012e).

Focused Assessment Following the general inspection, a more focused assessment is conducted. Although the sequence of physical examination depends on the circumstances and on the

patient’s reason for seeking health care, the complete examination usually proceeds in a head to toe format as follows (Skillen, 2012e): • • • • • • • • • • • •

Skin, hair, nails Head and neck Eyes, ears, nose, mouth, and throat Spine, thorax, and lungs Cardiovascular system (heart and great vessels) Breasts and axillae Abdomen Musculoskeletal system Neurologic system Arms and legs Rectum Genitalia

In clinical practice, all relevant body systems are tested throughout the physical examination, not necessarily in the sequence described. For example, when the face is examined, it is appropriate to check for facial asymmetry and, thus, for the integrity of the fifth and seventh cranial nerves; the examiner does not need to repeat this as part of a neurologic examination. When systems are combined in this manner the patient does not need to change positions repeatedly, which can be exhausting and time consuming. The traditional sequence in the focused portion of the examination is inspection, palpation, percussion, and then auscultation, except in the case of an abdominal examination.

Inspection The first fundamental technique is inspection or observation of each relevant body system in more detail as indicated from the health history or the general inspection. Characteristics such as skin colour, presence and size of lesions, edema, erythema, symmetry, and pulsations are noted. Specific body movements that are noted on inspection include spasticity, muscle spasms, and an abnormal gait (Pleuss, Matfin, & Moisey, 2010).

Palpation Palpation is a vital part of the physical examination. Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation (Fig. 5-3). Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds (Roach, 2012). Sounds generated within the body, if within specified frequency ranges, also may be detected through touch. For example, certain murmurs generated in the heart or within blood vessels (thrills) may be detected. Thrills cause a sensation to the hand much like the purring of a cat. Voice sounds are transmitted along the bronchi to the periphery of the lung. These may be perceived by touch and may be altered by disorders affecting the lungs. The phenomenon is called tactile fremitus and is useful in assessing diseases of the chest. The significance of these findings is discussed in Chapters 22 and 27.

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with a firm object. The sound produced reflects the density of the underlying structure. Certain densities produce sounds as percussion notes. These sounds, listed in a sequence that proceeds from the least to the most dense, are tympany, hyperresonance, resonance, dullness, and flatness. Tympany is the drumlike sound produced by percussing the air-filled stomach. Hyperresonance is audible when one percusses over inflated lung tissue in a person with emphysema. Resonance is the sound elicited over airfilled lungs. Percussion of the liver produces a dull sound, whereas percussion of the thigh produces a flat sound. Percussion allows the examiner to assess such usual anatomic details as the borders of the liver and the movement of the diaphragm during inspiration. It is also possible to determine the level of a pleural effusion (fluid in the pleural cavity) and the location of a consolidated area caused by pneumonia or atelectasis (collapse of alveoli). The use of percussion is described further with disorders of the thorax and abdomen (see Chapters 22 and 35).

Auscultation

B FIGURE 5-3. A, Light palpation. B: Deep palpation.

Percussion The technique of percussion translates the application of physical force into sound (Fig. 5-4). It is a skill requiring practice that yields much information about disease processes in the chest and abdomen (Harder, Skillen, & Bickley, 2010; Roach, 2012). The principle is to set the chest wall or abdominal wall into vibration by striking it

Auscultation is the skill of listening with a stethoscope to sounds produced within the body created by the movement of air or fluid. Examples include breath sounds, the spoken voice, bowel sounds, heart sounds, and cardiac murmurs. Physiologic sounds may be expected (e.g., first and second heart sounds) or pathologic (e.g., heart murmurs in diastole, crackles in the lung). Some expected sounds may be distorted by abnormalities of structures through which the sound must travel (e.g., changes in the character of breath sounds as they travel through the consolidated lung of a patient with lobar pneumonia). Sound produced within the body, if of sufficient amplitude, may be detected with the stethoscope, which functions as an extension of the human ear and channels sound. The nurse avoids touching the tubing or rubbing other surfaces (hair, clothing) during auscultation to minimize extraneous noises. Sound produced by the body, like any other sound, is characterized by intensity, frequency, and quality. The intensity, or loudness, associated with physiologic sound is low; therefore, the use of the stethoscope is needed. The frequency, or pitch, of physiologic sound is in reality “noise,” in that most sounds consist of a frequency spectrum, as opposed to the single-frequency sounds that we associate with music or a tuning fork. The frequency spectrum may be quite low, yielding a rumbling noise, or comparatively high, producing a harsh or blowing sound. Quality of sound relates to overtones that allow one to distinguish among various sounds. Sound quality enables the examiner to distinguish between the musical quality of high-pitched wheezing and the low-pitched rumbling of a diastolic murmur (Skillen, 2012d).

NUTRITIONAL ASSESSMENT FIGURE 5-4. Percussion technique. The middle finger of one hand

strikes the terminal phalanx of the middle finger of the other hand, which is placed firmly against the body. If the action is performed sharply, a brief, resonant tone will be produced. The clarity of the tone depends on the brevity of the action. The intensity of the tone varies with the force used.

Nutrition is important to maintain health and to prevent disease and death. When illness or injury occurs, optimal nutrition is essential for healing and resisting infection and other complications. An in-depth nutritional assessment is often integrated into the health history and

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physical examination. Assessment of nutritional status provides information about obesity, weight loss, undernutrition, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, the effects of medications on nutrition, and special issues affecting patients both in hospitals and in the home and other community settings (Day, 2012). Disorders caused by nutritional deficiency, overeating, or eating unhealthy meals are among the leading causes of illness and death in Canada today. The three leading causes of death—heart disease, cancer, and stroke—are related, in part, to consequences of unhealthy nutrition (Day, 2012). Other examples of health issues associated with poor nutrition include obesity, osteoporosis, cirrhosis, diverticulitis, and eating disorders. Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these are pursued further. Other physical signs may be subtle and need to be carefully assessed. For example, certain signs that appear to indicate nutritional deficiency may actually reflect other systemic conditions (e.g., endocrine disorders, infectious disease). Others may result from impaired digestion, absorption, excretion, or storage of nutrients in the body (Pleuss, Matfin, & Moisey, 2010).

Lifespan Considerations Adolescence is a time of critical growth and acquisition of lifelong eating habits, and therefore nutritional assessment, analysis, and intervention are critical (Day, 2012). In the past two decades rates of obesity in adolescents have increased at an alarming rate. Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels and they are a less physically active group compared to adolescent males. Adolescents with other nutritional disorders, such as anorexia and bulimia, have a better chance of recovery if these disorders are identified and treated in the adolescent years rather than in adulthood. Older adults are also at risk for altered nutrition. Special considerations for nutritional assessment in the older adult are presented in Chart 5-7.

Components of Nutritional Assessment The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of body mass index and waist circumference, biochemical measurements, clinical examination findings, and dietary data.

Body Mass Index Body mass index (BMI) is a ratio based on body weight and height. The obtained value is compared to the established standards; however, trends or changes in val-

CHART 5-7

Nutritional Assessment in the Older Adult Nutritional screening in older adults is a first step in maintaining adequate nutrition and replacing nutrient losses to maintain the individual’s health and well-being. Aging is associated with increases in the incidence of weight loss, being underweight, and having protein–energy malnutrition (Soriano et al., 2007). Older people who are malnourished tend to have longer and more expensive hospital stays than those who are adequately nourished; the risk of costly complications is also increased in malnourished patients (Dudek, 2013). Inadequate dietary intake in older adults may result from physiologic changes in the gastrointestinal tract, social and economic factors, drug interactions, disease, excessive use of alcohol, and poor dentition or missing teeth. Malnutrition is a common consequence of these factors and in turn leads to illness and frailty of older adults. Important aspects of care of older adults in the hospital, home, outpatient setting, or extended care facility include recognizing risk factors and identifying those who are at risk for inadequate nutrition (Soriano et al., 2007). Many older adults take excessive and inappropriate medications; this is referred to as polypharmacy. The number of adverse reactions increases proportionately with the number of prescribed and over-the-counter medications taken. Agerelated physiologic and pathophysiologic changes may alter the metabolism and elimination of many medications. Medications can influence food intake by producing side effects such as nausea, vomiting, decreased appetite, and changes in sensorium. They may also interfere with the distribution, utilization, and storage of nutrients. Disorders affecting any part of the gastrointestinal tract can alter nutritional requirements and health status in people of any age; however, they are likely to occur more quickly and more frequently in older adults. Nutritional problems in older adults often occur or are precipitated by such illnesses as pneumonia and urinary tract infections. Acute and chronic diseases may affect the metabolism and utilization of nutrients, which already are altered by the aging process. Up-to-date immunizations, prompt treatment of bacterial infections, and social programs such as Meals on Wheels may reduce the risk of illness-associated malnutrition. Alcohol and substance abuse are potential factors in the older adult population that should not be overlooked (OASAS, 2007). Even the well older adults may be nutritionally at risk because of decreased odour perception, poor dental health, limited ability to shop and cook, financial hardship, and the fact that they often eat alone. Also, reduction in exercise with age without concomitant changes in carbohydrate intake places older adults at risk for obesity.

ues over time are considered more useful than isolated or one-time measurements. BMI (Fig. 5-5) is highly correlated with body fat, but increased lean body mass, large muscles, edema, or a large body frame can also increase the BMI. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for health issues associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients

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Body Mass Index The body mass index (BMI) is used to determine who is overweight.

BMI !

703 " weight in pounds

weight in kilograms

OR

2

(height in inches)

2

(height in metres)

BMI score is at the intersection of height and weight. A body mass index score of 25 or more is considered overweight and 30 or more is considered obese. Overweight

25 Overweight Limit

Weight 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 Height

205

5!0" 5!1" 5!2" 5!3" 5!4" 5!5" 5!6" 5!7" 5!8" 5!9" 5!10" 5!11" 6!0" 6!1" 6!2" 6!3" 6!4"

40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25

20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12

21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13

21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13

22 22 21 20 20 19 19 18 17 17 17 16 16 15 15 14 14

23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15

24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15

25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16

26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16

27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17

28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18

29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18

30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19

31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19

32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20

33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21

34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21

35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22

36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23

37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23

38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24

39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24

Source: Shape Up America. National Institutes of Health. FIGURE 5-5. Body mass index.

and community-dwelling older adults. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese (Dudek, 2013). In analyzing BMI, the nurse is aware that cutoff scores for “normal,” “overweight,” and “obese” may differ for different ethnic groups. For example, in an Asian population, a BMI of 23 is considered overweight, while a BMI of 27 would be classified as obese (World Health Organization Expert Consultation, 2004). These scores may also differ by age. For adults 65 years and older, a BMI of 18.5 to 20 increases the risk of morbidity (Day, 2012; Brunet, Day, & Mager, 2010). It is important to assess for usual body weight and height and to compare these values with ideal weight. Current weight does not provide information about recent changes in weight; therefore, patients are asked about their usual body weight. Loss of height may be due to osteoporosis, an important problem related to nutrition, especially in postmenopausal women. A loss of 2 or 3 inches of height may indicate osteoporosis (Day, 2012; Brunet, Day, & Mager, 2010). In addition to the calculation of BMI, waist circumference measurement is particularly useful for adult patients who are categorized as being of normal weight or overweight (Dudek, 2013). To measure waist circumference, have patient stand with feet 25 to 30 cm apart, a tape measure is placed in a horizontal plane around the abdomen half way between the costal margin and the iliac crest (Fig. 5-6). The measurement is taken after the patient

exhales. A waist circumference greater than 102 cm for men or 88 cm for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation (Canadian Medical Association, 2005).

Biochemical Assessment Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. These determinations are made

FIGURE 5-6. Measuring waist circumference.

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from studies of serum (albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). See Appendix A for expected serum and urine biochemical values. Some of these tests, while reflecting recent intake of the elements detected, can also identify below-normal levels when there are no clinical symptoms of deficiency. Low serum albumin and prealbumin levels are most often used as measures of protein deficit in adults. Albumin synthesis depends on normal liver function and an adequate supply of amino acids. Because the body stores a large amount of albumin, the serum albumin level may not decrease until malnutrition is severe; therefore, its usefulness in detecting recent protein depletion is limited. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss due to burns, major surgery, infection, or cancer. Serial measurements of prealbumin levels are also used to assess the results of nutritional therapy. Prealbumin, also called thyroxin-binding protein, is a more sensitive indicator of protein status than albumin, but the test is more expensive and therefore less frequently ordered (Dudek, 2013). Additional laboratory data, such as levels of transferrin and retinol-binding protein, anergy panels, and lymphocyte and electrolyte counts, are used in many institutions. Transferrin is a protein that binds and carries iron from the intestine through the serum. Because of its short half-life, transferrin levels decrease more quickly than albumin levels in response to protein depletion. Although measurement of retinol-binding protein is not available from many laboratories, it may be a useful means of monitoring acute,

TABLE 5-1 Indicator

short-term changes in protein status. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-calorie feeding and in those with impaired cellular immunity. Anergy, the absence of an immune response to injection of small concentrations of recall antigen under the skin, may also indicate malnutrition because of delayed antibody synthesis and response. Serum electrolyte levels provide information about fluid and electrolyte balance and kidney function. The creatinine/height index calculated over a 24-hour period assesses the metabolically active tissue and indicates the degree of protein depletion, comparing expected body mass for height with actual body cell mass. A 24-hour urine sample is obtained, and the amount of creatinine is measured and compared to expected ranges based on the patient’s height and gender. Values lower than expected may indicate loss of lean body mass and protein malnutrition.

Clinical Examination The state of nutrition is often reflected in a person’s appearance. Although the most obvious physical sign of good nutrition is an appropriate body weight with respect to height, body frame, and age, other tissues can serve as indicators of general nutritional status and adequate intake of specific nutrients; these include the hair, skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles, abdomen, lower extremities, and thyroid gland (Table 5-1). Specific aspects of clinical examination that are useful in identifying nutritional deficits include an examination and assessment of skin for turgor, edema, elasticity, dryness, subcutaneous tone, poorly

Physical Indicators of Nutritional Status Signs of Adequate Nutrition

Signs of Inadequate Nutrition

General appearance

Alert, responsive, energetic

Listless, appears acutely or chronically ill

Hair

Shiny, lustrous; minimal loss, healthy scalp

Dull and dry, brittle, depigmented, easily plucked; thin and sparse, flaking scalp

Face

Skin colour uniform; smooth, moist

Skin dark over cheeks and under eyes, skin flaky, face swollen or hollow/sunken cheeks

Eyes

Bright, clear, moist

Eye membranes pale, dry (xerophthalmia); increased vascularity, cornea soft (keratomalacia)

Lips

Pink colour, smooth

Swollen and puffy; angular lesion at corners of mouth (cheilosis)

Tongue

Deep red in appearance; surface papillae present

Smooth appearance, swollen, beefy-red, sores, atrophic papillae

Teeth

Straight, no crowding, no dental caries, uniform bright colour

Dental caries, missing teeth, mottled appearance (fluorosis), malpositioned, dentures no longer fit

Gums

Firm, pink colour, margins tight around teeth

Spongy, bleed easily, marginal redness, recession

Thyroid

No enlargement of the thyroid

Thyroid enlargement (simple goitre)

Skin

Smooth, uniform colour, moist, warm

Rough, dry, flaky, swollen, pale, pigmented; lack of or excess fat under skin

Nails

Firm, pink

Spoon shaped, ridged, brittle Poor posture, bending of ribs, bowed legs, or knock knees

Skeleton

Erect posture, no malformation

Muscles

Well developed, firm

Flaccid, poor tone, wasted, underdeveloped

Extremities

No tenderness or edema

Weak and tender; edematous

Abdomen

Flat

Scaphoid (concave or hollow), protruding

Nervous system

Reflexes present

Decreased or absent ankle and knee reflexes

Weight

Appropriate for height, age, and body build

Overweight or underweight

CHAPTER 5

healing wounds and ulcers, purpura, and bruises (Pleuss, Matfin, & Moisey, 2010). The musculoskeletal examination also provides information about muscle wasting and weakness.

Dietary Data Commonly used methods of determining individual eating patterns include the food record, the 24-hour food recall, and a dietary interview. Each of these methods helps estimate whether food intake is adequate and appropriate. If these methods are used to obtain the dietary history, instructions should be given to the patient about measuring and recording food intake.

Methods of Collecting Data FOOD RECORD. The food record is used most often in nutritional status studies. A person is instructed to keep a record of food actually consumed over a period of time, varying from 3 to 7 days, and to accurately estimate and describe the specific foods consumed. Food records are fairly accurate if the person is willing to provide factual information and is able to estimate food quantities. Another option is to photograph all foods consumed. 24-HOUR RECALL. As the name implies, the 24-hour recall method is a recall of food intake over a 24-hour period. A person is asked to recall all foods eaten during the previous day and to estimate the quantities of each food consumed. Because information does not always represent usual intake, at the end of the interview the patient is asked whether the previous day’s food intake was typical. To obtain supplementary information about the typical diet, it is also necessary to ask how frequently the person eats foods from the major food groups. DIETARY INTERVIEW. The success of the interviewer in obtaining information for dietary assessment depends on effective communication, which requires that good rapport be established to promote respect and trust. The interviewer explains the purpose of the interview. The interview is conducted in a nondirective and exploratory way, allowing the respondent to express feelings and thoughts while encouraging him or her to answer specific questions. The manner in which questions are asked influences the respondent’s cooperation. The interviewer must be nonjudgmental and avoid expressing disapproval, either by verbal comments or by facial expression.

Character of General Intake. Several questions may be necessary to elicit the information needed. Assumptions are not made about the size of servings; instead, questions are phrased so that quantities are more clearly determined. For example, to help determine the size of one hamburger, the patient may be asked, “How many servings were prepared with the kilogram of meat you bought?” Another approach to determining quantities is to use food models of known sizes in estimating portions of meat, cake, or pie, or to record quantities in common measurements, such as cups or spoonfuls (or the size of containers, when discussing intake of bottled beverages). In recording a particular combination dish, such as a casserole, it is useful to ask about the ingredients, recording the largest quantities first. When recording quantities of ingredients, the interviewer notes whether the food item

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was raw or cooked and the number of servings provided by the recipe. When a patient lists the foods for the recall questionnaire, it may help to read back the list of foods and ask whether anything was forgotten, such as fruit, cake, candy, between-meal snacks, or alcoholic beverages. Additional information obtained during the interview includes methods of preparing food, sources available for food (including donated foods and food bank use), foodbuying practices, use of vitamin and mineral supplements, and amount of income available for food purchases. Cultural and Religious Considerations. An individual’s culture determines to a large extent which foods are eaten and how they are prepared and served. Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. Because of the importance of culture and religious beliefs to many individuals, it is important to be sensitive to these factors when obtaining a dietary history. It is, however, equally important not to stereotype individuals and assume that because they are from a certain culture or religious group, they adhere to specific dietary customs. One particular area of consideration is the presence of fish and shellfish in the diet, where they come from (farmed vs. wild), and the method of preparation. These methods may put certain populations at risk for toxicity due to contaminants. Culturally sensitive versions of Canada’s Food Guide are available in a variety of languages and for First Nations, Inuit, and Metis (Health Canada, 2007a,b).

Evaluating Dietary Information After obtaining basic dietary information, the nurse evaluates the patient’s dietary intake and communicates the information to the dietitian and the rest of the health care team for more detailed assessment and for clinical nutrition intervention. If the goal is to determine whether the patient generally eats a healthful diet, his or her food intake may be compared with the dietary guidelines outlined in “Eating well with Canada’s Food Guide” (Fig. 5-7). The Food Guide divides foods into five major groups (grains, vegetables, fruits, milk products, and meat and beans), plus fats and oils. Recommendations are provided for variety in the diet, proportion of food from each food group, and moderation in eating fats, oils, and sweets. A person’s food intake is compared with recommendations based on various food groups for different age groups and activity levels (Health Canada, 2007a,b). If nurses or dietitians are interested in knowing about the intake of specific nutrients, such as vitamin A, iron, or calcium, the patient’s food intake is analyzed by consulting a list of foods and their composition and nutrient content. The diet is analyzed in terms of grams and milligrams of specific nutrients. The total nutritive value is then compared with the recommended dietary allowances specific for the patient’s age category, gender, and special circumstances such as pregnancy or lactation. Fat intake and cholesterol levels are additional aspects of the nutritional assessment. Trans fats are produced when hydrogen atoms are added to monounsaturated or polyunsaturated fats to produce a semisolid product, such as margarine. Trans fats, which are contained in many

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Recommended Number of Food Guide Servings per Day Children Age in Years

2–3

Sex

4–8

Teens 9–13

Girls and Boys

Adults

14–18 Females

19–50

Males

Females

51+

Males

Females

Males

Vegetables and Fruit

4

5

6

7

8 7–8 8–10 7

7

Grain Products

3

4

6

6

7 6–7 8

6

7

Milk and Alternatives

2

2 3–4 3–4 3–4 2

2

3

3

Meat and Alternatives

1

1 1–2

3

2

3

2

3

2

The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and type of food recommended and following the tips in Canada’s Food Guide will help: • Meet your needs for vitamins, minerals, and other nutrients. • Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer, and osteoporosis. • Contribute to your overall health and vitality.

FIGURE 5-7. Eating well with Canada’s Food Guide. (From Health Canada. (2007c). Eating well with Canada’s Food Guide. Ottawa, ON: Minister of Health Canada. Retrieved from http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/ print_eatwell_bienmang-eng.pdf.)

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What is One Food Guide Serving? Look at the examples below.

Fresh, frozen, or canned vegetables 125 mL (1⁄ 2 cup)

Bread 1 slice (35g)

Bagel ⁄ 2 bagel (45 g)

1

Fresh, frozen, or canned fruits 1 fruit or 125 mL (1⁄ 2 cup)

Leafy vegetables Cooked: 125 mL (1⁄ 2 cup) Raw: 250 mL (1 cup)

Cooked rice, Flat breads 1 ⁄ 2 pita or 1⁄ 2 tortilla (35 g) bulgur, or quinoa 125 mL (1⁄ 2 cup)

Milk or powdered milk (reconstituted) 250 mL (1 cup)

Canned milk (evaporated) 125 mL (1⁄ 2 cup)

Cooked fish, shellfish, poultry, lean meat 75 g (2 1⁄ 2 oz.)/125 mL (1⁄ 2 cup)

Cooked legumes 175 mL (3⁄ 4 cup)

Fortified soy beverage 250 mL (1 cup)

Cereal Cold: 30 g Hot: 175 mL (3⁄ 4 cup)

Yogurt 175 g (3⁄ 4 cup)

Tofu 150 g or 175 mL (3⁄ 4 cup)

Eggs 2 eggs

100% Juice 125 mL (1⁄ 2 cup)

Kefir 175 g (3⁄ 4 cup)

Peanut or nut butters 30 mL (2 tbsp)

Cooked pasta or couscous 125 mL (1⁄ 2 cup)

Cheese 50 g (1 1⁄ 2 oz.)

Shelled nuts and seeds 60 mL (1⁄ 4 cup)

Oils and Fats

• Include a small amount – 30 to 45 mL (2 to 3 tbsp) – of unsaturated fat each day. This includes oil used for cooking, salad dressings, margarine and mayonnaise. • Use vegetable oils such as canola, olive, and soybean. • Choose soft margarines that are low in saturated and trans fats. • Limit butter, hard margarine, lard, and shortening.

FIGURE 5-7. Continued.

baked goods and restaurant foods, are a concern, because increased amounts of trans fats have been associated with increased risk for heart disease and stroke. Canada was the first country to require the inclusion of trans fats information on food labels.

Factors Influencing Nutritional Status in Various Situations One sensitive indicator of the body’s gain or loss of protein is its nitrogen balance. An adult is said to be in nitrogen equilibrium when the nitrogen intake (from food) equals the nitrogen output (in urine, feces, and perspiration); it is a sign of health. A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tis-

sue growth, such as occurs during pregnancy, childhood, recovery from surgery, and rebuilding of wasted tissue. A negative nitrogen balance indicates that tissue is breaking down faster than it is being replaced. In the absence of an adequate intake of protein, the body converts protein to glucose for energy. This can occur with fever, starvation, surgery, burns, and debilitating diseases. Each gram of nitrogen loss in excess of intake represents the depletion of 6.25 g of protein or 25 g of muscle tissue. Therefore, a negative nitrogen balance of 10 g/day for 10 days could mean the wasting of 2.5 kg (5.5 pounds) of muscle tissue as it is converted to glucose for energy. When conditions that result in negative nitrogen balance are combined with anorexia (loss of appetite), they can lead to malnutrition. Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications,

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!Eat at least one dark green and one orange vegetable each day. • Go for dark green vegetables such as broccoli, romaine lettuce ,and spinach. • Go for orange vegetables such as carrots, sweet potatoes, and winter squash.

!Choose vegetables and fruit prepared with little or no added fat, sugar, or salt. • Enjoy vegetables steamed, baked, or stir-fried instead of deep-fried.

!Have vegetables and fruit more often than juice. !Make at least half of your grain products whole grain each day. • Eat a variety of whole grains such as barley, brown rice, oats, quinoa, and wild rice. • Enjoy whole grain breads, oatmeal, or whole wheat pasta.

!Choose grain products that are lower in fat, sugar, or salt. • Compare the Nutrition Facts table on labels to make wise choices. • Enjoy the true taste of grain products. When adding sauces or spreads, use small amounts.

!Drink skim, 1%, or 2% milk each day. • Have 500 mL (2 cups) of milk every day for adequate vitamin D. • Drink fortified soy beverages if you do not drink milk.

!Select lower fat milk alternatives. • Compare the Nutrition Facts table on yogurts or cheeses to make wise choices.

!Have meat alternatives such as beans, lentils and tofu often. !Eat at least two Food Guide Servings of fish each week.* • Choose fish such as char, herring, mackerel, salmon, sardines, and trout.

!Select lean meat and alternatives prepared with little or no added fat or salt. • Trim the visible fat from meats. Remove the skin on poultry. • Use cooking methods such as roasting, baking, or poaching that require little or no added fat. • If you eat luncheon meats, sausages, or prepackaged meats, choose those lower in salt (sodium) and fat.

Enjoy a variety of foods from the four food groups.

Satisfy your thirst with water! Drink water regularly. It’s a calorie-free way to quench your thirst. Drink more water in hot weather or when you are very active.

* Health Canada provides advice for limiting exposure to mercury from certain types of fish. Refer to www.healthcanada.gc.ca fo r the latest information.

FIGURE 5-7. Continued.

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TABLE 5-2

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Factors Associated with Potential Nutritional Deficits

Factor

Possible Consequences

Dental and oral issues (missing teeth, ill-fitting dentures, impaired chewing, or swallowing)

Inadequate intake of high-fibre foods

NPO for diagnostic testing

Inadequate caloric and protein intake; dehydration

Prolonged use of glucose and saline IV fluids

Inadequate caloric and protein intake

Nausea and vomiting

Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals

Stress of illness, surgery, and/or hospitalization

Increased protein and caloric requirement; increased catabolism

Wound drainage

Loss of protein, fluid, electrolytes, and minerals

Pain

Loss of appetite; inability to shop, cook, eat

Fever

Increased caloric and fluid requirement; increased catabolism

Gastrointestinal intubation

Loss of protein, fluid, and minerals

Tube feedings

Inadequate amounts; various nutrients in each formula

Gastrointestinal disease

Inadequate intake and malabsorption of nutrients

Alcoholism

Inadequate intake of nutrients; increased consumption of calories without other nutrients; vitamin deficiencies

Depression

Loss of appetite; inability to shop, cook, eat

Eating disorders (anorexia, bulimia)

Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals

Medications

Inadequate intake due to medication side effects, such as dry mouth, loss of appetite, decreased taste perception, difficulty swallowing, nausea and vomiting, physical problems that limit shopping, cooking, eating; malabsorption of nutrients

Restricted ambulation or disability

Inability to help self to food, liquids, other nutrients

longer hospital stays, and prolonged confinement of patients to bed (Pleuss, Matfin, & Moisey, 2010). Patients who are hospitalized may have an inadequate dietary intake because of the illness or disorder that necessitated the hospital stay or because the hospital’s food is unfamiliar or unappealing. Patients who are cared for at home may feel too sick or fatigued to shop and prepare food, or they may be unable to eat because of other physical problems or limitations. Limited or fixed incomes or the high costs of medications may result in insufficient money to buy nutritious foods. Patients with inadequate housing or inadequate cooking facilities are unlikely to have an adequate nutritional intake (Day, 2012). Because complex treatments (e.g., mechanical ventilation, intravenous infusions, chemotherapy), once used only in the hospital setting, are now being provided in the home and outpatient settings, nutritional assessment of patients in these settings is an important aspect of home and community-based care. Many medications influence nutritional status by suppressing the appetite, irritating the oral or gastric mucosa, or causing nausea and vomiting. Others may influence bacterial flora in the intestine or directly affect nutrient absorption so that secondary malnutrition results. People who must take many medications in a single day often report feeling too full to eat. A patient’s use of prescription and OTC medications and their effects on appetite and dietary intake are assessed. Many of the factors that contribute to poor nutritional status are identified in Table 5-2.

Analysis of Nutritional Status Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in com-

bination to determine a patient’s nutritional status. Often, these data provide more information about the patient’s nutritional status than the clinical examination, which may not detect subclinical deficiencies unless they become so advanced that overt signs develop. A low intake of nutrients over a long period may lead to low biochemical levels and, without nutritional intervention, may result in characteristic and observable signs and symptoms (see Table 5-2). A plan of action for nutritional intervention is based on the results of the dietary assessment and the patient’s clinical profile. To be effective, the plan must meet the patient’s need for a healthy diet, maintain (or control) weight, and compensate for increased nutritional needs.

ASSESSMENT IN THE HOME AND COMMUNITY Assessment of people in community settings, including the home, consists of collecting information specific to existing health conditions, including data on the patient’s physiologic and emotional status, the community and home environment, the adequacy of support systems or care given by family and other care providers, and the availability of needed resources. In addition, it is important to evaluate the ability of the individual and family to cope with and address their respective needs. The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible. See Chapter 2. Before the first home visit, the nurse calls the patient’s home to determine a convenient time to expect the home care nurse; this also gives the patient’s primary caregiver

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CHART 5-8

Assessing the Home Environment Physical Facilities (check all that apply) EXTERIOR ❑ steps ❑ unsafe steps ❑ porch ❑ litter ❑ noise ❑ inadequate lighting ❑ other INTERIOR ❑ accessible bathroom ❑ level, safe floor surface ❑ number of rooms ❑ privacy ❑ sleeping arrangements ❑ refrigeration ❑ garbage management ❑ animals ❑ adequate lighting ❑ steps/stairs ❑ other

❑ inadequate lighting ❑ unsafe gas/electric appliances ❑ inadequate heating ❑ inadequate cooling ❑ lack of fire safety devices ❑ unsafe floor coverings ❑ inadequate stair rails ❑ lead-based paint ❑ improperly stored hazardous material ❑ improper wiring/electrical cords ❑ other

Safety Factors (check all that apply) ❑ fire/smoke detectors ❑ fire extinguisher ❑ carbon monoxide detector ❑ telephone ❑ placement of electrical cords ❑ emergency plan ❑ emergency phone numbers displayed ❑ safe portable heaters ❑ obstacle-free paths ❑ other

Safety Hazards found in the patient’s current residence (check all that apply) ❑ none ❑ inadequate floor, roof, or windows

the opportunity to be available. During the home visit, assessment is not limited to physical assessment of the patient. Other aspects of assessment are related to the home environment and support systems (Chart 5-8). The patient may not have family members available to assist him or her and may live alone in substandard housing or in a shelter for the homeless. Therefore, the nurse needs to be aware of resources available in the community and methods of obtaining those resources for the patient.

Critical Thinking Exercises 1 Your health history and physical examination of a young adult male patient alerts you to the possibility of substance abuse. Explain how you would pursue this. What is the evidence base for available assessments to assist in a more comprehensive evaluation? Identify the criteria used to evaluate the strength of the evidence for this practice. 2

Your health assessment of a female college freshman reveals that she has a high fat intake, has a minimal calcium intake, and gets little exercise. What recommendations would you make for this patient? If the patient is a vegetarian, what dietary instructions would

you develop for her? What is the evidence base for the type of instructional method to use with a college student? Identify the criteria used to evaluate the strength of the evidence for this practice. 3 How would you modify your health history and physical assessment technique if your patient has the following disabilities: (1) impaired communication due to aphasia secondary to stroke, (2) impaired mobility due to spinal cord injury, or (3) cognitive impairment?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Anderson, M. C., Hunter, K., & Bickley, L. S. (2010). The older adult. In T.C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 887–932). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Brunet, K., Day, R. A., & Mager, D. (2010). Nutritional assessment. In T.C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 167–201). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Crowe, C. (2007). Dying for a home: Homeless activists speak out. Toronto, ON: Between the Lines.

CHAPTER 5 Day, R. A. (2012). Nutrition assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s ursing health assessment: A best practice approach (1st ed., pp. 152–184). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Dudek, S. G. (2013). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Harder, N., Skillen, D. L., & Bickley, L. S. (2010). The Abdomen. In Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 509– 561). Philadelphia, PA: Wolters Klluwer Health/Lippincott Williams & Wilkins. Herdman, T. H. (2012). NANDA International nursing diagnoses: Definitions and classification, 2012–2014 (9th ed.). Oxford, UK: Wiley-Blackwell. Karch, A. M. (2012). Lippincott’s Nursing Drug Guide. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pleuss, J. Matfin, G., & Moisey, L. L. (2010). Alterations in nutritional status. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Alterations in nutritional status (pp. 943–966). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Roach, S. (2012). Abdominal assessment. In T.C. Stephen, D.L. Skillen, & R.A. Day, et al. (eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 602–644). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012a). Older adults. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 925–956). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012b). Assessment of social, cultural, and spiritual health. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s health assessment for nurses: A best practice approach (1st ed., pp. 231–247. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012c). Techniques of physical examination and equipment. In T. C. Stephen, D. L. Skillen, R. A.Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st. ed., pp. 231–247). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012d). General survey and vital signs assessment. In T. C Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 91–124). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012a). The interview and therapeutic dialogue. In T. C. Stephen, D. L. Skillen, R .A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 20–36). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012b). The health history. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (pp. 37--51). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012c). Documentation and interprofessional communication. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed, pp. 69–88). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012d). Assessment of human violence. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 248–264). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Assessment Aboriginal Nurses Association of Canada, Canadian Association of Schools of Nursing, & Canadian Nurses Association. (2009). Cultural Competence

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and Cultural Safety in Nursing Education. Ottawa, ON: Aboriginal Nurses Association of Canada. Retrieved from http://www.anac.on.ca/ **Chan, A. W. K., Pristach, E. A., Welte, J. W., et al. (1993). Use of the TWEAK test in screening for alcoholism/heavy drinking in three populations. Alcoholism: Clinical and Experimental Research, 17 (6), 1188–1192. *Chen, C. C.-H., Chyun, D. A., Li, C. Y., et al. (2007). A single-item approach to screening elders for oral health assessment. Nursing Research, 56 (5), 332–338. **Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252(14), 1906. Institute for Safe Medication Practices Canada. (2012). Safer medication use in older persons. Retrieved from http://www.ismp-canada.org/beers_list/ *Irving, K., Treacy, M., Scott, A., et al. (2006). Discursive practices in the documentation of patient assessments. Journal of Advanced Nursing, 53(2), 151–159. *Markle-Reid, M., Weir, R., Browne, G., et al. (2006). Health promotion for frail older home care clients. Journal of Advanced Nursing, 55(3), 381–395. *Neville, S., & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55(4), 407–415. The New York State Office of Alcoholism and Substance Abuse Services (OASAS). (2007). Elderly alcohol and substance abuse. Available at: www.oasas.state.ny.us/AdMed/pubs/FYI/FYIInDepth-Elderly.cfm/ PHAC (2008). Complementary and alternative health. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/chn-res/cah-acpseng.php?rd=complement_eng PHAC (2012a). Canadian immunization guide: Part 2, Vaccine safety and adverse events following immunization. Retrieved from http:// www.phac-aspc.gc.ca/publicat/cig-gci/p02-02-eng.php PHAC (2012b). Canadian immunization guide: Part 4, Active vaccines. Retrieved from http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-eng.php *Secrest, J. A., Norwood, B. R., & DuMont, P. D. (2005). Physical assessment skills: A descriptive study of what is taught and what is practiced. Journal of Professional Nursing, 21(2), 114–118. Smeltzer, S. C., Sharts-Hopko, N., Ott, B., et al. (2007). Perspectives of women with disabilities on reaching those who are hard to reach. Journal of Neuroscience Nursing, 39 (3), 163–171. Smeltzer, S. C., Zimmerman, V., & Capriotti, T. (2005). Bone mineral density and osteoporosis risks in women with disabilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 582–586. Nutritional Assessment *Berry, D., Savoye, M., Melkus, G., et al. (2007). An intervention for multiethnic obese parents and overweight children. Applied Nursing Research, 20(2), 63–71.

RESOURCES Alliance of Cannabis Therapeutics: http://marijuana-as-medicine.org/ alliance.htm Canadian Cancer Society, Cancer Information Service: www.cancer.ca Canadian Diabetes Association: http://www.diabetes.ca Heart and Stroke Foundation of Canada: http://www.heartandstroke.com

GENETICS RESOURCES FOR NURSES AND PATIENTS ON THE WEB Gene Clinics: www.geneclinics.org Genetic Alliance: www.geneticalliance.org National Organization of Rare Disorders: www.rarediseases.org OMIM: Online Mendelian Inheritance in Man: www.ncbi.nlm.nih.gov/ Omim/mimstats.html

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6 Obesity Written by Pauline Paul and Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Discuss the prevalence of obesity. 2. Identify and understand determinants of obesity. 3. Identify health issues related to obesity. 4. Discuss the importance of individual intervention, community-based interventions, and policies to deal with obesity.

*Selected chapter content adapted from Hannon, R. A., & Porth, C. M. (2017). Porth pathophysiology: Concepts of altered states (2nd Canadian ed.). Philadelphia, PA: Wolters Kluwer and Grossman, S., & Porth, C. M. (2014). Porth’s pathophysiology: Concepts of altered states (9th ed.). Philadelphia, PA: Wolters Kluwer. 77

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In this chapter we provide a general overview about the prevalence and determinants of obesity. We present a brief overview of health issues related to obesity, as well as selected considerations relative to the prevention and management of obesity. It is important to begin this chapter on obesity with the need for “people first language” (Wittert, Huang, & Heilbronn, 2015, p. 309). While progress has been made with other medical conditions (e.g., the person with a disability), even journals with a focus on obesity are still putting the disease first. “It is well past time we put people before their medical diagnosis of obesity and make a concerted effort to reduce the stigma that is associated with obesity” (Wittert et al., 2015). Using “people first language” is “more respectful and less stigmatising than labelling people by their disease” (Wittert et al., 2015, p. 309).

DEFINITION Overweight and obesity are defined by the World Health Organization (WHO) as “abnormal or excessive fat accumulation that may impair health” (WHO, 2015, p. 1). The body mass index (BMI) is often used to classify people as being overweight (BMI greater than or equal to 25) or obese (BMI greater than or equal to 30). The BMI is defined as “a person’s weight in kilograms divided by the square of his height in metres (kg/m2)” (WHO, 2015, p. 1). Obesity has become a significant global health problem. In 2008, almost 1.5 billion people were classified as overweight, 500 million of which were obese (WHO, 2014). See Chart 6-1 for facts from WHO about obesity. Clinically, obesity and overweight have been defined in terms of the BMI (Fig. 6-1). Historically, various world

Glossary adiposity: another word for obesity bariatrics: “The branch of medicine that deals with prevention, control, and treatment of obesity” (Taber’s Cyclopedic Medical Dictionary, 2009, p. 244) binge eating: period of uncontrolled or excessive indulgence eating or drinking, occasionally followed by purging body mass index (BMI): a simple index of weight-forheight that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his/her height in metres (kg/m2). BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals depression: obesity increases the risk of being diagnosed with major depression by 37%, whereas obese men have a 37% lower risk of depression than men of normal weight. In men, underweight is associated with significantly higher risks of depression and suicide, although whether the association is causal, or whether depressed men smoke more heavily, for example, is unclear drug therapy: may be a helpful component of the treatment regimen for subjects who are obese; with a BMI greater than 30, or a BMI of 27 to 29.9 if they have comorbid conditions (Padwal, Li, & Lau, 2004). The role of drug therapy has been questioned because of concerns about efficacy, the potential for abuse, and side effects dyslipidemia: progressively develops as BMI increases from 21 with a rise in proatheromatous, dense, smallparticle–sized low-density lipoprotein. This change increases the risk of coronary heart disease by a rise in proatheromatous, dense, small-particle–sized lowdensity lipoprotein concentrations, as well as high concentrations of triglycerides, coronary heart disease risk increases

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grazing: eating small amounts of food continuously left ventricular hypertrophy: occurs in 70% of women with both obesity and hypertension, and around 14% of cases of heart failure in women (11% in men) are attributable to obesity. The effect of obesity on heart function is probably due to a combination of factors including hypertension, dyslipidemia, diabetes mellitus, increased fat mass and left ventricular mass, endothelial dysfunction, and atherosclerosis night eating syndrome: consumption of at least 25% (and usually more than 50%) of energy between the evening meal and the next morning; a well-known pattern of disturbed eating in people who are obese obesity: “an unhealthy accumulation of body fat” (Taber’s Cyclopedic Medical Dictionary, 2009, p. 1614); a BMI greater than or equal to 30 obesogenic environment: an environment that contributes to weight gain in a population; this environment includes changes in the food environment and in the level of activity of people (Standing Senate Committee on Social Affairs, Science and Technology, 2016) overweight: a BMI greater than or equal to 25 sleep apnea: the mechanical effects of bulky fatty tissue around the neck induce an obstruction to breathing, particularly during sleep, leading to this. A neck circumference of 43 cm or more in men or 40.5 cm or more in women is associated with episodes of disrupted breathing, recurring up to 30 times a night. Observers describe loud snoring, followed by a pause of 10 seconds or longer in breathing, then a loud grunt and resumption of usual respiration surgical treatment: is increasingly used, particularly in the United States, on patients with BMI of more than 40 and those with severe comorbidity at BMI more than 35. Laparoscopic adjustable banding of the stomach along with roux-en-Y and other forms of gastric bypass are now favoured.

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FIGURE 6.1 Determining body mass index from weight and height.

The health risk from any level of BMI is increased if the patient has gained more than 5 kg (11 pounds) since age 25, or if the waist circumference is above 100 cm (40 in) due to central fatness. BMI: body mass index. * Divide weight by 2.2 to convert pounds into kilograms; multiply height by 2.54 to convert inches into centimeters.

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CHART 6-1

Ten Facts About Obesity (WHO, 2014) 1. Overweight and obesity are defined as “abnormal or excessive fat accumulation that may impair health” 2. More than 1.4 billion adults were overweight in 2008, and more than half a billion were obese 3. Globally, 42 million preschool children were overweight in 2013 4. Overweight and obesity are linked to more deaths worldwide than underweight 5. For an individual, obesity is usually the result of an imbalance between calories consumed and calories expended 6. Supportive environments and communities are fundamental in shaping people’s choices and preventing obesity 7. Children’s choices, diet, and physical activity habits are influenced by their surrounding environment 8. Eating a healthy diet can help prevent obesity 9. Regular physical activity helps maintain a healthy body 10. Curbing the global obesity epidemic requires a population-based multisectoral, multidisciplinary, and culturally relevant approach

bodies have used different BMI cutoff points to define obesity. In 1997, WHO defined the various classifications of overweight (BMI ≥25) and obesity (BMI ≥30); this classification system is also employed by Health Canada (Health Canada, 2003; Health Statistics Division, 2012). In Canada, data from the Canadian Health Measures Survey (CHMS) (2009–2011) showed that almost two of three adults are overweight or obese, with approximately 40% of adults classified as overweight and a further 27% classified as obese (Health Statistics Division, 2012). In the Aboriginal population, the prevalence of obesity is 38%, significantly higher than in the rest of the population (Katzmarzyk, 2008; Public Health Agency of Canada, Canadian Institute for Health Information [PHAC/CIHI], 2011). The prevalence of overweight and obesity is alarming not only because of the number of people affected but because the prevalence continues to increase from previous surveys. In comparing data from the 1978/1979 to the 2009/2011 Canadian Community Health Surveys, the prevalence of obesity has increased from 13.8% of the population to 27% (Health Statistics Division, 2012; Tjepkema, 2005). Perhaps of greater concern is that 32% of Canadian children (5 to 17 years of age) are overweight or obese (Statistics Canada, 2012).

TYPES OF OBESITY Two types of obesity based on distribution of fat have been described: upper body and lower body obesity. Upper body obesity is also referred to as central, abdominal, visceral, or male (“android”) obesity. Lower body obesity is also known as peripheral, gluteal-femoral, or

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female (“gynoid”) obesity. Subjects with upper body obesity are often referred to as being shaped like an “apple,” compared with lower body obesity, which is more “pear” shaped (Fig. 6-2). In general, men have more intra-abdominal fat and women more subcutaneous fat. As men age, the proportion of intra-abdominal fat to subcutaneous fat increases. After menopause, women tend to acquire more central fat distribution. The obesity type is determined by dividing the waist by the hip circumference. A waist-to-hip ratio greater than 1.0 in men and 0.8 in women indicates upper body or central obesity. Central obesity can be further differentiated into intra-abdominal adipose tissue (visceral fat) and subcutaneous abdominal adipose tissue by the use of CT or MRI scans. Waist circumference, which is a measure of central fat distribution, measures both subcutaneous abdominal adipose tissue and intra-abdominal adipose tissue. One of the characteristics of visceral fat is the release of adipokines (such as TNF-α and adiponectin) and fatty acids directly to the liver before entering the systemic circulation, having a potentially greater impact on hepatic function (i.e., the increased fatty acids are deposited in the liver, causing fatty liver, resulting in insulin resistance in the liver). Higher levels of these adipokines and circulating free fatty acids in people with obesity, particularly those with upper body obesity, are thought to be associated with many of the adverse effects of obesity (Ruderman, Carling, Prentki, et al., 2013). The presence of excess fat in the abdomen out of proportion to total-body fat is an independent predictor of risk factors and mortality. Both BMI and waist circumference are positively correlated with totalbody adipose tissue, but waist circumference is a better predictor of abdominal or visceral fat content than BMI (Heart & Stroke Foundation, 2010). A waist circumference greater than 102 cm in men and 88 cm in women is considered high risk for cardiovascular disorders for most Canadians but for some ethnicities (i.e., Asians and south Americans) the cutoff numbers are 90 cm for men and 80 cm for women (Heart & Stroke Foundation, 2010). Weight loss causes a preferential loss of visceral fat (due to higher turnover of visceral fat cells than subcutaneous) and can result in improvements in metabolic and hormonal abnormalities. Although peripheral obesity is associated with varicose veins in the legs and mechanical problems, it is not as strongly associated with cardiometabolic risk. In terms of weight reduction, some studies have shown that persons with upper body obesity are easier to treat than those with lower body obesity. Other studies have shown no difference in terms of success with weight reduction programs between the two types of obesity. Weight cycling (the losing and regaining of weight) has been found to have little or no effect on metabolic variables, central obesity, or cardiovascular risk factors or future amount of weight loss. More research is needed to determine its effect on dietary preference for fat, psychological adjustment, disordered eating, and mortality. It is postulated that it is the underlying obesity and not the weight fluctuation that affects life expectancy (Montani, Viecelli, Prevot, et al., 2006).

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B

FIGURE 6.2 Distribution of adipose tissue in (A) upper body or central (visceral) obesity and (B) lower body or peripheral (subcutaneous) obesity.

People with upper body obesity are often described as having an “apple-shaped” body and those with lower body obesity as having a “pear-shaped” body.

PREVALENCE OF OBESITY According to WHO, the prevalence of obesity has more than doubled since 1980, and “most of the world’s population live in countries where overweight and obesity kills more people than underweight” (WHO, 2015, p. 1). WHO (2015) estimates that in 2014 more than 1.9 billion adults were overweight, including in this number more than 600 million persons who were obese. Based on weight data from 2007 to 2009, the Public Health Agency of Canada and the Canadian Institute for Health Information (PHAC/ CIHI, 2011) estimate that one in four Canadian adults is obese. It is alarming that in Canada, between 1981 and 2007/09, obesity is considered to have doubled in both men and women (PHAC/CIHI, 2011). It has been estimated that “obesity costs Canada between $4.6 billion and $7.1 billion annually in health care and lost productivity” (Standing Senate Committee on Social Affairs, Science and Technology, 2016, p. iv). Vanasse, Demers, Hemiari, et al. (2006), analyzed data from the 2003 Canadian Community Survey and found that rates of obesity were the highest in Newfoundland and Labrador, followed by the Prairies and the North, and the lowest in British Columbia, Quebec, and Ontario.

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Obesity was also found to be less prevalent in the three largest metropolitan areas of the country (Toronto, Montreal, and Vancouver). In Canada, obesity is higher in indigenous populations, and more common in men than women (PHAC/CIHI, 2011).

Childhood Obesity The global prevalence of childhood obesity is rising dramatically over the past three decades with substantially greater increases observed in economically developed regions (Han, Lawlor, & Kimm, 2010; Ng, Fleming, Robinson, et al., 2014). In 2014, the Canadian adapted WHO BMI-for-age growth charts for boys and girls aged 2 to 19 years was released (Dieticians of Canada, 2014). Other growth charts that are used less frequently in Canada are the U.S. Center for Disease Control (CDC) charts. Subsequently, the definition for obesity in Canadian children (ages 5 to 19) using the WHO charts is defined as a BMI at or above the sex- and age-specific 97th percentile, whereas a BMI between the 85th and 97th percentiles is defined as being overweight (Dieticians of Canada, 2014). In North America, childhood obesity has become rampant. Findings from the CHMS indicated obesity has increased 2.5 times in the last decades (Fig. 6-3) (PHAC/CIHI, 2011).

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Percentage overweight or obese, by sex and age group, household population aged 2 to 17, Canada (2004) and United States (1992–2002) Overweight Obese

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Data sources: 2004 Canada Community Health Survey: Nutrition; 1992–2002. National Health and Nutrition Examination Survey Note: Because of rounding, detail may not add to totals. E Coefficient of variation 16.6% to 33.3% (interpret with caution) *Significantly different from estimate for Canada (p < 0.05) FIGURE 6.3 Percentage of overweight or obese children and youth by sex and age groups, comparing Canada (2004) and the United States (1999–

2002). (From Minister of Industry. (2012). Health fact sheet: Body mass index of Canadian children and youth, 2009 to 2011. Statistics Canada, Catalogue No. 82–625-X.)

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Childhood obesity prevalence data surveys were further stratified by ethnicity and in Canada, the prevalence of obesity amongst young individuals of Aboriginal origin is much greater than the national average. In the United States, obesity prevalence amongst young black, Hispanic, and Mexican Americans was significantly greater than among their Caucasian counterparts. The major concern of childhood obesity is that obese children will grow up to become obese adults. Pediatricians are now beginning to see hypertension, dyslipidemia, type 2 diabetes, orthopedic complications, and psychosocial stigma in obese children and adolescents (Han, Lawlor, & Kimm, 2010). In Canada, a study found that 95% of children newly diagnosed with type 2 diabetes were obese (Amed, Dean, Panagiotopoulos, et al., 2010). In addition, there is a growing concern that childhood and adolescent obesity may be associated with negative psychosocial consequences, such as low self-esteem and discrimination by adults and peers (PHAC/CIHI, 2011). Childhood obesity is determined by a combination of hereditary and environmental factors. It is associated with parents who are obese, gestational diabetes and excessive weight gain during pregnancy, formula feeding, parenting style, parental eating, energy-dense food choices, erratic eating patterns, ethnicity, and sedentary lifestyle (Han et al., 2010; PHAC/CIHI, 2011). Children with overweight parents are at highest risk. One of the factors leading to childhood obesity is the increase in inactivity, including increased time indoors engaging in sedentary activities such as television viewing and computer usage. Television viewing is associated with consumption of calorie-dense snacks and decreased indoor activity. Studies have shown preschool children watching more than 2 hours per days of screens (TV or video games) were 34% more likely to be overweight or at risk for becoming overweight compared to children who watch less than 2 hours per day (Steffen, Sinaiko, Zhou, et al., 2013). Obese children also may have a deficit in recognizing hunger sensations, stemming perhaps from parents who use food as gratification. Increasing perceptions that neighbourhoods are unsafe has resulted in less time spent outside playing and walking. Fast food, increased portion sizes, increased energy density, sugarsweetened soft drinks, and foods with a high glycemic index are all likely contributing to the increased weights in children and adolescents. Because of the enormity of the problem of overweight and obesity in children, Obesity Canada (a not-for-profit organization) convened a panel of experts to establish Canadian recommendations for the management of both adult and pediatric obesity (Lau, Douketis, Morrison, et al., 2007). The Canadian guidelines recommend measuring BMI in all children and adolescents aged 2 years and older (Lau et al., 2007). Assessment of the dietary habits of the child who is overweight or obese is an important component of the overall health assessment. This assessment should include self-efficacy and readiness to change; frequency of eating at restaurants or fast food outlets; frequency of consumption of sweetened beverages, 100% fruit juice, and foods high in energy density; examination of portion sizes in relation to appropriateness for

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age; frequency and quality of breakfast and snacks; and frequency of vegetable and fruit consumption. Time spent engaging in physical and sedentary activities should also be assessed. Because adolescent obesity is predictive of adult obesity, treatment of childhood obesity is desirable (Amed et al., 2010; Dieticians of Canada, 2014; Han et al., 2010; Steffen et al., 2013). The goals of therapy in uncomplicated obesity are directed toward healthy eating and activity behaviours, with the focus on sustainable lifestyle changes rather than weight or food restrictions. Families should be taught awareness of current eating habits, activity, and parenting behaviour and how to modify them. For children with complications secondary to the obesity, the goal should be normalization of weight and treatment of the complications. The weight loss interventions should include all family members and caregivers; begin early at a point when the family is ready for change; assist the family to learn to monitor eating and activity patterns and make small and acceptable changes in these patterns; and be designed to encourage and emphasize, not criticize. They should include information about the medical complications of obesity and be directed at permanent changes, not short-term diets or exercise programs aimed at rapid weight loss. It is recommended that health care providers counsel parents and caregivers of children with a BMI between the 5th and 84th percentiles to limit sugar-sweetened beverages and encourage the recommended amount of vegetables and fruits, limit screen time to no more than 2 hours daily, remove television and computer screens from the child’s sleeping area, have the child eat breakfast daily, limit portion size and eating out, especially at fast food restaurants, and encourage family meals where parents and children eat together (Lau et al., 2007; PHAC/ CIHI, 2011). Primary and secondary schools (grades 1 through 12) are pivotal in the promotion of active living and schools have been encouraged to increase daily physical activity and opportunities for recreation (Lau et al., 2007). Education regarding the prevention of childhood obesity can begin in the prenatal stage. The Canadian obesity guidelines encourage discussions regarding the prevention of childhood obesity with pregnant women. In addition, it is recommended that infants be breast-fed exclusively to 6 months of age and that discussion should ensue with the family encouraging limited intake of energy-dense snacks and foods that are high in fat and sugar (Lau et al., 2007). The first treatment options for children who are overweight or obese include dietary counselling (with the goal of reducing energy intake) and promotion of regular physical activity. An optimal diet plan to achieve a healthy body weight should be developed by a qualified health practitioner (preferably a Registered Dietitian) (Lau et al., 2007). Dietary goals should focus on wellbalanced, healthy meals with a healthy approach to eating. Specific strategies can include reduction of specific high-calorie foods or an appropriate balance of foods that are low, medium, and high calorie. Commercial diets should be used with caution. Pharmacologic therapy (i.e., orlistat) may be considered in adolescents to aid in weight reduction and/or maintenance when added to a regimen of lifestyle intervention (Han et al., 2010). Due

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to lack of evidence, pharmacologic therapy is not recommended in prepubertal children. Bariatric surgery in adolescents should be limited to exceptional cases and only be carried out by experienced health care teams (Lau et al., 2007).

HEALTH IMPACT OF OBESITY Obesity is a condition that affects overall health. The excess body fat associated with obesity often impairs health. It has been predicted that the health effects of

Cerebral atherosclerosis, stroke

Hypoventilation (“Pickwickian” syndrome)

Gallstones

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obesity will result in a shorter life expectancy for today’s youth. People who are obese have a 50% to 100% increased risk of premature death from all causes compared to people with a healthy weight. Obesity affects nearly every body system. It is associated with an increased risk of cardiac disease, hypertension, hypertriglyceridemia, and decreased high-density lipoprotein (HDL) cholesterol. Significant weight gain increases the risk of developing type 2 diabetes, obstructive sleep apnea, gastric reflux, urinary stress incontinence, and gallbladder disease (Fig. 6-4). Limited mobility and increased joint disorders are functional results of increased weight on the body’s skeletal system. In women, obesity can contribute to infertility, higher risk pregnancy,

Hypertension, left ventricular hypertrophy

Coronary artery atherosclerosis, myocardial infarction

Diabetes

Hyperlipoproteinemia

FIGURE 6.4 Complications of obesity. (From Rubin, R., Strayer, D. (Eds.). (2012). Rubin’s pathology: Clinicopathologic foundations of medicine (p. 1085). Philadelphia, PA: Lippincott Williams & Wilkins.)

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gestational diabetes, maternal hypertension, and difficulty in labour and delivery. Infants who are born to obese mothers are more likely to be high birth weight, contributing to an increased rate of caesarean section delivery. Several types of cancer are seen in higher frequency in people who are obese, including endometrial, colon, gallbladder, prostate, kidney, and postmenopausal breast cancer. Obesity also causes nonalcoholic steatohepatitis and fatty liver disease. Because some drugs are lipophilic and exhibit increased distribution in fat tissue, the administration of these drugs, including some anesthetic agents, can be more dangerous in persons who are obese. If surgery is required, the person who is obese often heals more slowly than the nonobese person of the same age. Massive obesity, because of its close association with so many health problems, can be regarded as a disease in its own right.

Stigma Individuals who suffer from obesity are often stigmatized and this has an important impact on their psychological health, which may in turn make it more difficult for them to have healthy eating behaviour (Puhl & Heuer, 2010; Schmaltz & Colistra, 2016). It is critical that health professionals reflect on their own perceptions about obesity in order to be able to provide good care. “Although nurses, physicians, and other health professionals are aware of the low success rate and difficulty in treating weight problems, they still may place the blame on the obese patient” (Pleuss, Matfin, & Moisey, 2010, p. 956). Multiple factors come into play in the development of obesity and one must understand that it is a complex condition that has multiple determinants that can interact with each other in a given individual. In Canada and many other countries, there are many negative stereotypes associated with obesity (Puhl & Heuer, 2009; 2010). People, especially women, are expected to be thin, and obesity may be seen as a sign of lack of self-control. Obesity may negatively affect employment and educational opportunities, as well as marital status. Obesity also may play a role in a person’s treatment by health professionals. Although nurses, physicians, and other health professionals are aware of the low success rate and difficulty in treating weight problems, they still may place the blame on the patient who is obese (Puhl & Heuer, 2009; Teixeira & Budd, 2010).

DETERMINANTS OF OBESITY Commonly cited determinants of obesity include physical activity, diet, socioeconomic status, ethnicity and immigration, and environmental factors (PHAC/CIHI, 2011). Although information is presented for each determinant successively, it is critical to understand that obesity is often the result of a combination of determinants.

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Lack of sleep is increasingly being seen as a determinant of obesity and because of this we have added information about the role of sleep in keeping a healthy weight. Psychological and medical and genetic factors have also been added.

Physical Activity Lack of physical activity combined with overeating has long been associated with obesity. Simplistically, eating without burning calories results in weight gain. It is also common knowledge that a sedentary life style leads to ill-health. Sitting too much is associated with many occupations. However, small interventions may have a great impact in reducing this type of immobility. Interventions do not have to be sophisticated; for example, an Australian study used an e-health intervention that prompted employees to move at their work station and saw an increase in activity (Pedersen, Cooley, & Mainsbridge, 2014)

Diet Having healthy eating patterns and access to healthy food are correlated with maintaining a healthy weight (PHAC/ CIHI, 2011). Details about nutrition assessment are presented in Chapter 5. The epidemic of obesity has brought to the forefront issues related to ever-increasing portion sizes, and to the unhealthy amounts of sugar, fat, and salt found in manufactured food. The internet is replete with websites that propose “miracle diets.” It should be understood that changing unhealthy eating habits takes time and is difficult, and that keeping healthy habits is critical to weight control. Some individuals who have weight problems may suffer from additional conditions such as the binge eating disorder and the night eating syndrome. Binge eating is characterized by eating excessively for a number of episodes or days (Goracci, Casamassima, Iovieno, et al., 2015; Grilo, 2002), while the night eating syndrome is characterized by insomnia and overeating during the night (Stunkard, 2002). In both situations, mood disturbances come into play.

Socioeconomic Status Low income has been found to be a contributing factor to obesity in women (Hajizadeh, Campbell, & Sarma, 2014; PHAC/CIHI, 2011). Obesity is less frequent in women who have a higher income. This relationship has not been found for the male population. However, in both men and women there is an association between higher obesity rates and lower level of education (PHAC/ CIHI, 2011). In a recent study conducted with a sample of 5,391 adults living in rural Saskatchewan, researchers found that those who did not live on a farm were more

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likely to be obese than those who lived on a farm. However, living on a farm while having a low income increased the risk of obesity. In the same study, researchers found that individuals who had completed postsecondary education were less likely to be obese (Chen, Rennie, Karunanayake, et al., 2015).

Ethnicity and Immigration Using data from the 2000/2001 Canadian Community Health Survey of Statistics Canada, Tremblay, Pérez, Ardem, et al. (2005) found that obesity was more prevalent in certain ethnic groups. Indigenous people were the most likely to be overweight and obese, while East and South Asians were the least likely to be overweight and obese. In another study, McDonald & Kennedy (2005) found that immigrants were less likely to be overweight but that their weight increased with the number of years they spent in Canada. However, Chinese immigrants did not show the same correlation between increased weight and number of years in Canada. Interestingly, McDonald and Kennedy also found that if an immigrant is from an ethnic group less likely to be obese and this immigrant lives in a neighbourhood where there are more members of his ethnic group, it is less likely that he will become overweight. This may in part explain why Chinese immigrants are less likely to gain weight, as they tend to have established communities and thus may become less acculturated (McDonald & Kennedy, 2005).

Environmental Factors Environmental factors can also play a role in becoming overweight or obese. In Canada, recent research has examined the distribution of supermarkets and fast food outlets in Edmonton neighbourhoods. Smoyer-Tomic, Spence, Raine, et al. (2007) found that fast food outlets were more often in a walking distance in poorer neighbourhoods. Even if a causal relationship cannot be established between the presence of fast food outlets and obesity, it is important to reflect on the impact these outlets may have on weight gain (Hemphill, Raine, Spence, et al., 2008). Similarly, Prince, Kristjansson, Russell, et al. (2012) conducted a study in Ottawa, where 86 neighbourhoods were examined to ascertain if there were links between obesity and multiple variables, including the density of fast food outlets and convenience stores and availability of park areas. The results of this study revealed that when parks were present, females were more likely to be active, and that a greater density of fast food outlets and convenience stores was associated with increased obesity. This type of situation corresponds well to an obesogenic environment as defined by the Standing Senate Committee on Social Affairs, Science and Technology (2016).

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Psychological Factors Psychological factors are another area of influence on behaviour related to weight gain. Eating may be a way to cope with stress, boredom, or anxiety. However, the relationships of these behaviours to mental health and obesity are complex and poorly understood (Koch, Sepa, & Ludvigsson, 2008; Talen & Mann, 2009). No specific personality traits characteristic of people who are obese have been identified (Talen & Mann, 2009). While the causal relationship of psychological behaviours is not clear, binge-eating disorder (BED) behaviours, described as uncontrolled consumption of large quantities of food, have been found in 20% to 30% of people who are obese seeking weight loss treatment (Talen & Mann, 2009). Culture and socioeconomic status are also believed to be contributing factors in the increased rates of overweight and obesity. Increased rates of obesity are seen in Canadian Aboriginal populations, African American, and Hispanic groups, particularly in women. Although many theories have been set forth it is not yet clear what impact cultural food choices and accepted cultural behaviours have on these rates. It is clear that interventions will need to be developed to address the needs of different cultures, as well as address the socioeconomic barriers to improved dietary choices (Calzada & Anderson-Worts, 2009). Much discussion and debate will continue related to causative factors, especially as effective means to treat and prevent obesity are sought.

Medical and Genetic Factors Medical conditions such as thyroid disorder, Cushing syndrome, and polycystic ovarian syndrome can also contribute to weight gain and obesity, as do many medications. The relationship between genetics and weight gain is complex, and, as yet, not fully understood. The most recent and last update of the human obesity gene map series, completed in 2005, reported 135 candidate genes had been identified that are associated with obesity-related phenotypes (Choquet & Meyre, 2011; Rankinen, Zuberi, Chagnon, et al., 2006). Many of these relate to known brain-gut controls of hunger and satiety, metabolism, and the body’s storage mechanisms. Researchers theorize this may help to explain differences in obesity levels found in various populations. Identification of these genetic influences may allow for more targeted treatment interventions in the future. It is yet unknown how genes and mutations may directly or indirectly interact with environmental causes of obesity. One description for the complex interaction between environment and genetics is attributed to George Bray, a noted expert on obesity, who stated “the genetic background loads the gun, but the environment pulls the trigger” (Bray, 2004). There is new evidence that behaviour-based interventions may attenuate the genetic influence of obesity (Temelkova-Kurktschiev & Stefanov, 2012). Though genetic research gives new insight into the genesis of obesity, environmental influence remains the

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major contributor to this worldwide issue (Swinburn, Sacks, Hall, et al., 2011).

Sleep Lack of sleep has been associated with increased obesity in both children and adults. For example, Chaput, Lambert, Gray-Donald, et al. (2015) studied 550 Quebec children and found that “. . . short sleep duration is a risk factor for overweight and obesity, independent of potential covariates” (2015, p. 369). An association has also been made between lack of sleep and weight gain in adults (Patel, Malhotra, White, et al., 2006). There is mounting evidence that lack of sleep negatively affects the metabolic and endocrine systems, resulting in increased appetite and greater fatigue, which would in turn affect energy levels and thus reduce the extent to which the person is physically active (Zimberg, Dâmaso, Del Re, et al., 2012).

PREVENTION OF OBESITY Obesity in epidemic proportions has led to much discussion on methods of prevention, yet few effective approaches have resulted. More research is now being focused on prevention efforts directed at children and adolescents. Most interventions involve modification of lifestyle behaviours to promote healthy food choices and more physical activity. Public debate is also focused on policy methods to regulate availability of less desirable food choices, such as high-calorie snacks and sweetened drinks. Major public education and policy efforts are being undertaken by federal agencies. The Pan-Canadian Healthy Living Strategy is a government endorsed conceptual framework that aspires to a future where the health of Canadians is improved and chronic disease reduced. The targets of this program, to be achieved by 2015, include increasing the proportion of Canadians making healthy food choices, participating in physical activity 30 minutes per day and achieving a BMI within the healthy range (18.5 to 24.9) by 20% (ACPHHS, 2005). Health Canada has developed Canada’s Food Guide which translates dietary guidelines into demonstratable eating behaviours. In addition to the traditional print version, Canada’s Food Guide is also accessible via an interactive websites and applications for electronics that enables individuals to create a personalized food guide and provides tips on maintaining healthy habits (i.e., EATracker.ca) (Health Canada, 2011). Mass media strategies employed to combat obesity have included the nationwide ParticipACTION campaign (ParticipACTION, 2013) which brings together partners from the public, private, and nonprofit sectors to promote physical activity and fitness, and the Half Your Plate campaign (Canadian Produce Marketing Association, 2014) that aims to increase fruit and vegetable consumption. Ultimately, successful prevention measures will utilize not

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only governmental agency strategies and regulatory measures, but also private sector initiatives and communication as well (Gortmaker, Swinburn, Levy, et al., 2011; Swinburn et al., 2011 ).

MANAGEMENT OF OBESITY Considering the complexity of obesity, the management of this condition requires three levels of interventions; individual-based interventions, community-based interventions, and public policy (PHAC/CIHI, 2011). Before treatment begins, an assessment should be made of the degree of overweight and the overall risk status. This should include assessment of the following risk factors or complications (as well as many other important considerations): coronary heart disease and other atherosclerotic diseases, sleep apnea, gynecologic abnormalities, osteoarthritis, gallstones, stress incontinence, cigarette smoking, depression, eating and/or mood disorders, hypertension, high low-density lipoprotein (LDL) cholesterol levels, reduced HDL cholesterol levels, high triglyceride levels, prediabetes or type 2 diabetes, family history of premature coronary heart disease, and physical inactivity (Lau et al., 2007). It also is advisable to determine the person’s barriers and readiness to lose weight (Lau et al., 2007). Several factors can be evaluated to make this assessment. These include reasons and motivations for weight loss, previous history of weight loss attempts, social support, attitude toward physical activity, ability to participate in physical activity, time available for attempting intervention, and understanding the causes of the obesity and its contribution to disease. These help identify the person’s emotional, psychological, physical, and social barriers for making changes.

Individual Interventions Individual interventions target what can be done at the individual level to manage obesity. Life style interventions, dietary interventions, physical activity, pharmacological management, and surgical treatment have been included in the 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children (Lau et al., 2007). Lifestyle modification is an essential factor in treating weight loss. Lifestyle interventions are designed to help individuals change their habits. Strategies include helping participants learn to self-monitor eating habits, including where and when they eat, and identifying situations that trigger eating behaviour. Techniques for changing behaviour include stress management, stimulus control, problem solving, contingency management, cognitive restructuring, social support, and relapse prevention (Jacob & Isaac, 2012). Another important aspect to behaviour modification is helping the person to set realistic weight loss goals (Jacob & Isaac, 2012). Weight loss from diet therapy, exercise, and behavioural

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therapy typically is 10% below the initial baseline (Wadden, Butryn, Wilson, et al., 2007). In many cases, this level can lessen health risks, but often falls short of individual expectations. Dietary interventions include reducing the caloric intake, changing eating habits, and help individuals learn to eat a balanced diet (Lau et al., 2007). The two major components of all diet therapy are caloric restriction and diet composition. While diet modification and caloric restriction are important components of weight loss therapy, no one method has been shown to be most effective. Therefore, dietary therapy should be individually prescribed based on the person’s overweight status and risk profile. The diet should be a personalized plan with realistic goals. Caloric restriction may vary from low-calorie diets to very low-calorie diets. Low-calorie diets typically restrict caloric intake to 1,200 kcal/day. This results in a variable reduction, depending on the initial dietary intake of the individual. Very low–calorie diets restrict calories to approximately 450 kcal/day, primarily made up of protein. This diet has higher risks, including abnormal heart rhythms, and cholelithiasis, and anyone on this diet should be under direct supervision of a medical professional. A more conservative dietary approach is to reduce the current dietary intake by 500 to 1,000 kcal/day. Total caloric intake should be distributed in four or five meals or snacks throughout the day. Portion control is an effective technique to help achieve calorie reduction. Many people who are overweight have not practiced or monitored portion size. Chart 6-2 shows how portion sizes have changed over the years. One strategy for individual portion control is to keep daily diet logs of all food ingested to facilitate awareness of both content and frequency. Meal replacements, such as protein shakes with vitamins and minerals, may also be used as a substitute for solid food meals. After caloric restriction is determined diet composition should be addressed. There are many methods of altering dietary content, including low fat diets, and low carbohydrate/ high protein diets. Low fat diets strive to limit daily calo-

ries from fat to 10% to 15% of total calorie intake. This level may be difficult to achieve, and often is less palatable. Low carbohydrate/high protein diets became popular in the 1960s and 1970s. Although effective for weight loss, especially in the initial stages, they can contribute to health risks. Higher protein diets can increase the risk of kidney stones, and the decrease in fibre can also increase risks of cancer and raise cholesterol levels. Increasing physical activity is also commonly recommended. There is convincing evidence that increased physical activity decreases the risk of overweight and obesity. “Physical activity and exercise should be sustainable and tailored to the individual” (Lau et al., 2007, p. 54). In addition, it reduces cardiovascular and diabetes risk beyond that achieved by weight loss alone. Physical activity is an important part of weight loss therapy and helps with maintaining weight loss. In addition, it may help reduce abdominal fat, increase cardiorespiratory fitness, and prevent the decrease in muscle mass that often occurs with weight loss. Exercise should be started slowly with the duration and intensity increased independently of each other. The goal should be 60 minutes or more of moderate to vigorous activity on most days of the week to maintain weight, and 60 to 90 minutes when trying to sustain weight loss (ACPHHS, 2005; Health Canada, 2011; ParticipACTION, 2013). The activity can be performed at one time or intermittently over the day. It is however telling that only 15% of Canadian adults reach this target (Standing Senate Committee on Social Affairs, Science and Technology (2016). Pharmacotherapy can be used as an adjunct to the aforementioned regimen in some patients with a BMI of 30 or more with no other risk factors or diseases, and for patients with a BMI of 27 or more with concomitant risk factors or diseases. Risk factors and diseases defined as warranting pharmacotherapy are coronary heart disease, type 2 diabetes, metabolic syndrome, gynecologic abnormalities, osteoarthritis, gallbladder disease, stress incontinence, and sleep apnea (Lau et al., 2007). In selected patients with acceptable operative risk factors, surgical therapy is currently the most effective treatment

CHART 6-2

Portion Distortion (National Heart, Lung, and Blood Institute, 2015)

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Food

Portion Size 20 Years Ago

Present Portion Size Today

Soda pop

200 mL (85 calories)

600 mL (250 calories)

Cheeseburger

(333 calories)

(590 calories)

French fries

2.4 oz (210 calories)

6.9 oz (610 calories)

Bagel

3-in diametre (140 calories)

6-in diametre (350 calories)

Turkey sandwich

320 calories

820 calories

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of severe obesity with respect to degree and duration of weight reduction achieved (Dixon, Zimmet, Albertit, et al., 2011). Bariatric surgery, although invasive, does afford significant weight loss, long-term weight loss maintenance, improved quality of life, decreased incidence of associated diseases, and decreased all-cause mortality (including mortality due to cardiovascular disease and cancer). This option is usually limited to persons with a BMI greater than 40; those with a BMI greater than 35 who have comorbid conditions and in whom efforts at medical therapy have failed; and those who have complications of extreme obesity. Pharmacological management and surgical management (bariatric surgery) of obesity are presented in more detail in Chapter 38.

Community-based Interventions Community-based interventions consist of the development and implementation of programs at the community level. For example, physical activity programs at work can be considered community-based programs. Communitybased interventions can also include comprehensive programs that target multiple determinants of obesity. Social marketing programs are also considered to be communitybased interventions (PHAC/CIHI, 2011). ParticipAction is probably the most famous Canadian social marketing campaign. It has been proposing ways for Canadians to be more active since the 1970s. An example of a community-based intervention program is the Healthy Foods North nutrition and lifestyle intervention program, which targeted Inuit and Inuvialuit communities. The program used behaviour change strategies as well as environmental strategies. For example, it used pedometer challenges at work and promoted the use of traditional food instead of manufactured products. The importance of using traditional food is key when one considers the cost of bringing fresh produce to the North. Such costs can make it very difficult for the average person to buy perishable foods and instead pushes them to purchase unhealthy items that could be replaced by cheaper and healthier traditional foods (Sharma, Gittelsohn, Rosol, et al., 2010).

Public Policy From a public health perspective, it is important that policy makers be involved in the management of obesity. For example, one of the recommendations of a study by Smoyer-Tomic et al. (2007) is that urban centres may want to consider zoning bylaws that would regulate the extent to which food stores can be present in a given neighbourhood. Similarly, schools’ board can also play a role in preventing obesity in children by limiting the

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number of vending machines and replacing them by fresh food. Higher level policy makers such as provincial and federal governments can bring legislation that regulated the amounts of salt and sugar included in processed food. They can also create measures that facilitate access to healthy food, or limit access to unhealthy food. In March 2016, the Standing Senate Committee on Social Affairs, Science and Technology released its report on obesity in Canada (Standing Senate Committee on Social Affairs, Science and Technology, 2016). The report includes an exhaustive list of recommendations that will hopefully be addressed by policy makers. These very comprehensive recommendations are presented in Chart 6-3. Much needs to be done by policy makers to better regulate the food industry. For example, “there are 56 different names for sugar alone and manufacturers do not have to group them together” (Standing Senate Committee on Social Affairs, Science and Technology, 2016, p. iv). It has also been noted that the absence of stringent regulations mean that manufacturers create their own versions of food labelling systems, which are very confusing for consumers.

SUMMARY OF KEY POINTS multiple organ-specific pathologic consequences. factors, psychological influences, and activity levels have been implicated as causative factors in the development of obesity. The health risks associated with obesity affect almost every body system. body obesity. Upper body obesity is associated with a higher incidence of complications. ing the Canadian pediatric populations. Factors that predispose to childhood obesity include erratic eating patterns, calorie-dense food choices, and lack of exercise and sedentary lifestyle. The major concern of childhood obesity is that obese children will grow up to become obese adults. Pediatricians are now beginning to see hypertension, dyslipidemia, type 2 diabetes, orthopedic complications, and psychosocial stigma in obese children and adolescents. Because of the scope of the problem, it is recommended that the weight status of all children be evaluated yearly and that measures to prevent and treat obesity be included in the health care plan for all children. interventions; individual-based interventions, community-based interventions, and public policy (PHAC/ CIHI, 2011). The treatment of obesity focuses on nutritionally adequate weight loss diets, behaviour modification, exercise, social support, and, in situations of marked obesity, pharmacotherapy and surgical methods.

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CHART 6-3

Recommendations of the Standing Senate Committee on Social Affairs, Science, and Technology (Standing Senate Committee on Social Affairs, Science and Technology, 2016, pp. 40–44). Recommendation 1—The committee recommends that the federal government, in partnership with the provinces and territories and in consultation with a wide range of stakeholders, create and implement a National Campaign to Combat Obesity which includes goals, timelines, and annual progress reports. Recommendation 2—The committee recommends that the federal government: Immediately conduct a thorough assessment of the prohibition on advertising food to children in Quebec; and, Design and implement a prohibition on the advertising of foods and beverages to children based on that assessment. Recommendation 3—The committee recommends that the federal government: Assess the options for taxation levers with a view to implementing a new tax on sugar-sweetened as well as artificially sweetened beverages; and, Conduct a study, and report back to this committee by December 2016, on potential means of increasing the affordability of healthy foods including, but not limited to, the role of marketing boards, food subsidies, and the removal or reduction of existing taxes. Recommendation 4—The committee further recommends that the Indigenous and Northern Affairs Canada immediately: Address the recommendations made by the Auditor General with respect to the Nutrition North program and report back to this committee on its progress by December 2016. Recommendation 5—The committee further recommends that the federal government conduct assessments of the Children’s Fitness Tax Credit, the Working Income Tax Benefit, and the Universal Child Care Benefit with a view to determining how fiscal measures could be used to help Canadians of lower socioeconomic status, including our Aboriginal population, choose healthy lifestyle options. Recommendation 6—The committee recommends that the Minister of Health immediately undertake a complete revision of Canada’s Food Guide in order that it better reflect the current state of scientific evidence. The revised food guide must: Be evidence based; Apply meal-based rather than nutrient-based principles; Effectively and prominently describe the benefits of fresh, whole foods compared to refined grains, ready-to-eat meals, and processed foods; and Make strong statements about restricting consumption of highly processed foods. Recommendation 7—The committee further recommends that the Minister of Health revise the food guide on the guidance of an advisory body which: Comprises experts in relevant areas of study, including but not limited to nutrition, medicine, metabolism, biochemistry, and biology; and Does not include representatives of the food or agriculture industries. Recommendation 8—The committee therefore recommends that the Minister of Health prohibit the use of partially hydrogenated oils, to minimize trans fat content in food, unless specifically permitted by regulation. Recommendation 9—The committee further recommends that the Minister of Health: Reassess the daily value applied to total carbohydrates based on emerging evidence regarding dietary fat and the fat promoting nature of carbohydrates; Ensure that the regulatory proposals for serving size have addressed all of the concerns raised by stakeholders during public consultation; and Require that the daily intake value for protein be included in the Nutrition Facts table. Recommendation 10—The committee further recommends that the Minister of Health assess whether sugar and starch should be combined under the heading of total carbohydrate within the Nutrition Facts table and report back to this committee by December 2016. Recommendation 11—The committee therefore recommends that the Minister of Health implement strict limits on the use of permitted health claims and nutrient content claims based on a measure of a food’s energy density relative to its total nutrient content.

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Recommendation 12—The committee therefore recommends that the Minister of Health: Immediately undertake a review of front-of-package labelling approaches that have been developed in other jurisdictions and identify the most effective one; Report back to this committee on the results of the review by December 2016; Amend the food regulations to mandate the use of the identified front-of-package approach on those foods that are required to display a Nutrition Facts table; and Encourage the use of this labelling scheme by food retailers and food service establishments on items not required to display a Nutrition Facts table. Recommendation 13—The committee therefore recommends that the Minister of Health encourage nutrition labelling on menus and menu boards in food service establishments. Recommendation 14—The committee therefore recommends that the federal government increase funding to ParticipACTION to a level sufficient for the organization to: Proceed with Active Canada 20/20; and Become the national voice for Canada’s physical activity messaging. Recommendation 15—The committee further recommends that the Minister of Health and the Minister of Sport and Persons with Disabilities together use the recently established National Health and Fitness Day to promote the Canadian Physical Activity Guidelines. Recommendation 16—The committee further recommends that the Public Health Agency of Canada provide sustained or bridged funding for pilot projects that have been assessed as effective. Recommendation 17—The committee further recommends that the Minister of Health in discussion with provincial and territorial counterparts as well as nongovernmental organizations already engaged in these initiatives: Encourage improved training for physicians regarding diet and physical activity; Promote the use of physician counselling, including the use of prescriptions for exercise; Bridge the gap between exercise professionals and the medical community by preparing and promoting qualified exercise professionals as a valuable part of the health care system and health care team; Address vulnerable populations, such as Canadians of lower socioeconomic status including Canada’s Aboriginal population, and pregnant women; Advocate for childcare facility and school programs related to breakfast and lunch programs, improved physical education, physical activity, and nutrition literacy courses; and, Engage provincial governments in discussions about infrastructure requirements for communities that encourage active transportation and active play. Recommendation 18—The committee further recommends that the federal government provide funding under the New Building Canada Fund to communities for infrastructure that enables, facilitates, and encourages an active lifestyle, both indoors and outdoors. Recommendation 19—The committee therefore recommends that the Public Health Agency of Canada implement a strategy to increase the visibility, uptake, and use of the Best Practices Portal by stakeholders across the country. Recommendation 20—The committee therefore recommends that Health Canada design and implement a public awareness campaign on healthy eating based on tested, simple messaging. These messages should relate to, but not be limited to: Most of the healthiest food doesn’t require a label; Meal preparation and enjoyment; Reduced consumption of processed foods; and The link between poor diet and chronic disease. Recommendation 21—The committee further recommends that Health Canada and other relevant departments and agencies, together with existing expertise and trusted organizations, implement a comprehensive public awareness campaign on healthy active lifestyles.

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Chaput, J. P., Lambert, M., Gray-Donald, K., et al. (2011). Short sleep duration is independently associated with overweight and obesity in Quebec children. Canadian Journal of Public Health, 102(5), 369– 374. Chau, J. Y., van der Ploeg, H. P., Merom, D., et al. (2012). Cross-sectional associations between occupational and leisure-time sitting, physical activity and obesity in working adults. Preventive Medicine, 54, 195– 200. Chen, Y., Rennie, D. C., Karunanayake, C. P., et al. (2015). Income adequacy and education associated with the prevalence of obesity in rural Saskatchewan, Canada. BMC Public Health, 15, 700. Choquet, H., & Meyre, D. (2011). Genetics of obesity: What have we learned? Current Genomics, 12(3), 169–179. Cossrow, N. H., Jeffery, R. W., & McGuire, M. T. (2001). Understanding weight stigmatization: A focus group study. Journal of Nutrition Education, 33(4), 208–214. De Maio, F. G. (2010). Immigration as pathogenic: A systematic review of the health of immigrants to Canada. International Journal for Equity and Health, 9, 27. deZwaan, M., Marshchollek, M., & Allison, K. C. (2015). The night eating syndrome (NES) in bariatric surgery patients. European Eating Disorders Review, 23, 426–434. Dieticians of Canada. (2014). WHO growth charts for Canada: Updated March 2014. Available at: http://www.dietitians.ca/Secondary-Pages/ Public/WHO-Growth-Charts.aspx Dixon, J. B., Zimmet, P., Albertit, K. G., et al. (2011). Bariatric surgery: An IDF statement for obese type 2 diabetes. Diabetic Medicine, 28(6), 628–642. Dunn, J. R., & Dyck, I. (2000). Social determinants of health in Canada’s immigrant population: Results from the National Population Health Survey. Social Science and Medicine, 51, 1573–1593. Fencl, J. L., Walsh, A., & Vocke, D. (2015). The bariatric patient: An overview of perioperative care. AORN Journal, 102(2), 116–131. Flattum, C., Draxten, M., Horning, M., et al. (2015). HOME Plus: Program intervention to promote the frequency and healthfulness of family meals, reduce children’s sedentary behavior, and prevent obesity. International Journal of behavioral Nutrition and Physical Activity, 12(53), 1–9. Galloway, T., Johnson-Down, L., & Egeland, G. M. (2015). Socioeconomic and cultural correlates of diet quality in the Canadian Arctic: Results from the 2007–2008 Inuit Health Survey. Canadian Journal of Dietetic Practice and Research, 76(3), 117–125. Goracci, A., Casamassima, F., Iovieno, N., et al. (2015). Binge eating disorder: From clinical research to clinical practice. Journal of Addiction Medicine, 9(1), 20–24. Gortmaker, S. L., Swinburn, B. A., Levy, D., et al. (2011). Changing the future of obesity: Science, policy and action. Lancet, 378(9793), 838– 847. Hajizadeh, M., Campbell, M. K., & Sarma, S. (2014). Socioeconomic inequalities in adult obesity risk in Canada: Trends and decomposition analyses. The European Journal of Health Economics, 15, 203–221. Han, J. C., Lawlor, D. A., & Kimm, S. Y. (2010). Childhood obesity. Lancet, 375(9727), 1737–1748. Health Canada. (2011). Eating well with Canada’s food guide. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php Health Statistics Division. (2012). Body composition of Canadian adults, 2009 to 2011. Available at: http://www.statcan.gc.ca/pub/82-625-x/2012001/ article/11708-eng.htm Heart & Stroke Foundation. (2010). Healthy waists. Available at: http:// www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3876195/ Hemphill, E., Raine, K., Spence, J. C., et al. (2008). Exploring obesogenic food environments in Edmonton, Canada: The association between socioeconomic factors and fast-food outlet access. American Journal of Health Promotion, 22(8), 426–432. Hieke, S., Palascha, A., Jola, C., et al. (2016). The pack size effect: Influence on consumer perceptions of portion sizes. Appetite, 96, 225–238. Hopping, B. N., Erber, E., Mead, E., et al. (2010). High levels of physical activity and obesity co-exist amongst Inuit adults in Arctic Canada. Journal of Human Nutrition and Dietetics, 23(Suppl 1), 110–114. Jacob, J. J., & Isaac, R. (2012). Behavioral therapy for management of obesity. Indian Journal of Endocrinology and Metabolism, 16(1), 28–32. Katzmarzyk, P. (2008). Obesity and physical activity among Aboriginal Canadians. Obesity, 16(1), 184–190. Koch, F. S., Sepa, A., & Ludvigsson, J. (2008). Psychological stress and obesity. Journal of Pediatrics, 153(6), 839–844.

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CHAPTER 6 Kuk, J. L. (2014). The influence of ethnicity and gender on the association between measured obesity and cardiorespiratory fitness with selfrated overweight, physical activity and health. Perspectives in Public Health, 134(1), 38–43. Lau, D. C., Douketis, J. D., Morrison, K. M., et al.; Obesity Canada Clinical Guidelines Expert Panel. (2007). 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. Canadian Medical Association Journal, 176(Suppl 8), S1–13. McDonald, J. T., & Kennedy, S. (2005). Is immigration to Canada associated with unhealthy weight gain? Overweight and obesity among Canada’s immigrants. Social Science and Medicine, 61, 2469–2481. Montani, J., Viecelli, A. K., Prevot A., et al. (2006). Weight cycling during growth and beyond as a risk factor of later cardiovascular diseases: The ‘repeated overshoot’ theory. International Journal of Obesity, 30(Suppl 4), S58–S66. Mooney, S. J., El-Sayed, A. M. (2006). Stigma and the etiology of depression among the obese: An agent-based exploration. Social Science and Medicine, 148, 1–7. National Heart, Lung, and Blood Institute. (2015). Portion Distortion. Do you know how food portions have changed in twenty years? Washington, DC: Author. Available at: http://www.nhlbi.nih.gov/health/educational/wecan/eat-right/portion-distortion.htm Neil, J. A., Robertson, D. W. (2015). Enhancing nursing care by understanding the bariatric patient’s journey. AORN Journal, 102, 132– 140. Ng, M., Fleming, T., Robinson, M., et al. (2014). Global, regional and national prevalence of overweight and obesity in children and adults during 1980–2013: A systemic analysis for the Global Burden of Disease Study 2013. Lancet, 384(9945), 766–781. O’Donnell, S., Rusu, C., Bernatsky, S., et al. (2013). Exercise/physical activity and weight management efforts in Canadians with selfreported arthritis. Arthritis Care & Research, 65(12), 2015–2023. Padwal, R., Li, S. K., & Lau, D. C. (2004). Long-term pharmacology for obesity and overweight. Cochrane Database of Systematic Reviews, (3), CD004094. ParticipACTION. (2013). Participaction: Let’s get moving. Available at: http://www.participaction.com Patel, S. R., Malhotra, A., White, D. P., et al. (2006). Association between sleep and weight gain in women. American Journal of Epidemiology, 164, 947–954. Pearl, R. L., & Lebowitz, M. S. (2016). Beyond personal responsibility: Effects of causal attributions for overweight and obesity on weightrelated beliefs, stigma, and policy support. Psychology & Health, 29(10), 1176–1191. Pederson, S. J., Cooley, P. D., & Mainsbridge, C. (2014). An e-health intervention designed to increase workday energy expenditure by reducing prolonged occupational sitting habits. Work, 49(2), 289– 295. Pietinläinen, K. H., Saarni, S. E., Kaprio, J., et al. (2012). Does dieting make you fat? A twin study. International Journal of Obesity, 36, 456– 464. Prince, S. A., Kristjansson, E. A., Russell, K., et al. (2012). Relationship between neighborhoods, physical activity, and obesity: A multilevel analysis of a large Canadian city. Obesity, 20(10), 2093–2100. Public Health Agency of Canada and Canadian Institute for Health Information. (2011). Obesity in Canada. Ottawa: Authors. Available at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity, 17(5), 941–964. Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important considerations for public health. American Journal of Public Health, 100(6), 1019–1028. Pysarenko, S., & Yu, W. (2015). The effects of demographic, socio-economic and lifestyle component on adult obesity in Canada: Empirical study. International Journal of Business and Public Administration, 12(1), 133–151. Raine, K. D., Plotnikoff, R., Schopflocher, D., et al. (2013). Healthy Alberta Communities: Impact of a three-year community-based obesity and chronic disease prevention intervention. Preventive Medicine, 57, 955–962. Rankinen, T., Zuberi, A., Chagnon, Y. C., et al. (2006). The human obesity gene map: The 2005 update. Obesity, 14(4), 529–644. Rockingham, L. (2016). Ethical aspects of nurses’ thought ‘too fat to care’. Nursing Ethics, 23(1), 117–120.

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Rowen, L., & Huseman, S. (2010). Possibilities for nursing classroom and curricula changes: Obesity trends require a new way to educate student nurses. Bariatric Nursing And Surgical Patient Care, 5(2), 95–102. Ruderman, N. B., Carling, D., Prentki, M., et al. (2013). AMPK, insulin resistance, and the metabolic syndrome. Journal of Clinical Investigation, 123(7), 2764–2772. Runfola, C. D., Allison, K. C., Hardy, K., et al. (2014). Prevalence and clinical significance of night eating syndrome in university students. Journal of Adolescent Health, 59, 41–48. Schmaltz, D. L., & Colistra, C. M. (2016). Obesity stigma as a barrier to healthy eating behavior. Topics in Clinical Nutrition, 31(1), 86–94. symptom: An aetiological framework for the assessment and management of obesity. Obesity Reviews, 11, 362–370. Sharma, S., Gittelsohn, J., Rosol, R., et al. (2010). Addressing the public burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention programme. Journal of Human Nutrition and Dietetics, 23(Suppl 1), 120–127. Smoyer-Tomic, K. E., Spence, J. C., Raine, K. D., et al. (2007) The association between neighborhood socioeconomic status and exposure to supermarkets and fast food outlets. Health & Place, 14, 740–754. Standing Senate Committee on Social Affairs, Science and Technology. (2016). Report of the Standing Senate Committee on Social Affairs, Science and Technology. Obesity in Canada; A whole-of-society approach for a healthier Canada. Ottawa: Author. Available at: http://www.parl. gc.ca/Content/SEN/Committee/421/soci/RMS/01mar16/Report-e.htm Statistics Canada. (2012). Body mass index of Canadian children and youth, 2009 to 2011. Available at: http://www.statcan.gc.ca/pub/82625-x/2012001/article/11712-eng.htm Steffen, L. M., Sinaiko, A. R., Zhou, X., et al. (2013). Relation of adiposity, television and screen time in offspring to their parents. BMC Pediatrics, 13, 133. Swinburn, B. A., Sacks, G., Hall, K. D., et al. (2011). The global obesity pandemic: Shaped by global drivers and local environments. Lancet, 378(9793), 804–814. Talen, M. R., & Mann, M. M. (2009). Obesity and mental health. Primary Care, 36(2), 287–305. Teixeira, M. E., & Budd, G. M. (2010). Obesity stigma: A newly recognized barrier to comprehensive and effective type 2 diabetes management. Journal of the American Academy of Nurse Practitioners, 22(10), 527–533. Temelkova-Kurktschiev, T., & Stefanov, T. (2012). Lifestyle and genetics in obesity and type 2 diabetes. Experimental and Clinical Endocrinologyand Diabetes, 120(1), 1–6. The Secretariat for the Intersectoral Healthy Living Network in partnership with the F/P/T Healthy Living Task Group and the F/P/T Advisory Committee on Population Health and Health Security (ACPHHS). (2005). The integrated Pan-Canadian healthy living strategy. Health Canada, Catalogue No. HP10–1/2005. Tjepkema, M. (2005). Adult obesity in Canada: Measured height and weight. Statistics Canada Catalogue no. 82–620-MWE2005001. Towns, C., Cooke, M., Rysdale, L., et al. (2014). Healthy weights interventions in Aboriginal children and youth: A review of the literature. Canadian Journal of Dietetic Practice and Research, 75(3), 125–131. Tremblay, A., & Chaput, J. P. (2008). About unsuspected potential determinants of obesity. Applied Physiology Nutrition and Metabolism, 33, 791–796. Tremblay, M. S., Pérez, C. E., Ardem, C. I., et al. (2005). Obesity, overweight and ethnicity. Statistics Canada Catalogue 82–003, Health Reports, 16(4), 23–34. Tu, A. W., & Mâsse, L. C. (2012). The relationship between income and weight control strategies among Canadian adults. Canadian Journal of Public Health, 103(6), 438–442. Vanasse, A., Demers, M., Hemiari, A., et al. (2006). Obesity in Canada: Where and how many? International Journal of Obesity, 30, 677–783. Wadden, T. A., Butryn, M. L., & Wilson, C. (2007). Lifestyle modification for the management of obesity. Gastroenterology, 132(6), 2226– 2238. Wansink, B., & Wansink, C. S. (2010). The largest Last Supper: Depictions of food portions and plate size increased over the millennium. International Journal of Obesity, 34, 943–944. Ward, H., Tarasuk, B., & Mendelson, R. (2007). Socioeconomic patterns of obesity in Canada: Modeling the role of health behaviour. Applied Physiology Nutrition Metabolism, 32, 206–216.

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Witter, G. A., Huang, K. C., & Heilbron, L. K. (2015). Supporting for callout for people first language in obesity. Obesity Research and Clinical Practice, 9(4), 309. World Health Organization. (2014). Ten facts about obesity. Geneva: Author. Available at: http://www.who.int/features/factfiles/obesity/en/ World Health Organization. (2015). Obesity and overweight. Fact Sheet 311. Geneva: Author. Available at: http://www.who.int/mediacentre/ factsheets/fs311/en/ Zimberg, I. Z., Dâmaso, A., Del Re, M., et al. (2012). Short sleep duration and obesity: Mechanisms and future perspectives. Cell Biochemistry and Function, 30, 524–529.

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RESOURCES Canada’s Food Guides: http://healthycanadians.gc.ca/eating-nutrition/ healthy-eating-saine-alimentation/food-guide-aliment/index-eng. php Canadian Obesity Network: http://www.obesitynetwork.ca/ Canadian Society for Exercise Physiology, Canadian Physical Activity Guidelines: http://www.csep.ca/en/guidelines/get-the-guidelines National Association of bariatric Nurses: http://www.bariatricnurses.org/ ParticipAction: http://www.participaction.com/fr/splash/ The Obesity Society: http://www.obesity.org/home

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U N I T

2

Case Study Applying Concepts From NANDA-I, NIC, and NOC A Patient With Fear Accompanied by Somatic Complaints Unsubstantiated by Physical Findings Mr. Roberts is a 40-year-old man who comes to the emergency department (ED) for treatment of high blood pressure. On his previous visit to the ED he reported chest pressure, feelings of numbness and tingling in his arms, and extreme fearfulness that he was having a heart attack. Even though a myocardial infarction was ruled out and subsequent testing revealed that he had no heart disease, Mr. Roberts continues to have feelings of chest pressure and fear that he is having a heart attack. The only unexpected finding has been an elevation of blood pressure (158/88 mm Hg). The nurse interviews Mr. Roberts, who reveals he is under intense financial pressure. The nurse assesses his adherence with his antihypertensive therapy and suggests interventions to help with Mr. Robert’s anxiety. Visit to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems.

Biophysical and Psychosocial Concepts in Nursing Practice

A patient with fear accompanied by somatic complaints unsubstantiated by physical findings receives the nursing diagnoses Anxiety

is managed by

requires nursing interventions Anxiety Reduction

outcomes should show improvement in may lead to improved

Self-Control

and

Coping Enhancement

and

and

Ineffective Coping

may benefit from

Counselling

and may lead to improved

may lead to improved

and may help improve Support System Enhancement

Coping

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes

Anxiety—Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Anxiety Reduction—Minimizing apprehension, dread, foreboding, or uneasiness related to unidentified source of anticipated danger

Anxiety Self-Control—Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source

Ineffective Coping—Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Coping Enhancement—Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles

Coping—Personal actions to manage stressors that tax an individual’s resources

Return to functional baseline status, stabilization of, or improvement in:

Counseling—Use of an interactive helping process focusing on the needs, problems, or feelings of the patient and significant others to enhance or support coping, problem solving, and interpersonal relationships Support System Enhancement— Facilitation of support to patient by family, friends, and community From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St Louis, MO: Mosby-Elsevier; Herdman, T. H. (Ed.). (2012). NANDA International Nursing Diagnoses: Definitions & classification, 2012–2014. Oxford, UK: Wiley-Blackwell; Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds). (2013). Nursing outcomes classification (NOC): Measurement of health outcomes. (5th ed.). St. Louis, MO: Mosby-Elsevier.

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7 Homeostasis, Stress, and Adaptation Adapted by Beverly Williams

Learning Objectives On completion of this chapter, the learner will be able to: 1. Relate the principles of internal constancy, homeostasis, stress, and adaptation to the concept of steady state. 2. Identify the significance of the body’s compensatory mechanisms in promoting adaptation and maintaining the steady state. 3. Identify physiologic and psychosocial stressors. 4. Compare the sympathetic–adrenal–medullary and hypothalamic–pituitary responses to stress. 5. Describe the general adaptation syndrome as a theory of adaptation to biologic stress. 6. Describe the relationship of the process of negative feedback to the maintenance of the steady state. 7. Compare the adaptive processes of hypertrophy, atrophy, hyperplasia, dysplasia, and metaplasia. 8. Describe the inflammatory and reparative processes. 9. Assess the health patterns of a person and determine their effects on maintenance of the steady state. 10. Identify ways in which maladaptive responses to stress can increase the risk of illness and cause disease. 11. Identify individual and group measures that are useful in reducing stress.

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When the body is threatened or suffers an injury, its response may involve functional and structural changes; these changes may be adaptive (having a positive effect) or maladaptive (having a negative effect). The defense mechanisms that the body uses determine the difference between adaptation and maladaptation—health and disease. This chapter discusses homeostasis, stress, adaptation, health problems associated with maladaptation, and ways nurses can intervene to reduce stress and its healthrelated effects.

FUNDAMENTAL CONCEPTS Each body system performs specific functions to sustain optimal life for an organism. Mechanisms for adjusting internal conditions promote the usual steady state of the organism and its survival. These mechanisms are compensatory in nature and work to restore balance in the body. An example of this restorative effort is the development of rapid breathing (hyperpnea) after intense exercise in an attempt to compensate for an oxygen deficit and excess lactic acid accumulated in the muscle tissue. Pathophysiologic processes result when cellular injury occurs at such a rapid rate that the body’s compensatory mechanisms can no longer make the adaptive changes necessary to remain healthy. An example of a pathophysiologic change is the development of heart failure; the body reacts by retaining sodium and water and increasing venous pressure, which worsens the condition. These pathophysiologic responses give rise to symptoms that are reported by patients or signs that are observed by patients, nurses, or other health care providers. These observations,

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plus a sound knowledge of physiologic and pathophysiologic processes, can assist in determining the existence of a problem and can guide nurses in planning the appropriate course of action.

Steady State Physiologic mechanisms must be understood in the context of the body as a whole. Each person, as a living system, has both an internal and an external environment, between which information and matter are continuously exchanged. Within the internal environment, each organ, tissue, and cell is also a system or subsystem of the whole, each with its own internal and external environment, each exchanging information and matter (Fig. 7-1). The goal of the interaction of the body’s subsystems is to produce a dynamic balance or steady state (even in the presence of change), so that all subsystems are in harmony with each other. Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Claude Bernard, a 19th-century French physiologist, developed the biologic principle that for life there must be a constancy or “fixity of the internal milieu” despite changes in the external environment. The internal milieu was the fluid that bathed the cells, and the constancy was the balanced internal state maintained by physiologic and biochemical processes. His principle implied a static process. Homeostasis refers to a steady state within the body. When a change or stress occurs that causes a body function to deviate from its stable range, processes are initiated

Glossary adaptation: a change or alteration designed to assist in adjusting 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 cortisol 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 behavioural strategies used to manage the stressors that tax a person’s resources dysplasia: bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type glucocorticoids: the group of steroid hormones, such as cortisol, that are produced by the adrenal cortex; they are involved in carbohydrate, protein, and fat metabolism and have anti-inflammatory properties gluconeogenesis: the formation of glucose by the liver from noncarbohydrate sources, such as amino acids and the glycerol portion of fats

guided imagery: the mindful use of a word, phrase, or visual image 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 of a tissue hypoxia: inadequate supply of oxygen to the cell inflammation: a localized, protective reaction of tissue to injury, irritation, or infection, manifested by pain, redness, heat, swelling, and sometimes loss of function metaplasia: a cell transformation in which there is conversion of one type of mature cell into another type of 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

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External environment: Family Group Community Society as a whole Humans

Organ system

Organ

Tissue

Cell

FIGURE 7-1. Constellation of systems. Each system is a subsystem of

the larger system (suprasystem) of which it is a part. In this figure the cells represent the smallest system and are a subsystem of all other systems.

to restore and maintain dynamic balance. When these adjustment processes or compensatory mechanisms are not adequate, steady state is threatened, function becomes disordered, and dysfunctional responses occur. This can lead to disease, which is a threat to steady state. Disease is an unexpected variation in the structure or function of any part of the body. It disrupts function and therefore can limit freedom of action.

Stress and Adaptation Stress is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium. The person may feel unable to meet the demands of the new situation. The change or stimulus that evokes this state is the stressor. The nature of the stressor is variable; an event or change that is stressful for one person may not be stressful for another, and an event that produces stress at one time and place may not do so at another time and place. A person appraises and copes with changing situations. The desired goal is adaptation or adjustment to the change so that the person is again in equilibrium and has the energy and ability to meet new demands. This is the process of coping with the stress, a compensatory process that has physiologic and psychological components. Adaptation is a constant, ongoing process that requires a change in structure, function, or behaviour so that a person is better suited to the environment; it involves an interaction between the person and the environment. The outcome depends on the degree of “fit” between the skills and capacities of the person, the type of social support available, and the various challenges or stressors encountered. As such, adaptation is an individual process: Each

person has varying abilities to cope or respond. As new challenges are met, this ability to cope and adapt can change, thereby providing the person with a wide range of adaptive ability. Adaptation occurs throughout the lifespan as the person encounters many developmental and situational challenges, especially related to health and illness. The goal of adaptation is optimal wellness. Because both stress and adaptation may exist at different levels of a system, it is possible to study these reactions at the cellular, tissue, and organ levels. Biologists are concerned mainly with subcellular components or with subsystems of the total body. Behavioural scientists, including many nurse researchers, study stress and adaptation in individuals, families, groups, and societies; they focus on how a group’s organizational features are modified to meet the requirements of the social and physical environment in which the group exists. In any system, the desired goals of adaptation are survival, growth, and reproduction.

OVERVIEW OF STRESS Types of Stressors Each person operates at a certain level of adaptation and regularly encounters a certain amount of change. Such change is expected; it contributes to growth and enhances life. A stressor can upset this equilibrium. A stressor may be defined as an internal or external event or situation that creates the potential for physiologic, emotional, cognitive, or behavioural changes in an individual. Stressors exist in many forms and categories. They may be described as physical, physiologic, or psychosocial. Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. An example of a psychosocial stressor is fear (e.g., fear of failing an examination, losing a job, and waiting for a diagnostic test result). Stressors can also occur as expected life transitions that require some adjustment, such as going from childhood into puberty, getting married, or giving birth. Stressors have also been classified as (1) day-to-day frustrations or hassles, (2) major complex occurrences involving large groups, and (3) stressors that occur less frequently and involve fewer people. The first group, the day-to-day stressors, includes such common occurrences as getting caught in a traffic jam, experiencing computer downtime, and having an argument with a spouse or roommate. These experiences vary in effect. For example, encountering a rainstorm while you are vacationing at the beach will most likely evoke a more negative response than it might at another time. These daily hassles have been shown to have a greater health impact than major life events because of the cumulative effect they have over time. They can lead to high blood pressure, palpitations, or other physiologic changes (Rice, 2005). The second group of stressors influences larger groups of people, sometimes even entire nations. These include events of history, such as terrorism and war, experienced either directly in the war zone or indirectly through live news coverage. The demographic, economic, and

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technologic changes occurring in society also serve as stressors. The tension produced by any stressor is sometimes a result not only of the change itself, but also of the speed with which the change occurs. The third group of stressors has been studied most extensively and concerns relatively infrequent situations that directly affect people. This category includes the influence of life events such as death, birth, marriage, divorce, and retirement. It also includes the psychosocial crises that occur in the life cycle stages of the human experience. More enduring chronic stressors may include having a permanent disability or coping with the need to provide long-term care to a frail older parent. Duration may also be used to categorize stressors, as in the following: • An acute, time-limited stressor, such as studying for final examinations • A stressor sequence—a series of stressful events that result from an initial event such as job loss or divorce • A chronic intermittent stressor, such as daily hassles • A chronic enduring stressor that persists over time, such as chronic illness, a disability, or poverty

Stress as a Stimulus for Disease Relating life events to illness (the theoretical approach that defines stress as a stimulus) has been a major focus of psychosocial studies. Research has revealed that people under constant stress have a high incidence of psychosomatic disease. Holmes and Rahe (1967) developed life event scales that assign numerical values, called life-change units, to typical life events. Because the items in the scales reflect events that require a change in a person’s life pattern, and stress is defined as an accumulation of changes in one’s life that require psychological adaptation, one can theoretically predict the likelihood of illness by checking off the number of recent events and deriving a total score. The Recent Life Changes Questionnaire (Tausig, 1982) contains 118 items such as death, birth, marriage, divorce, promotions, serious arguments, and vacations. The items include both desirable and undesirable events. Sources of stress for people have been well researched (Barnard, Street, & Love, 2006; Lunney, 2006; Tak, 2006). People typically experience distress related to alterations in their physical and emotional health status, changes in their level of daily functioning, and decreased social support or the loss of significant others. Fears of immobilization, isolation, loneliness, sensory changes, financial issues, and death or disability increase a person’s anxiety level. Loss of one’s role or perceived purpose in life can cause intense discomfort. Any of these identified variables, plus myriad other conditions or overwhelming demands are likely to cause ineffective coping, and a lack of necessary coping skills is often a source of additional distress for the person. When a person endures prolonged or unrelenting suffering, the outcome is frequently the development of a stress-related illness. Nurses have the skills to assist people to alter their distressing circumstances and manage their responses to stress.

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Psychological Responses to Stress After recognizing a stressor, a person consciously or unconsciously reacts to manage the situation. This is termed the mediating process. A theory developed by Lazarus (1991a) emphasizes cognitive appraisal and coping as important mediators of stress. Appraisal and coping are influenced by antecedent variables, including the internal and external resources of the individual person.

Appraisal of the Stressful Event Cognitive appraisal (Lazarus, 1991a; Lazarus & Folkman, 1984) is a process by which an event is evaluated with respect to what is at stake (primary appraisal) and what might and can be done (secondary appraisal). What a person sees as being at stake is influenced by his or her personal goals, commitments, or motivations. Important factors include how important or relevant the event is to the person, whether the event conflicts with what the person wants or desires, and whether the situation threatens the person’s own sense of strength and ego identity. Primary appraisal results in the situation being identified as either nonstressful or stressful. Secondary appraisal is an evaluation of what might and can be done about the situation. Reappraisal, a change of opinion based on new information, may occur. The appraisal process is not necessarily sequential; primary and secondary appraisal and reappraisal may occur simultaneously. The appraisal process contributes to the development of an emotion. Negative emotions such as fear and anger accompany harm/loss appraisals, and positive emotions accompany challenge. In addition to the subjective component or feeling that accompanies a particular emotion, each emotion also includes a tendency to act in a certain way. For example, unprepared students may view an unexpected quiz as threatening. They might feel fear, anger, and resentment and might express these emotions through hostile behaviour or comments. Lazarus (1991a) expanded his initial ideas about stress, appraisal, and coping into a more complex model relating emotion to adaptation. He called this model a “cognitivemotivational-relational theory,” with the term relational “standing for a focus on negotiation with a physical and social world” (p. 13). A theory of emotion was proposed as the bridge to connect psychology, physiology, and sociology: “More than any other arena of psychological thought, emotion is an integrative, organismic concept that subsumes psychological stress and coping within itself and unites motivation, cognition, and adaptation in a complex configuration” (p. 40).

Coping With the Stressful Event Coping consists of the cognitive and behavioural efforts made to manage the specific external or internal demands that tax a person’s resources and may be emotion focused or problem focused. Coping that is emotion focused seeks to make the person feel better by lessening the emotional distress. Problem-focused coping aims to make direct

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changes in the environment so that the situation can be managed more effectively. Both types of coping usually occur in a stressful situation. Even if the situation is viewed as challenging or beneficial, coping efforts may be required to develop and sustain the challenge—that is, to maintain the positive benefits of the challenge and to ward off any threats. In harmful or threatening situations, successful coping reduces or eliminates the source of stress and relieves the emotion generated. Appraisal and coping are affected by internal characteristics such as health, energy, personal belief systems, commitments or life goals, self-esteem, control, mastery, knowledge, problem-solving skills, and social skills. The characteristics that have been studied most often in nursing research are health-promoting lifestyles and hardiness. A health-promoting lifestyle buffers the effect of stressors. From a nursing practice standpoint, this outcome— buffering the effect of stressors—supports nursing’s goal of promoting health. In many circumstances, promoting a healthy lifestyle is more achievable than altering the stressors. Hardiness is a general quality that comes from having rich, varied, and rewarding experiences. Hardy people perceive stressors as something they can change and therefore control. To them, potentially stressful situations are interesting and meaningful; change and new situations are viewed as challenging opportunities for growth. Researchers have found positive support for hardiness as a significant variable that positively influences rehabilitation and overall improvement after an onset of an illness (Ayalon & Covinsky, 2007; Baumgartner, 2007; Greeff & Holtzkamp, 2007; Travis, 2007).

Physiologic Response to Stress The physiologic response to a stressor, whether it is physical or psychological, is a protective and adaptive mechanism to maintain the homeostatic balance of the body. When a stress response occurs, it activates a series of neurologic and hormonal processes within the brain and body systems. The duration and intensity of the stress can cause both short-term and long-term effects. A stressor can disrupt homeostasis to the point where adaptation to the stressor fails, and a disease process results.

Selye’s Theory of Adaptation Hans Selye developed a theory of adaptation that profoundly influenced the scientific study of stress (1976). Selye first described a syndrome consisting of enlargement of the adrenal cortex; shrinkage of the thymus, spleen, lymph nodes, and other lymphatic structures; and the appearance of deep, bleeding ulcers in the stomach and duodenum. He identified this as a nonspecific response to diverse, noxious stimuli.

General Adaptation Syndrome Selye then developed a theory of adaptation to biologic stress that he named the general adaptation syndrome (GAS), which has three phases: alarm, resistance, and exhaustion. During the alarm phase, the sympathetic

“fight-or-flight” response is activated with release of catecholamines and the onset of the adrenocorticotropic hormone (ACTH)–adrenal cortical response. The alarm reaction is defensive and anti-inflammatory but self-limited. Because living in a continuous state of alarm would result in death, people move into the second stage, resistance. During the resistance stage, adaptation to the noxious stressor occurs, and cortisol activity is still increased. If exposure to the stressor is prolonged, the third stage, exhaustion, occurs. During the exhaustion stage, endocrine activity increases, and this has negative effects on the body systems (especially the circulatory, digestive, and immune systems) that can lead to death. Stages one and two of this syndrome are repeated, in different degrees, throughout life as the person encounters stressors. Selye compared the GAS with the life process. During childhood, too few encounters with stress occur to promote the development of adaptive functioning, and children are vulnerable. During adulthood, a number of stressful events occur, and people develop resistance or adaptation. During the later years, the accumulation of life’s stressors and wear and tear on the organism again decrease people’s ability to adapt, resistance falls, and eventually death occurs.

Local Adaptation Syndrome According to Selye, a local adaptation syndrome also occurs. This syndrome includes the inflammatory response and repair processes that occur at the local site of tissue injury. The local adaptation syndrome occurs in small, topical injuries, such as contact dermatitis. If the local injury is severe enough, the GAS is activated as well. Selye emphasized that stress is the nonspecific response common to all stressors, regardless of whether they are physiologic, psychological, or social. The many conditioning factors in each person’s environment account for why different demands are experienced by different people as stressors. Conditioning factors also account for differences in the tolerance of different people for stress: Some people may develop diseases of adaptation, such as hypertension and migraine headaches, whereas others are unaffected.

Interpretation of Stressful Stimuli by the Brain Physiologic responses to stress are mediated by the brain through a complex network of chemical and electrical messages. The neural and hormonal actions that maintain homeostatic balance are integrated by the hypothalamus, which is located in the centre of the brain, surrounded by the limbic system and the cerebral hemispheres. The hypothalamus is made up of a number of nuclei and integrates autonomic nervous system mechanisms that maintain the chemical constancy of the internal environment of the body. Together with the limbic system, which contains the amygdala, hippocampus, and septal nuclei, along with other structures, the hypothalamus regulates emotions and many visceral behaviours necessary for survival (e.g., eating, drinking, temperature control, reproduction, defense, aggression).

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Each of the brain structures responds differently to stimuli. The cerebral hemispheres are concerned with cognitive functions: thought processes, learning, and memory. The limbic system has connections with both the cerebral hemispheres and the brain stem. In addition, the reticular activating system (RAS), a network of cells that forms a two-way communication system, extends from the brain stem into the midbrain and limbic system. This network controls the alert or waking state of the body. In the stress response, afferent impulses are carried from sensory organs (eye, ear, nose, skin) and internal sensors (baroreceptors, chemoreceptors) to nerve centres in the brain. The response to the perception of stress is integrated in the hypothalamus, which coordinates the adjustments necessary to return to homeostatic balance. The degree and duration of the response vary; major stress evokes both sympathetic and pituitary adrenal responses. Neural and neuroendocrine pathways under the control of the hypothalamus are also activated in the stress response. Initially, there is a sympathetic nervous system discharge, followed by a sympathetic–adrenal–medullary discharge. If the stress persists, the hypothalamic–pituitary system is activated (Fig. 7-2).

Physiology/Pathophysiology Stressors

Cortex, limbic system, reticular formation Norepinephrine neurons

CRH neurons

CRH neurons

Cortisol

Sympathetic neurons

Hypothalamus

Spinal cord ACTH

Arousal, Feeding and behavioural sexual activity activation, aggressiveness

Growth and reproductive function

Medulla Adrenal gland Epinephrine

Energy mobilization and redistribution, cardiovascular responsivity

Stimulate Inhibit Inflammatory and immune responses

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Sympathetic Nervous System Response The sympathetic nervous system response is rapid and short lived. Norepinephrine is released at nerve endings that are in direct contact with their respective end organs to cause an increase in function of the vital organs and a state of general body arousal. The heart rate is increased and peripheral vasoconstriction occurs, raising the blood pressure. Blood is also shunted away from abdominal organs. The purpose of these responses is to provide better perfusion of vital organs (brain, heart, skeletal muscles). Blood glucose is increased, supplying more readily available energy. The pupils are dilated, and mental activity is increased; a greater sense of awareness exists. Constriction of the blood vessels of the skin limits bleeding in the event of trauma. The person is likely to experience cold feet, clammy skin and hands, chills, palpitations, and “knots” in the stomach. Typically, the person appears tense, with the muscles of the neck, upper back, and shoulders tightened; respirations may be rapid and shallow, with the diaphragm tense.

Sympathetic–Adrenal–Medullary Response In addition to its direct effect on major end organs, the sympathetic nervous system stimulates the medulla of the adrenal gland to release the hormones epinephrine and norepinephrine into the bloodstream. The action of these hormones is similar to that of the sympathetic nervous system and has the effect of sustaining and prolonging its actions. Epinephrine and norepinephrine are catecholamines that stimulate the nervous system and produce metabolic effects that increase the blood glucose level and increase the metabolic rate. The effect of the sympathetic– adrenal–medullary responses is summarized in Table 7-1. This effect is called the “fight-or-flight” reaction.

Hypothalamic–Pituitary Response

Pituitary

Cortex Cortisol

●

Visceral function

FIGURE 7-2. Integrated responses to stress mediated by the sympa-

thetic nervous system and the hypothalamic–pituitary–adrenocortical axis. The responses are mutually reinforcing at both the central and peripheral levels. Negative feedback by cortisol also can limit an overresponse that might be harmful to the individual. Coloured arrows represent stimulation; open arrows, inhibition. CRH, corticotropinreleasing hormone; ACTH, adrenocorticotropic hormone. (Reproduced with permission from Berne, R. M. & Levy, M. N. [2003]. Physiology. St. Louis, MO: C. V. Mosby.)

The longest-acting phase of the physiologic response, which is more likely to occur in persistent stress, involves the hypothalamic–pituitary pathway. The hypothalamus secretes corticotropin-releasing factor, which stimulates the anterior pituitary to produce ACTH, which in turn stimulates the adrenal cortex to produce glucocorticoids, primarily cortisol. Cortisol stimulates protein catabolism, releasing amino acids; stimulates liver uptake of amino acids and their conversion to glucose (gluconeogenesis); and inhibits glucose uptake (anti-insulin action) by many body cells but not those of the brain and heart. These cortisol-induced metabolic effects provide the body with a ready source of energy during a stressful situation. This effect has some important implications. For example, a person with diabetes who is under stress, such as that caused by an infection, needs more insulin than usual. Any patient who is under stress (e.g., illness, surgery, trauma, or prolonged psychological stress) catabolizes body protein and needs supplements. The actions of the catecholamines (epinephrine and norepinephrine) and cortisol are the most important in the general response to stress. Other hormones that play a role are antidiuretic hormone (ADH) released from the posterior pituitary and aldosterone released from the adrenal cortex. ADH and aldosterone promote sodium

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Sympathetic–Adrenal–Medullary Response to Stress

Effect

Purpose

Mechanism

Increased heart rate and blood pressure Increased blood glucose level

Better perfusion of vital organs

Mental acuity

Alert state

Dilated pupils Increased tension of skeletal muscles Increased ventilation (may be rapid and shallow) Increased coagulability of blood

Increased awareness Preparedness for activity, decreased fatigue Provision of oxygen for energy

Increased cardiac output due to increased myocardial contractility and heart rate; increased venous return (peripheral vasoconstriction) Increased liver and muscle glycogen breakdown; increased breakdown of adipose tissue triglycerides Increase in amount of blood shunted to the brain from the abdominal viscera and skin Contraction of radial muscle of iris Excitation of muscles; increase in amount of blood shunted to the muscles from the abdominal viscera and skin Stimulation of respiratory centre in medulla; bronchodilation

Increased available energy

Prevention of hemorrhage in event of trauma

Vasoconstriction of surface vessels

and water retention, which is an adaptive mechanism in the event of hemorrhage or loss of fluids through excessive perspiration. ADH has also been shown to influence learning and may thus facilitate coping in new and threatening situations. Secretion of growth hormone and glucagon stimulates the uptake of amino acids by cells, helping to mobilize energy resources. Endorphins, which are endogenous opioids, increase during stress and enhance the threshold for tolerance of painful stimuli. They may also affect mood and have been implicated in the so-called high that long-distance runners experience. The secretion of other hormones is also affected, but their adaptive function is less clear.

Immunologic Response Research findings show that the immune system is connected to the neuroendocrine and autonomic systems. Lymphoid tissue is richly supplied by autonomic nerves capable of releasing a number of different neuropeptides that can have a direct effect on leukocyte regulation and the inflammatory response. Neuroendocrine hormones released by the central nervous system and endocrine tissues can inhibit or stimulate leukocyte function. The wide variety of stressors a person experiences may result in different alterations in autonomic activity and subtle variations in neurohormone and neuropeptide synthesis. All of these possible autonomic and neuroendocrine responses can interact to initiate, weaken, enhance, or terminate an immune response. The study of the relationships among the neuroendocrine system, the central and autonomic nervous systems, and the immune system and the effects of these relationships on overall health outcomes is called psychoneuroimmunology. Because one’s perception of events and one’s coping styles determine whether, and to what extent, an event activates the stress response system, and because the stress response affects immune activity, one’s perceptions, ideas, and thoughts can have profound neurochemical and immunologic consequences. Studies have demonstrated alteration of immune function in people who are under stress (Kendall-Tackett, 2007; Leserman & Drossman, 2007; Mertin, Sawatzky, Diehl-Jones, et al., 2007). Other studies have identified certain personality traits, such as optimism and active coping, as having positive effects on health (Dilworth-Anderson, Boswell, & Cohen,

2007; Krucoff, 2007; Verhaeghe, van Zuuren, DeFloor, et al., 2007). As research continues, this field of study will likely uncover to what extent and by what mechanisms people can consciously influence their immunity.

Maladaptive Responses to Stress The stress response, as indicated earlier, facilitates adaptation to threatening situations, and is retained from humans’ evolutionary past. The “fight-or-flight” response, for example, is an anticipatory response that mobilized the bodily resources of our ancestors to deal with predators and other harsh factors in their environment. This same mobilization comes into play in response to emotional stimuli unrelated to danger. For example, a person may get an “adrenaline rush” when competing over a decisive point in a ball game, or when excited about attending a party. When responses to stress are ineffective, they are referred to as maladaptive. Maladaptive responses are chronic, recurrent responses or patterns of response that do not promote the goals of adaptation. The goals of adaptation are somatic or physical health (optimal wellness); psychological health or having a sense of well-being (happiness, satisfaction with life, morale); and enhanced social functioning, which includes work, social life, and family (positive relationships). Maladaptive responses that threaten these goals include faulty appraisals and inappropriate coping (Lazarus, 1991a). The frequency, intensity, and duration of stressful situations contribute to the development of emotions and subsequent patterns of neurochemical discharge. By appraising situations adequately and coping appropriately, it is possible to anticipate and defuse some of these situations. For example, frequent stressful encounters (e.g., marital discord) might be avoided with better communication and problem solving, or a pattern of procrastination (e.g., delaying work on tasks) could be corrected to reduce stress when deadlines approach. Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness. Other inappropriate coping patterns may increase the risk of illness less directly. For example, people who demonstrate

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“type A” behaviours, including impatience, competitiveness, and achievement orientation, have an underlying aggressive approach to life and are more prone than others to develop stress-related illnesses. Type A behaviours increase the output of catecholamines, the adrenal– medullary hormones, with their attendant effects on the body. Additional forms of inappropriate coping include denial, avoidance, and distancing. Denial may be illustrated by the woman who feels a lump in her breast but downplays its seriousness and delays seeking medical attention. The intent of denial is to control the threat, but it may also endanger life. Models of illness frequently include stress and maladaptation as precursors to disease. A general model of illness, based on Selye’s theory, suggests that any stressor elicits a state of disturbed physiologic equilibrium. If this state is prolonged or the response is excessive, it increases the susceptibility of the person to illness. This susceptibility, coupled with a predisposition in the person (from genetic traits, health, or age), leads to illness. If the sympathetic adrenal–medullary response is prolonged or excessive, a state of chronic arousal develops that may lead to high blood pressure, arteriosclerotic changes, and cardiovascular disease. If the production of ACTH is prolonged or excessive, behaviour patterns of withdrawal and depression are seen. In addition, the immune response is decreased, and infections and tumours may develop. Selye (1976) proposed a list of disorders known as diseases of maladaptation: high blood pressure (including hypertension of pregnancy), diseases of the heart and blood vessels, diseases of the kidney, rheumatic and rheumatoid arthritis, inflammatory diseases of the skin and eyes, infections, allergic and hypersensitivity diseases, nervous and mental diseases, sexual dysfunction, digestive diseases, metabolic diseases, and cancer.

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CHART 7-1

Assessing for Stress Be alert for the following signs and symptoms: Restlessness Depression Dry mouth Overpowering urge to act out Fatigue Loss of interest in life activities Intense periods of anxiety Strong startle response Hyperactivity Gastrointestinal distress Diarrhea Nausea or vomiting Changes in menstrual cycle Change in appetite Injury prone Palpitations Impulsive behaviours Emotional lability Concentration difficulties Feeling weak or dizzy Increased body tension Tremors Nervous habits Nervous laughter Bruxism (grinding of teeth) Difficulty sleeping Excessive perspiration Urinary frequency Headaches Pain in back, neck, or other parts of the body Increased use of tobacco Substance use or abuse Unintentional weight loss or gain

Indicators of Stress Indicators of stress and the stress response include both subjective and objective measures. Chart 7-1 lists signs and symptoms that may be observed directly or reported by a person. They are psychological, physiologic, or behavioural and reflect social behaviours and thought processes. Some of these reactions may be coping behaviours. Over time, each person tends to develop a characteristic pattern of behaviour during stress to warn that the system is out of balance. Laboratory measurements of indicators of stress have helped in understanding this complex process. Blood and urine analyses can be used to demonstrate changes in hormonal levels and hormonal breakdown products. Blood levels of catecholamines, glucocorticoids, ACTH, and eosinophils are reliable measures of stress. Serum cholesterol and free fatty acid levels can be used to measure stress. When the body experiences distress, there are changes in adrenal hormones such as cortisol and aldosterone. As the levels of these chemicals increase, there is a simultaneous release of additional cholesterol into the general circulation. Both physical and psychological distress can trigger an elevated cholesterol level. In addition, the results of immunoglobulin assays are increased when a person is exposed to a variety of stressors, especially

infections and immunodeficiency conditions. With greater attention to the field of neuroimmunology, improved laboratory measures are likely to follow. In addition to using laboratory tests, researchers have developed questionnaires to identify and assess stressors, stress, and coping strategies. The work of Rice (2005), a compilation of information gained from research on stress, coping, and health, includes some of these questionnaires. Research reports also contain examples of instruments that nurses use to measure levels of patient distress and patient functioning (Caetano, Ramisetty-Miller, CaetanoVaeth, et al., 2007; Weisel, Most, & Michael, 2007). Miller and Smith (1993) provided a stress audit and a stress profile measurement tool that is available in the popular lay literature.

Nursing Implications It is important for nurses to realize that the optimal point of intervention to promote health is during the stage when a person’s own compensatory processes are still functioning effectively. A major role of nurses is the early identification of both physiologic and psychological stressors.

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Nurses should be able to relate the presenting signs and symptoms of distress to the physiology they represent and identify a person’s position on the continuum of function, from health and compensation to pathophysiology and disease. For example, if an anxious, middle-aged woman presented for a checkup and was found to be overweight with a blood pressure of 150/85 mm Hg, the nurse would counsel her with respect to diet, stress management, and activity. The nurse would also encourage weight loss and discuss the woman’s intake of salt (which affects fluid balance) and caffeine (which provides a stimulant effect). The patient and the nurse would identify both individual and environmental stressors and discuss strategies to decrease her lifestyle stress, with the ultimate goal being to create a healthy lifestyle and prevent hypertension and its sequelae.

STRESS AT THE CELLULAR LEVEL Pathologic processes may occur at all levels of the biologic organism. If the cell is considered the smallest unit or subsystem (tissues being aggregates of cells, organs aggregates of tissues, and so on), the processes of health and disease or adaptation and maladaptation can all occur at the cellular level. Indeed, pathologic processes are often described by scientists at the subcellular or molecular level. The cell exists on a continuum of function and structure, ranging from the usual cell, to the adapted cell, to the injured or diseased cell, to the dead cell (Fig. 7-3). Changes from one state to another may occur rapidly and may not be readily detectable, because each state does not have discrete boundaries, and disease represents disruption of usual processes. The earliest changes occur at the molecular or subcellular level and are not perceptible until steady-state functions or structures are altered. With cell injury, some changes may be reversible; in other instances, the injuries are lethal. For example, tanning of the skin is an adaptive, morphologic response to exposure to the rays of the sun. However, if the exposure is continued, sunburn and injury occur, and some cells may die, as evidenced by desquamation (“peeling”).

Physiology/Pathophysiology HEALTH Normal cell

Adapted cell

Compensatory mechanisms; cell remains intact

DISEASE Injured or diseased cell

Dead cell

Pathophysiologic mechanisms; loss of cell integrity

FIGURE 7-3. The cell on a continuum of function and structure.

Changes in the cell are not as easily discerned as the diagram depicts, and the point at which compensation subsides and pathophysiology begins is not clearly defined.

Different cells and tissues respond to stimuli with different patterns and rates of response, and some cells are more vulnerable to one type of stimulus or stressor than others. The cell involved, its ability to adapt, and its physiologic state are determinants of the response. For example, cardiac muscle cells respond to hypoxia (inadequate oxygenation) more quickly than do smooth muscle cells. Other determinants of cellular response are the type or nature of the stimulus, its duration, and its severity. For example, neurons that control respiration can develop a tolerance to regular, small amounts of a barbiturate, but one large dose may result in respiratory depression and death.

Control of the Steady State The concept of the cell as existing on a continuum of function and structure includes the relationship of the cell to compensatory mechanisms, which occur continuously in the body to maintain the steady state. Compensatory processes are regulated primarily by the autonomic nervous system and the endocrine system, with control achieved through negative feedback.

Negative Feedback Negative feedback mechanisms throughout the body monitor the internal environment and restore homeostasis when conditions shift out of the usual range. These mechanisms work by sensing deviations from a predetermined set point or range of adaptability and triggering a response aimed at offsetting the deviation. Blood pressure, acid– base balance, blood glucose level, body temperature, and fluid and electrolyte balance are examples of functions regulated through such compensatory mechanisms. Most of the human body’s control systems are integrated by the brain with feedback from the nervous and endocrine systems. Control activities involve detecting deviations from the predetermined reference point and stimulating compensatory responses in the muscles and glands of the body. The major organs affected are the heart, lungs, kidneys, liver, gastrointestinal tract, and skin. When stimulated, these organs alter their rate of activity or the amount of secretions they produce. Because of this, they have been called the “organs of homeostasis or adjustment.” In addition to the responses influenced by the nervous and endocrine systems, local responses consisting of small feedback loops in a group of cells or tissues are possible. The cells detect a change in their immediate environment and initiate an action to counteract its effect. For example, the accumulation of lactic acid in an exercised muscle stimulates dilation of blood vessels in the area to increase blood flow and improve the delivery of oxygen and removal of waste products. The net result of the activities of feedback loops is homeostasis. A steady state is achieved by the continuous, variable action of the organs involved in making the adjustments and by the continuous exchange of chemical substances among cells, interstitial fluid, and blood. For example, an increase in the CO2 concentration of the extracellular fluid leads to increased pulmonary

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ventilation, which decreases the CO2 level. On a cellular level, increased CO2 raises the hydrogen ion concentration of the blood. This is detected by chemosensitive receptors in the respiratory control centre of the medulla of the brain. The chemoreceptors stimulate an increase in the rate of discharge of the neurons that innervate the diaphragm and intercostal muscles, which increases the rate of respiration. Excess CO2 is exhaled, the hydrogen ion concentration returns to a steady state, and the chemically sensitive neurons are no longer stimulated (Kunert, 2010).

Positive Feedback Another type of feedback, positive feedback, perpetuates the chain of events set in motion by the original disturbance instead of compensating for it. As the system becomes more unbalanced, disorder and disintegration occur. There are some exceptions to this; blood clotting in humans, for example, is an important positive feedback mechanism.

Cellular Adaptation Cells are complex units that dynamically respond to the changing demands and stresses of daily life. They possess a maintenance function and a specialized function. The maintenance function refers to the activities that the cell must perform with respect to itself; specialized functions are those that the cell performs in relation to the tissues and organs of which it is a part. Individual cells may cease to function without posing a threat to the organism. However, as the number of dead cells increases, the specialized functions of the tissues are altered, and health is threatened. Cells can adapt to environmental stress through structural and functional changes. Some of these adaptations include cellular hypertrophy, atrophy, hyperplasia, dysplasia, and metaplasia (Table 7-2). These adaptations reflect changes in the usual cell in response to stress. If TABLE 7-2

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the stress is unrelenting, cellular injury and death may occur. Hypertrophy and atrophy lead to changes in the size of cells and hence the size of the organs they form. Compensatory hypertrophy is the result of an enlarged muscle mass and commonly occurs in skeletal and cardiac muscle that experiences a prolonged, increased workload. One example is the bulging muscles of the athlete who engages in body building. Atrophy can be the consequence of disease, decreased use, decreased blood supply, loss of nerve supply, or inadequate nutrition. Disuse of a body part is often associated with the aging process and immobilization. Cell size and organ size decrease, and the structures principally affected are the skeletal muscles, the secondary sex organs, the heart, and the brain. Hyperplasia is an increase in the number of new cells in an organ or tissue. As cells multiply and are subjected to increased stimulation, the tissue mass enlarges. This mitotic response (a change occurring with mitosis) is reversible when the stimulus is removed. This distinguishes hyperplasia from neoplasia or malignant growth, which continues after the stimulus is removed. Hyperplasia may be hormonally induced. An example is the increased size of the thyroid gland caused by thyroidstimulating hormone (secreted from the pituitary gland) when a deficit in thyroid hormone occurs. Dysplasia is bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type. Dysplastic cells have a tendency to become malignant; dysplasia is seen commonly in epithelial cells in the bronchi of people who smoke. Metaplasia is a cell transformation in which there is a conversion of one type of mature cell into another type of cell. This serves a protective function, because less transformed cells are more resistant to the stress that stimulated the change. For example, the ciliated columnar epithelium lining the bronchi of people who smoke is replaced by squamous epithelium. The squamous cells can survive; loss of the cilia and protective mucus, however, can have damaging consequences.

Cellular Adaptation to Stressors

Adaptation

Stimulus

Example

Hypertrophy—increase in cell size leading to increase in organ size

Increased workload

Leg muscles of runner Arm muscles in tennis player Cardiac muscle in person with hypertension

Atrophy—shrinkage in size of cell, leading to decrease in organ size

Decrease in: Use Blood supply Nutrition Hormonal stimulation Innervation

Secondary sex organs in aging person Extremity immobilized in cast

Hyperplasia—increase in number of new cells (increase in mitosis)

Hormonal influence

Breast changes of girl in puberty or of pregnant woman Regeneration of liver cells New red blood cells in blood loss

Dysplasia—bizarre changes in the appearance of cells

Reproduction of cells with resulting alteration of their size and shape

Alterations in epithelial cells of the skin or the cervix, producing irregular tissue changes that could be the precursors of a malignancy

Metaplasia—transformation of one adult cell type to another (reversible)

Stress applied to highly specialized cell

Changes in epithelial cells lining bronchi in response to smoke irritation (cells become less specialized)

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Cellular Injury

Hypoxia

Injury is defined as a disorder in steady-state regulation. Any stressor that alters the ability of the cell or system to maintain optimal balance of its adjustment processes leads to injury. Structural and functional damage then occurs, which may be reversible (permitting recovery) or irreversible (leading to disability or death). Homeostatic adjustments are concerned with the small changes within the body’s systems. With adaptive changes, compensation occurs and a new steady state may be achieved. With injury, steady-state regulation is lost, and changes in functioning ensue. Causes of disorder and injury in the system (cell, tissue, organ, body) may arise from the external or internal environment (Fig. 7-4) and include hypoxia, nutritional imbalance, physical agents, chemical agents, infectious agents, immune mechanisms, genetic defects, and psychogenic factors. The most common causes are hypoxia (oxygen deficiency), chemical injury, and infectious agents. In addition, the presence of one injury makes the system more susceptible to another injury. For example, inadequate oxygenation and nutritional deficiencies make the system vulnerable to infection. These agents act at the cellular level by damaging or destroying: • The integrity of the cell membrane, necessary for ionic balance • The ability of the cell to transform energy (aerobic respiration, production of adenosine triphosphate) • The ability of the cell to synthesize enzymes and other necessary proteins • The ability of the cell to grow and reproduce (genetic integrity)

External

Internal

Processing of information and matter

Environment

Inadequate cellular oxygenation (hypoxia) interferes with the cell’s ability to transform energy. Hypoxia may be caused by a decrease in blood supply to an area, a decrease in the oxygen-carrying capacity of the blood (decreased hemoglobin), a ventilation/perfusion or respiratory problem that reduces the amount of arterial oxygen available, or a problem in the cell’s enzyme system that makes it unable to use oxygen. The usual cause of hypoxia is ischemia, or deficient blood supply. Ischemia is commonly seen in myocardial cell injury in which arterial blood flow is decreased because of atherosclerotic narrowing of blood vessels. Ischemia also results from intravascular clots (thrombi or emboli) that may form and interfere with blood supply. Thrombi and emboli are common causes of cerebrovascular accidents (strokes, brain attacks). The length of time different tissues can survive without oxygen varies. For example, brain cells most often succumb in 3 to 6 minutes. If the condition leading to hypoxia is slow and progressive, collateral circulation may develop, whereby blood is supplied by other blood vessels in the area. However, this mechanism is not highly reliable.

Nutritional Imbalance Nutritional imbalance refers to a relative or absolute deficiency or excess of one or more essential nutrients. This may be manifested as undernutrition (inadequate consumption of food or calories) or overnutrition (caloric excess). Caloric excess to the point of obesity overloads cells in the body with lipids. By requiring more energy to maintain the extra tissue, obesity places a strain on the body and has been associated with the development of disease, especially pulmonary and cardiovascular disease. Specific deficiencies arise when an essential nutrient is deficient or when there is an imbalance of nutrients. Protein deficiencies and avitaminosis (deficiency of vitamins) are typical examples. An energy deficit leading to cell injury can occur if there is insufficient glucose, or insufficient oxygen to transform the glucose into energy. A lack of insulin, or the inability to use insulin, may also prevent glucose from entering the cell from the blood. This occurs in diabetes mellitus, a metabolic disorder that can lead to nutritional deficiency, as well as a host of short-term and long-term life-threatening complications.

Physical Agents Physical agents, including temperature extremes, radiation, electrical shock, and mechanical trauma, can cause injury to the cells or to the entire body. The duration of exposure and the intensity of the stressor determine the severity of damage.

Temperature Environment FIGURE 7-4. Influences leading to disorder may arise from the internal

environment and the external environment of the system. Excesses or deficits of information and matter may occur, or there may be faulty regulation of processing.

When a person’s temperature is elevated, hypermetabolism occurs and the respiratory rate, heart rate, and basal metabolic rate all increase. With fever induced by infections, the hypothalamic thermostat may be reset at a higher temperature and then return to normal when the fever abates. The increase in body temperature is achieved

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through physiologic mechanisms. Body temperatures greater than 41°C (106°F) indicate hyperthermia, because the physiologic function of the thermoregulatory centre breaks down and the temperature soars. This physiologic condition occurs in people who have heat stroke. Eventually, the high temperature causes coagulation of cell proteins, and cells die. The body must be cooled rapidly to prevent brain damage. The local response to burn injury is similar. There is an increase in metabolic activity, and, as heat increases, proteins coagulate and enzyme systems are destroyed. In extreme situations, charring or carbonization occurs. For more information about burn injuries, see Chapter 58. Extremes of low temperature, or cold, cause vasoconstriction. Blood flow becomes sluggish and clots form, leading to ischemic damage in the involved tissues. With still lower temperatures, ice crystals may form, and cells may burst.

Radiation and Electrical Shock Radiation is used for diagnosis and treatment of diseases. Ionizing forms of radiation may cause injury by their destructive action. Radiation decreases the protective inflammatory response of the cell, creating a favourable environment for opportunistic infections. Electrical shock produces burns as a result of the heat generated when electrical current travels through the body. It may also unexpectedly stimulate nerves, leading, for example, to fibrillation of the heart.

Mechanical Trauma Mechanical trauma can result in wounds that disrupt the cells and tissues of the body. The severity of the wound, the amount of blood loss, and the extent of nerve damage are significant factors in the outcome.

Chemical Agents Chemical injuries are caused by poisons, such as lye, which have a corrosive action on epithelial tissue, or by heavy metals, such as mercury, arsenic, and lead, each of which has its own specific destructive action. Many other chemicals are toxic in certain amounts, in certain people, and in specific tissues. For example, excessive secretion of hydrochloric acid can damage the stomach lining; large amounts of glucose can cause osmotic shifts, affecting the fluid and electrolyte balance; and too much insulin can cause unusual levels of glucose in the blood (hypoglycemia) and can lead to coma. Drugs, including prescribed medications, can also cause chemical poisoning. Some people are less tolerant of medications than others and manifest toxic reactions at the usual or customary dosages. Aging tends to decrease tolerance to medications. Polypharmacy (taking many medications at one time) also occurs frequently in the aging population and is a problem because of the unpredictable effects of the resulting medication interactions. Alcohol (ethanol) is also a chemical irritant. In the body, alcohol is broken down into acetaldehyde, which has a direct toxic effect on liver cells that leads to a variety of liver abnormalities, including cirrhosis in susceptible people. Disordered liver cell function leads to complications in other organs of the body.

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Infectious Agents Biologic agents known to cause disease in humans are viruses, bacteria, rickettsiae, mycoplasmas, fungi, protozoa, and nematodes. The severity of the infectious disease depends on the number of microorganisms entering the body, their virulence, and the host’s defenses (e.g., health, age, immune responses). Some bacteria, such as those that cause tetanus and diphtheria, produce exotoxins that circulate and create cell damage. Others, such as gram-negative bacteria, produce endotoxins when they die. Tubercle bacilli induce an immune reaction. Viruses, the smallest living organisms known, survive as parasites of the living cells they invade. Viruses infect specific cells. Through a complex mechanism, viruses replicate within cells and then invade other cells, where they continue to replicate. An immune response is mounted by the body to eliminate the viruses, and the cells harbouring the viruses can be injured in the process. Typically, an inflammatory response and immune reaction are the physiologic responses of the body to viral infection.

Disordered Immune Responses The immune system is an exceedingly complex system, the purpose of which is to defend the body from invasion by any foreign object or foreign cell type, such as cancerous cells. This is a steady-state mechanism, but like other adjustment processes it can become disordered, and cellular injury results. The immune response detects foreign bodies by distinguishing non self substances from self substances and destroying the non self entities. The entrance of an antigen (foreign substance) into the body evokes the production of antibodies that attack and destroy the antigen (antigen–antibody reaction). The immune system may function as expected or it may be hypoactive or hyperactive. When it is hypoactive, immunodeficiency diseases occur; when it is hyperactive, hypersensitivity disorders occur. A disorder of the immune system itself can result in damage to the body’s own tissues. Such disorders are labelled autoimmune diseases (see Unit 11).

Genetic Disorders There is intense research interest in genetic defects as causes of disease and modifiers of genetic structure. Many of these defects produce mutations that have no recognizable effect, such as lack of a single enzyme; others contribute to more obvious congenital abnormalities, such as Down syndrome. People can be assessed for many genetic conditions (or the risk for such conditions) such as sickle cell disease, cystic fibrosis, hemophilia A and B, breast cancer, obesity, cardiovascular disease, phenylketonuria, and Alzheimer’s disease. The availability of genetic information and technology enables health care providers to perform screening, testing, and counselling for people with genetics concerns. Knowledge obtained from the Human Genome Project has also created opportunities for assessing a person’s genetic profile and preventing or treating diseases. Diagnostic genetics and gene therapy have the potential to identify and modify genes before they begin to express traits that would lead to disease or disability. (For further information, see Chapter 10.)

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Cellular Response to Injury: Inflammation Cells or tissues of the body may be injured or killed by any of the agents (physical, chemical, infectious) described earlier. When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the site of injury. Inflammation is a defensive reaction intended to neutralize, control, or eliminate the offending agent and to prepare the site for repair. It is a nonspecific response (not dependent on a particular cause) that is meant to serve a protective function. For example, inflammation may be observed at the site of a bee sting, in a sore throat, in a surgical incision, and at the site of a burn. Inflammation also occurs in cell injury events, such as strokes and myocardial infarctions. Inflammation is not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. An infection exists when the infectious agent is living, growing, and multiplying in the tissues and is able to overcome the body’s usual defenses. Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration (Fig. 7-5). As these changes take place, five cardinal signs of inflammation are produced: redness, heat, swelling, pain, and loss of function. The transient vasoconstriction that occurs immediately after injury is followed by vasodilation and an increased rate of blood flow through the microcirculation to the area of tissue damage. Local heat and redness result. Next, the structure of the microvascular system changes to accommodate the movement of plasma protein from the blood into the tissues. Following this increase in vascular permeability, plasma fluids (including proteins and solutes) leak into the inflamed tissues, producing swelling. Leukocytes migrate through the endothelium and accumulate in the tissue at the site of the injury. The pain that occurs is attributed to the pressure of fluids or swelling on nerve endings and to the irritation of nerve endings by chemical mediators released at the site. Bradykinin is one of the chemical mediators suspected of causing pain. Loss of function is most likely related to the pain and swelling, but the exact mechanism is not completely known. As blood flow increases and fluid leaks into the surrounding tissues, the formed elements (red blood cells, white blood cells, and platelets) remain in the blood, causing it to become more viscous. Leukocytes (white blood cells) collect in the vessels, exit, and migrate to the site of injury to engulf offending organisms and to remove cellular debris in a process called phagocytosis. Fibrinogen in the leaked plasma fluid coagulates, forming fibrin for clot formation, which serves to wall off the injured area and prevent the spread of infection.

Chemical Mediators of Inflammation Injury initiates the inflammatory response, but chemical substances released at the site induce vascular changes.

Physiology/Pathophysiology Disruption of tissue integrity

Injury

Ischemic damage

Immune reaction

Inflammatory response

Vascular changes: Vasodilation ↑Capillary permeability ↑Blood flow Local tissue congestion

Cellular changes: Phagocytosis ↑ Leukocytes (granulocytes and monocytes) Release of chemical mediators (mast cells and macrophages)

Body responses

Local effects: Erythema Warmth Edema Pain Impaired functioning

Systemic effects: Fever Leukocytosis Malaise Anorexia Sepsis

FIGURE 7-5. Inflammatory response.

Foremost among these chemicals are histamine and kinins. Histamine is present in many tissues of the body but is concentrated in the mast cells. It is released when injury occurs and is responsible for the early changes in vasodilation and vascular permeability. Kinins increase vascular dilations and permeability and attract neutrophils to the area. Prostaglandins, another group of chemical substances, are also suspected of causing increased vascular permeability (Kunert, 2010).

Systemic Response to Inflammation The inflammatory response is often confined to the site, causing only local signs and symptoms. However, systemic responses can also occur. Fever is the most common sign of a systemic response to injury, and it is most likely caused by endogenous pyrogens (internal substances that cause fever) released from neutrophils and macrophages (specialized forms of leukocytes). These substances reset the hypothalamic thermostat, which controls body temperature, and produce fever. Leukocytosis, an increase in the synthesis and release of neutrophils from bone marrow, may occur to provide the body with greater ability to fight infection. During this process, general, nonspecific symptoms develop, including malaise, loss of appetite, aching, and weakness.

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Types of Inflammation Inflammation is categorized primarily by its duration and the type of exudate produced. It may be acute, subacute, or chronic. Acute inflammation is characterized by the local vascular and exudative changes described previously and usually lasts less than 2 weeks. An acute inflammatory response is immediate and serves a protective function. After the causative agent is removed, the inflammation subsides and healing takes place with the return of usual or near-usual structure and function. Chronic inflammation develops if the injurious agent persists and the acute response is perpetuated. Symptoms are present for many months or years. Chronic inflammation may also begin insidiously and never have an acute phase. The chronic response does not serve a beneficial and protective function; on the contrary, it is debilitating and can produce long-lasting effects. As the inflammation becomes chronic, changes occur at the site of injury and the nature of the exudate becomes proliferative. A cycle of cellular infiltration, necrosis, and fibrosis begins, with repair and breakdown occurring simultaneously. Considerable scarring may occur, resulting in permanent tissue damage. Subacute inflammation falls between acute and chronic inflammation. It includes elements of the active exudative phase of the acute response as well as elements of repair, as in the chronic phase. The term subacute inflammation is not widely used.

Cellular Healing The reparative process begins at approximately the same time as the injury. Healing proceeds after the inflammatory debris has been removed. Healing may occur by regeneration, in which gradual repair of the defect occurs by proliferation of cells of the same type as those destroyed, or by replacement, in which cells of another type, usually connective tissue, fill in the tissue defect and result in scar formation.

Regeneration The ability of cells to regenerate depends on whether they are labile, permanent, or stable. Labile cells multiply constantly to replace cells worn out by usual physiologic processes; these include epithelial cells of the skin and those lining the gastrointestinal tract. Permanent cells include neurons—the nerve cell bodies, not their axons. Destruction of neurons is permanent, but axons may regenerate. If usual activity is to return, tissue regeneration must occur in a functional pattern, especially in the growth of several axons. Stable cells in some organ systems have a latent ability to regenerate. Under usual physiologic processes, they are not shed and do not need replacement, but if they are damaged or destroyed, they are able to regenerate. Examples include functional cells of the kidney, liver, and pancreas. Cells in other organs, such as the brain, for example, do not regenerate.

Replacement The condition of the host, the environment, and the nature and severity of the injury affect the processes of

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inflammation, repair, and replacement. Depending on the extent of damage, repair and replacement may occur by first-, second-, or third-intention healing. In first-intention healing, the wound edges are approximated, as in a surgical wound. Little scar formation occurs, and the wound healing occurs without granulation. In secondintention healing, the edges are not approximated and the wound fills with granulation tissue. The process of repair takes longer and may result in scar formation, with loss of specialized function. For example, people who have recovered from myocardial infarction have abnormal electrocardiographic tracings because the electrical signal cannot be conducted through the connective tissue that has replaced the infarcted area. In third-intention healing, the wound edges are not approximated and healing is delayed. For more information about wound healing see Chapter 52.

Nursing Implications In the assessment of people who seek health care, both objective signs and subjective symptoms are the primary indicators of existing physiologic processes. The following questions are addressed: • Are the heart rate, respiratory rate, and temperature normal? • What emotional distress may be contributing to the patient’s health issues? • Are there other indicators of steady-state deviation? • What are the patient’s blood pressure, height, and weight? • Are there any problems in movement or sensation? • Are there any problems with affect, behaviour, speech, cognitive ability, orientation, or memory? • Are there obvious impairments, lesions, or deformities? Objective evidence can be obtained from laboratory data, such as electrolytes, blood urea nitrogen, blood glucose, and urinalysis results. Further signs of change are seen in diagnostic studies such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Further information on diagnostic studies can be found in assessment chapters of each unit of the book. In making a nursing diagnosis, the nurse must relate the symptoms or problems reported by the patient to the existing physical signs. Management of specific biologic disorders is discussed in subsequent chapters; however, nurses can assist any patient to respond to stress-inducing biologic or psychological disorders with stress management interventions.

STRESS MANAGEMENT: NURSING INTERVENTIONS Stress or the potential for stress is ubiquitous; that is, it is both everywhere and anywhere (Kunert, 2010). Anxiety, frustration, anger, and feelings of inadequacy, helplessness, or powerlessness are emotions often associated with stress. In the presence of these emotions, the customary

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activities of daily living may be disrupted; for example, a sleep disturbance may occur, eating and activity patterns may be altered and family processes or role performance may be disrupted. Many nursing diagnoses are possible for patients suffering from stress. One nursing diagnosis related to stress is “Anxiety,” which is defined as a vague, uneasy feeling, the source of which may be nonspecific or not known to the person. Stress may also be manifested as ineffective coping patterns, impaired thought processes, or disrupted relationships. These human responses are reflected in the nursing diagnoses of “Risk-prone health behaviour,” “Ineffective coping,” “Defensive coping,” and “Ineffective denial,” all of which indicate poor adaptive responses (Herdman, 2012). Other possible nursing diagnoses include “Social isolation,” “Risk for impaired parenting,” “Risk for spiritual distress,” “Readiness for enhanced family coping,” “Decisional conflict,” “Situational low self-esteem,” and “Risk for powerlessness,” among others. Because human responses to stress are varied, as are the sources of stress, arriving at an accurate diagnosis allows interventions and goals to be more specific and leads to improved outcomes. Stress management is directed toward reducing and controlling stress and improving coping. The need to prevent illness, improve the quality of life, and decrease the cost of health care makes efforts to promote health essential, and stress control is a significant health promotion goal. Stress reduction methods and coping enhancements can derive from either internal or external sources. For example, healthy eating habits and relaxation techniques are internal resources that help reduce stress, and a broad social network is an external resource that helps reduce stress. Goods and services that can be purchased are also external resources for stress management. It may be easier for people with adequate financial resources to cope with constraints in the environment, because their sense of vulnerability to threat is decreased compared to those without adequate financial resources.

Promoting a Healthy Lifestyle A health-promoting lifestyle provides internal resources that aid in coping, and it buffers or cushions the impact of stressors. Lifestyles or habits that contribute to the risk of illness can be identified through a health risk appraisal, an assessment method designed to promote health by examining a person’s habits, and recommending changes when a health risk is identified. Health risk appraisals involve the use of health risk questionnaires to estimate the likelihood that people with a given set of characteristics will become ill. It is hoped that if people are provided with this information, they will adopt healthy behaviours (e.g., stop smoking, have periodic screening examinations) to improve their health. Questionnaires typically address the information presented in Chart 7-2. The personal information is compared with average population risk data, and the risk factors are identified and weighed. From this analysis, a person’s risks and major health hazards are identified. Further comparisons with population data can estimate how many years will

CHART 7-2

Information Addressed in Health Risk Questionnaires Demographic data: age, gender, race, ethnic background Personal and family history of diseases and health problems Lifestyle choices • Eating, sleeping, exercise, smoking, drinking, sexual activity, and driving habits • Stressors at home and on the job • Role relationships and associated stressors Physical measurements • Blood pressure • Height, weight, body mass index (BMI) • Laboratory analyses of blood and urine Participation in high-risk behaviours

be added to a person’s lifespan if the suggested changes are made. However, research has not yet demonstrated that providing people with such information ensures that they will change their behaviours. The single most important factor for determining health status is social class, and within a social class the research suggests that the major factor influencing health is level of education (Bastable, 2008).

Enhancing Coping Strategies Bulechek, et al. (2013, p. 228) identified “coping enhancement” as a nursing intervention and defined it as “assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles” (Chart 7-3). The nurse can build on the patient’s existing coping strategies, as identified in the health appraisal, or teach new strategies for coping if necessary. The five predominant ways of coping with illness identified in a review of 57 nursing research studies were as follows (Jalowiec, 1993): • • • •

Trying to be optimistic about the outcome Using social support Using spiritual resources (Skillen, 2012) Trying to maintain control either over the situation or over feelings • Trying to accept the situation Other ways of coping included seeking information, reprioritizing needs and roles, lowering expectations, making compromises, comparing oneself to others, planning activities to conserve energy, taking things one step at a time, listening to one’s body, and using self-talk for encouragement.

Teaching Relaxation Techniques Relaxation techniques are a major method used to relieve stress. Commonly used techniques include progressive muscle relaxation, the Benson Relaxation Response, and relaxation with guided imagery. The goal of relaxation

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CHART 7-3

Coping Enhancement: Nursing Interventions Definition Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles.

Selected Activities Use a calm, reassuring approach and provide an atmosphere of acceptance for patients and families. Assist the patient and family in developing an objective appraisal of the event. Provide factual information concerning diagnosis, treatment, and prognosis as needed. Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness. Acknowledge the patient’s spiritual/cultural background and encourage the use of spiritual resources if desired. Foster constructive methods of dealing with life problems for patients and families. Assist the patient and family to identify appropriate shortand long-term goals. Appraise the needs and desires for social support and assist the patient and family to identify available support systems. Assist the patient to identify positive strategies to deal with limitations, manage needed lifestyle or role changes, and work through the losses of chronic illness and/or disability if appropriate. Adapted from Bulechek, G. M., Butcher, H. K., & Dochterman, J. C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby.

training is to produce a response that counters the stress response. When this goal is achieved, the action of the hypothalamus adjusts and decreases the activity of the sympathetic and parasympathetic nervous systems. The sequence of physiologic effects and their signs and symptoms are interrupted, and psychological stress is reduced. This is a learned response and requires practice to achieve. The different relaxation techniques share four similar elements: (1) a quiet environment, (2) a comfortable position, (3) a passive attitude, and (4) a mental device (something on which to focus one’s attention, such as a word, phrase, or sound).

Progressive Muscle Relaxation Progressive muscle relaxation involves tensing and releasing the muscles of the body in sequence and sensing the difference in feeling. It is best if the person lies on a soft cushion, in a quiet room, breathing easily. Someone usually reads the instructions in a low tone in a slow and relaxed manner, or a recording of the instructions may be played. The person tenses the muscles in the entire body (one muscle group at a time), holds, senses the tension, and then relaxes. As each muscle group is tensed, the person keeps the rest of the body relaxed. Each time the focus is on feeling the tension and relaxation. When the exercise is completed, the entire body should be relaxed (Benson, 1993; Benson & Stark, 1996).

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Benson’s Relaxation Response Benson (1993) described the following steps of the Benson Relaxation Response: 1. Pick a brief phrase or word that reflects your basic belief system. 2. Choose a comfortable position. 3. Close your eyes. 4. Relax your muscles progressing from feet to head/neck. 5. Become aware of your breathing, and start using your selected focus word. 6. Maintain a passive demeanor saying “oh well” when other thoughts emerge. 7. Continue for a set period of time (10 to 15 minutes). 8. Open eyes and continue to sit for another minute. 9. Practice the technique twice daily. This response combines meditation with relaxation. Along with the repeated word or phrase, a passive demeanor is essential. If other thoughts or distractions (noises, pain) occur, Benson recommends not fighting the distraction but simply continuing to repeat the focus phrase. Time of day is not important, but the exercise works best on an empty stomach.

Relaxation With Guided Imagery Simple guided imagery is the mindful use of a word, phrase, or visual image for the purpose of distracting oneself from distressing situations or consciously taking time to relax or reenergize. A nurse can help a person select a pleasant scene or experience, such as watching the ocean or dabbling the feet in a cool stream. This image serves as the mental device in this technique. As the person sits comfortably and quietly, the nurse guides the person to review the scene, trying to feel and relive the imagery with all of the senses. A recording may be made of the description of the image, or commercial recordings for guided imagery and relaxation can be used. Other relaxation techniques include meditation, breathing techniques, massage, Reiki, music therapy, biofeedback, and the use of humour.

Educating About Stress Management Two commonly prescribed nursing educational interventions—providing sensory information and providing procedural information (e.g., preoperative teaching)—have the goal of reducing stress and improving the patient’s coping ability. This preparatory education includes giving structured content, such as a lesson in childbirth preparation to expectant parents, a review of cardiovascular anatomy to a cardiac patient, or a description of sensations a patient will experience during cardiac catheterization. These techniques may alter the person–environment relationship such that something that might have been viewed as harmful or a threat will now be perceived more positively. Giving patients information also reduces the emotional response so that they can concentrate and solve problems more effectively (Eggenberger & Nelms, 2007; Kasper, Köpke, Mühlhauser, et al., 2006).

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Enhancing Social Support The nature of social support and its influence on coping have been studied extensively. Social support has been demonstrated to be an effective moderator of life stress. Social support has been found to provide people with several different types of emotional information (Glass, Perrin, Campbell, et al., 2007; Wilsey & Shear, 2007). The first type of information leads people to believe that they are cared for and loved. This emotional support appears most often in a relationship between two people in which mutual trust and attachment are expressed by helping one another meet their emotional needs. The second type of information leads people to believe that they are esteemed and valued. This is most effective when there is recognition demonstrating a person’s favourable position in the group. Known as esteem support, this elevates the person’s sense of self-worth. The third type of information leads people to feel that they belong to a network of communication and mutual obligation. Members of this network share information and make goods and services available to the members as needed. Social support also facilitates a person’s coping behaviours; however, this depends on the nature of the social support. People can have extensive relationships and interact frequently, but the necessary support comes only when there is a deep level of involvement and concern, not when people merely touch the surface of each other’s lives. The critical qualities within a social network are the exchange of intimate communications and the presence of solidarity and trust. Emotional support from family and significant others provides love and a sense of sharing the burden. The emotions that accompany stress are unpleasant and often increase in a spiraling fashion if relief is not provided. Being able to talk with someone and express feelings openly may help a person gain mastery of the situation. Nurses can provide this support; however, it is important to identify the person’s social support system and encourage its use. People who are “loners,” who are isolated, or who withdraw in times of stress have a high risk of coping failure. Because anxiety can also distort a person’s ability to process information, it helps to seek information and advice from others who can assist with analyzing the threat and developing a strategy to manage it. Again, this use of others helps people maintain mastery of a situation and self-esteem. Thus, social networks assist with management of stress by providing people with: • • • • •

A positive social identity Emotional support Material aid and tangible services Access to information Access to new social contacts and new social roles

Recommending Support and Therapy Groups Support groups exist especially for people in similar stressful situations. Groups have been formed by parents of children with leukemia; people with ostomies; women who have had mastectomies; and people with other kinds

of cancer or other serious diseases, chronic illnesses, and disabilities. There are groups for single parents, who abuse substances and their family members, and victims of child abuse. Professional, civic, and religious support groups are active in many communities. There are also encounter groups, assertiveness training programs, and consciousness-raising groups to help people modify their usual behaviours in their transactions with their environment. Being a member of a group with similar issues or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas. As previously noted, a person’s psychological and biologic health, internal and external sources of stress management, and relationships with the environment are predictors of health outcomes. These factors are directly related to the person’s health patterns. The nurse has a significant role and responsibility in identifying the health patterns of the patient receiving care. If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote balance. Although this chapter has presented some physiologic mechanisms and perspectives on health and disease, the way that one copes with stress, the way one relates to others, and the values and goals held are also interwoven into those physiologic patterns. To evaluate a patient’s health patterns and to intervene if a disorder exists requires a total assessment of the person. Specific disorders and their nursing management are addressed in greater depth in other chapters.

Critical Thinking Exercises 1 A woman was carjacked, raped, and left on the shoulder of the road, where she was hit by a car. She is hospitalized with injuries related to her sexual assault and the hit-andrun vehicle crash. Describe the physiologic and psychological trauma she has experienced. Discuss the parameters that should be assessed. Identify appropriate nursing interventions used to alleviate the patient’s physiologic and emotional stressors. Address the need for emotional support from both the nursing staff and the family. 2 A 50-year-old woman had a successful kidney transplant 18 months ago. She developed an intimate relationship with a man in her neighbourhood. Several months later she was diagnosed with genital herpes. The woman verbalized to the nurse that this new illness only added to her health problems as well as to her financial, personal, and relational stressors. Discuss the methods the nurse would use to help this patient effectively cope with the multitude of stressors that she is experiencing. Address health care referrals to support groups or social networks that are appropriate for this patient. 3 A patient experiences burns to the upper extremities after being involved in a kitchen fire. Describe the manner in which homeostasis has been disrupted and the compensatory mechanisms that are evident. How does the patient’s medical treatment support the body’s compensatory mechanisms? Determine the evidence-based nursing interventions that are appropriate for promoting the healing process.

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A 70-year-old woman recently moved to a retirement community where she lives independently. A nurse practitioner assesses this patient’s health promotion needs. The family’s health history reveals that her mother had type 2 diabetes and thyroid disease, and that her father had hypertension and coronary artery disease. This patient has limited resources and support networks for making necessary lifestyle changes. What evidence exists to support the nurse practitioner’s initiating strategies to promote a healthy lifestyle? What is the evidence that supports intervention to limit or prevent maladaptive responses from occurring with this woman? Describe the strength of the evidence regarding the effectiveness of lifestyle changes in promoting health in older adults.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Bastable, S. B. (Ed.). (2008). Nurse as educator: Principles of teaching and learning (3rd ed.). Boston, MA: Jones & Bartlett. **Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind-body medicine: How to use your mind for better health. Yonkers, NY: Consumer Reports Books. **Benson, H., & Stark, M. (1996). Timeless healing. New York, NY: Scribner. Bulechek, G. M., Butcher, H. K., Dochterman, J. C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby. Fauci, A. (Ed.). (2006). Harrison’s principles of internal medicine (16th ed.). New York: McGraw-Hill. Herdman, T. H. (2012). NANDA Interventions and Nursing Diagnosis: Definitions and Classifications, 2012–2014. Oxford, UK: Wiley-Blackwell **Jalowiec, A. (1993). Coping with illness: Synthesis and critique of the nursing literature from 1980–1990. In J. D. Barnfather & B. L. Lyon (Eds.). Stress and coping: State of the science and implications for nursing theory, research, and practice. Indianapolis, IN: Sigma Theta Tau International. Kunert, M. P. (2010). Stress and adaptation. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states. (1st Canadian ed.), pp. 190–205. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. **Lazarus, R. S. (1991). Emotion and adaptation. New York, NA: Oxford University Press. **Lazarus, R. S. (1993). Why we should think of stress as a subset of emotion. In L. Goldberger & S. Breznitz (Eds.). Handbook of stress: Theoretical and clinical aspects (2nd ed.). New York, NY: The Free Press. **Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer Publishing Co. McPhee, S. J., Lingappa, V. R., Ganong, W. F. (2005). Pathophysiology of disease: An introduction to clinical medicine (5th ed.). New York, NY: McGraw-Hill. *Rice, V. H. (Ed.). (2005). Handbook of stress, coping, and health: Implications for theory, research, and practice. Bern, Germany: Huber Publishing. **Selye, H. (1976). The stress of life (Rev. ed.). New York, NY: McGraw-Hill. Skillen, D. L. (2012). Assessment of social, cultural, & spiritual health. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Jensen’s Canadian Health Assessment for Nurses: A best practice approach (First Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Thibodeau, G. A., & Patton, K. T. (2005). The human body in health and disease (4th ed.). Philadelphia, PA: Elsevier.

JOURNALS Austin, W., Gable, E., Leier, B., et al. (2009). Compassion fatigue: the experience of nurses. Ethics and Social Welfare, 3(2), 192–214.

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*Ayalon, L., & Covinsky, K. (2007). Late-life mortality in older Jews exposed to the Nazi regime. Journal of the American Geriatrics Society, 55(9), 1380–1386. *Barnard, D., Street, A., Love, A. (2006). Relationships between stressors, work supports, and burnout among cancer nurses. Cancer Nursing, 29 (4), 338–345. Baumann, S. (2007). Recovering from abuse: A comparison of three paths. Nursing Science Quarterly, 20 (4), 342–348. *Baumgartner, L. (2007). The incorporation of the HIV/AIDS identity into the self over time. Qualitative Health Research, 17 (7), 919–931. *Ben-Ari, A. (2004). Sources of social support and attachment styles among Israeli-Arab students. International Social Work, 47 (2), 187–201. Bradshaw, B., Richardson, G., Kumpfer, K., et al. (2007). Determining the efficacy of a resiliency training approach in adults with type 2 diabetes. Diabetes Educator, 33(4), 650–659. *Brewer, M., & Melnyk, B. (2007). Evidence-based practice. Effective coping/mental health interventions for critically ill adolescents: an evidence review. Pediatric Nursing, 33(4), 361. Briones, T. (2007). Psychoneuroimmunology and related mechanisms in understanding health disparities in vulnerable populations. Annual Review of Nursing Research, 25, 219–256. *Caetano, R., Ramisetty-Mikler, S., Caetano-Vaeth, P., et al. (2007). Acculturation stress, drinking, and intimate partner violence among Hispanic couples in the U.S. Journal of Interpersonal Violence, 22(11), 1431–1447. Chung, M. C., Berger, Z., Jones, R., et al. (2008). Posttraumatic stress and comorbidity following myocardial infarction among older patients. Aging and Mental Health, 12(1), 125–133. Cukrowicz, K. C., Ekblad, A. G., Cheavens, J. S., et al. (2008). Coping and thought suppression as predictors of suicidal ideation in depressed older adults with personality disorders. Aging and Mental Health, 12(1), 149–157. *Dilworth-Anderson, P., Boswell, G., & Cohen, M. (2007). Spiritual and religious coping values and beliefs among African American caregivers: A qualitative study. Journal of Applied Gerontology, 26(4), 355–369. *Dolbier, C. L. (2007). Relationships of protective factors to stress and symptoms of illness. American Journal of Health Behaviour, 31(4), 423–433. Dolbier, C. L., Smith, S. E., Steinhardt, M. A. (2007). Relationships of protective factors to stress and symptoms of illness. American Journal of Health Behaviour, 31(4), 423–433. *Eggenberger, S., & Nelms, T. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618–1628. *Flanagan, N. (2006). Testing the relationship between job stress and satisfaction in correctional nurses. Nursing Research, 55(5), 316–327. Forbes, D. A., & Neufeld, A. (2008). Looming dementia care crisis: Canada needs an integrated model of continuing care now! Canadian Journal of Nursing Research, 40(1), 9–10. Jansen, L., Forbes, D., Markle-Reid, M., et al. (2009). Formal care providers’ perceptions on home and community based services: Informing dementia care quality. Home Health Care Services Quarterly, 28, 1–23. *Glass, N., Perrin, N., Campbell, J. et al. (2007). The protective role of tangible support on post-traumatic stress disorder symptoms in urban women survivors of violence. Research in Nursing & Health, 30 (5), 558–568. Graham, J., Christian, L., & Kiecolt-Glaser, J. (2006). Stress, age, and immune function: Toward a lifespan approach. Journal of Behavioural Medicine, 29 (4), 389–400. *Greeff, A., & Holtzkamp, J. (2007). The prevalence of resilience in migrant families. Family & Community Health, 30 (3), 189–200. *Haight, W. L. (2007). Mothers’ strategies for protecting children from batterers: The perspectives of battered women involved in child protective services. Child Welfare, 86(4), 41–62. Herdman, T. H. (2012). (Ed). NANDA International Nursing Diagnoses: Definition and Classification, 2012–2014. Oxford, UK: Wiley-Blackwell. **Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213–218. Hurlbert, R. (2006). Strategies of medical intervention in the management of acute spinal cord injury. Spine, 31(11S), S16. Jackson, D., Firtko, A., Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing, 60 (1), 1–9. Jillings, C. (2007). Patients with recently diagnosed hypertension described risk in terms of acceptance and denial narratives, which served as personal frameworks of coping. Evidence-Based Nursing, 10(3), 96–96.

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Kasper, J., Köpke, S., Mühlhauser, I., et al. (2006). Evidence-based patient information about treatment of multiple sclerosis—a phase one study on comprehension and emotional responses. Patient Education & Counseling, 62(1), 56–63. *Kendall-Tackett, K. (2007). Inflammation, cardiovascular disease, and metabolic syndrome as sequelae of violence against women: The role of depression, hostility, and sleep disturbance. Trauma, Violence & Abuse, 8(2), 117–126. Kleinpell, R. (2007). Supporting independence in hospitalized elders in acute care. Critical Care Nursing Clinics of North America, 19(3), 247–252. Krucoff, C. (2007). Mind/body. Active coping for chronic pain: Simple steps to make the shift from patient to person. Alternative Medicine Magazine, 8(1), 37–38. Langley, P., Fonseca, J., Iphofen, R. (2006). Holistic care: Psychoneuroimmunology and health from a nursing perspective. British Journal of Nursing, 15(20), 1126–1129. **Lazarus, R. S. (1991b). Cognition and motivation in emotion. American Psychologist, 46(4), 352–367. **Lazarus, R. S. (1991c). Progress on a cognitive-motivational-relational theory of emotion. American Psychologist, 46(8), 819–834. *Leserman, J., & Drossman, D. (2007). Relationship of abuse history to functional gastrointestinal disorders and symptoms. Trauma, Violence & Abuse, 8(3), 331–343. *Lunney, M. (2006). Stress overload: A new diagnosis. International Journal of Nursing Terminologies & Classifications, 17 (4), 165–175. Lusk, B., & Lash, A. A. (2005). The stress response, psychoneuroimmunology, and stress among ICU patients. Dimensions of Critical Care Nursing, 24(1), 25–31. Maldonado, M., Murillo-Cabezas, F., Calvo, J., et al. (2007). Melatonin as pharmacologic support in burn patients: A proposed solution to thermal injury-related lymphocytopenia and oxidative damage. Critical Care Medicine, 35(4), 1177–1185. Mertin, S., Sawatzky, J., Diehl-Jones, W. L., et al. (2007). Roadblock to recovery: The surgical stress response. Canadian Association of Critical Care Nurses, 18(1), 14–22. Pace, T., Mletzko, T., Alagbe, O., et al. (2006). Increased stress-induced inflammatory responses in male patients with major depression and increased early life stress. American Journal of Psychiatry, 163(9), 1630–1633. *Park, N., & Kang, D. (2006). Breast cancer risk and immune responses in healthy women. Oncology Nursing Forum, 33(6), 1151–1159. Richter, R. (2007). Gender matters: Female-specific relief efforts during disasters are key. JEMS: Journal of Emergency Medical Services, 32(5), 58.

*Salick, E., & Auerbach, C. (2006). From devastation to integration: Adjusting to and growing from medical trauma. Qualitative Health Research, 16(8), 1021–1037. *Strickland, O., Giger, J., Nelson, M., et al. (2007). The relationships among stress, coping, social support, and weight class in premenopausal African American women at risk for coronary heart disease. Journal of Cardiovascular Nursing, 22(4), 272–278. *Tak, S. H. (2006). An insider perspective of daily stress and coping in elders with arthritis. Orthopaedic Nursing, 25(2), 127–132. **Tausig, M. (1982). Measuring life events. Journal of Health and Social Behaviour, 23(1), 52–64. *Travis, W. J. (2007). Resilient parenting: Overcoming poor parental bonding. Social Work Research, 31(3), 135–149. Verhaeghe, S., van Zuuren, F., Defloor, T., et al. (2007). How does information influence hope in family members of traumatic coma patients in intensive care unit? Journal of Clinical Nursing, 16(8), 1488–1497. Walsh, F. (2007). Traumatic loss and major disasters: strengthening family and community resilience. Family Process, 46(2), 207–227. Warbah, L., Sathiyaseelan, M., Vijaya-Kumar, C., et al. (2007). Psychological distress, personality, and adjustment among nursing students. Nurse Education Today, 27 (6), 597–560. *Weisel, A., Most, T., Michael, R. (2007). Mothers’ stress and expectations as a function of time since child’s cochlear implantation. Journal of Deaf Studies & Deaf Education, 12(1), 55–64. *Wilsey, S., & Shear, M. (2007). Descriptions of social support in treatment narratives of complicated grievers. Death Studies, 31(9), 801–819.

RESOURCES A.D.A.M. Inc., Stress: http://adam.about.com/reports/Stress.htm Centre for Stress Management: www.managingstress.com/articles/ definition.htm Inflammation—The Key to Chronic Disease: www.womentowomen. com/inflammation/default.aspx Institute of HeartMath: Empowering Heart-Based Living: www. heartmath.org/ Stress: The Silent Killer: http://holisticonline.com/stress/stress_GAS. htm The Psychology of Stress: www.guidetopsychology.com/stress.htm

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8 Individual and Family Considerations Related to Illness Adapted by Pauline Paul and Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the holistic approach to maintaining health and well-being. 2. Discuss the concepts of emotional well-being and emotional distress. 3. Describe recovery-oriented practice. 4. Explain the concepts of anxiety, posttraumatic stress disorder, depression, loss, and grief. 5. Determine the role of the nurse in identifying substance abuse problems and in helping families to cope. 6. Assess the impact of illness on the patient’s family and on family functioning. 7. Explore the concept of spirituality and address the spiritual needs of patients. 8. Identify nursing actions that promote effective coping for both patients and their families.

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When people experience threats to their health, they seek out various care providers for the purpose of maintaining or restoring health. In recent years, both patients and families have become increasingly involved in health care and health promotion activities. This chapter discusses the holistic approach to health and wellness, how a person’s emotional state contributes to health and illness, and how nurses can help individuals and families prevent the recurrence or exacerbation of health problems, and develop strategies to improve their future health status.

HOLISTIC APPROACH TO HEALTH AND HEALTH CARE Since the 1980s, holistic therapies often accompany traditional health care. According to the Public Health Agency of Canada (PHAC) (2008) approximately 70% of consumers in Canada follow holistic health practices. In ambulatory care settings, more consumers request these therapies, and increasing numbers of clinicians integrate them into their clinical practice (Hardy-Pickering, Adams, Sim, et al., 2007; Sood, 2007; van Tulder, 2007). In all settings, it is imperative that during clinical assessments the use of complementary and alternative therapies be assessed. Complementary and alternative therapies are discussed in Chapter 10. For some people, the holistic approach is viewed as a way to capitalize on personal strengths and recultivate the values and beliefs about health that were common before the age of technologic innovations and the sophistication of biomedical science. A lack of focus on individuals, families, and their environments by some health care providers has created feelings of disillusionment and depersonalization. Active participation by individuals and families in health promotion supports the self-care model historically embraced by the nursing profession. This model is congruent with the philosophy that seeks to balance and integrate the use of traditional medicine and advanced technology with the influence of the mind and spirit on

healing. A holistic approach to health reconnects the traditionally separate approaches to mind and body. Factors such as the physical environment, economic conditions, sociocultural issues, emotional state, interpersonal relationships, and support systems can influence health. The connections among physical health, emotional health, and spiritual well-being must be understood and considered when providing health care. It is the nurse’s conceptual integration of the physiologic health condition within the emotional and social context, along with the patient’s developmental life stage, that allows for the development of a holistic plan of nursing care.

THE BRAIN AND PHYSICAL AND EMOTIONAL HEALTH Research findings suggest fundamental relationships between the brain’s environment and mood, behaviour, and resistance to disease. One focus of brain research has been the biologic basis of mental disturbances and the relationship between mental disorders and changes in the brain. The field of psychoneuroimmunology examines connections between the emotions and the central nervous, neuroendocrine, and immune systems and has established compelling evidence that psychosocial variables can affect the functioning of the immune system. As neuroscientific research continues, data about neurotransmitters and brain functioning contribute to increased understanding of emotions, intelligence, memory, and many aspects of physical functioning. Increased knowledge about the brain and nervous system has led to breakthroughs in the treatment of both symptoms and illnesses. These findings suggest the need for health care professionals to recognize how biologic, emotional, and societal problems combine to affect individuals, families, and communities. Some problems that nurses and other health care providers must address include substance abuse, homelessness, family violence, eating disorders, trauma, and chronic mental health conditions such as anxiety and depression.

Glossary anxiety: an emotional state characterized by feelings of apprehension, discomfort, restlessness, or worry bereavement: feelings, thoughts, and responses that occur after a loss depression: state in which a person feels sad, distressed, and hopeless, with little to no energy for usual activities faith: belief and trust in God or a higher power family: a group whose members are related by reciprocal caring, mutual responsibilities, and loyalties grief: a universal response to any loss holistic health: promotion of the total health of mind, body, and spirit mental disorder: a state in which a person has deficits in functioning, has a distorted sense of self or the world, is unable to sustain relationships, or cannot handle stress or conflict effectively

mental health: a state in which a person can meet basic needs, assume responsibilities, sustain relationships, resolve conflicts, and grow throughout life posttraumatic stress disorder (PTSD): the development of severe anxiety-type symptoms after the experience of a traumatic life event recovery: a process in which people living with mental health problems and illnesses are actively engaged in their own journey of well-being (Mental Health Commission of Canada, 2014). spirituality: connectedness with self, others, a life force, or God that allows people to find meaning in life substance abuse: a maladaptive pattern of drug use that causes physical and emotional harm with the potential for disruption of daily life

CHAPTER 8

MENTAL HEALTH AND EMOTIONAL DISTRESS Emotional health involves the ability to function as comfortably and productively as possible. Typically, people who are mentally healthy are satisfied with themselves and their life situations. In the usual course of living, emotionally healthy people focus on activities geared to meet their needs and attempt to accomplish personal goals while managing everyday challenges and issues. Often, people must work hard to balance their feelings, thoughts (Pasch, 2010), and behaviours to alleviate emotional distress, and much energy is used to change, adapt, or manage the obstacles inherent in daily living. A mentally healthy person accepts reality and has a positive sense of self. Emotional health is also manifested by having moral and humanistic values and beliefs, having satisfying interpersonal relationships, doing productive work, and maintaining a realistic sense of hope. See the Mental Health Commission of Canada’s goals on helping Canadians achieve positive mental health and well-being in Chart 8-1. The Mental Health Commission of Canada (2014a) is promoting a new approach: ‘Recovery-Oriented Practice’. Recovery is a process in which people living with mental health problems and illnesses are actively involved in their own journey’s of well being”. Recovery principles, including hope, self-determination, and responsibility can be adapted to the realities of different life stages, and to the full range of mental health problems and illnesses.” When people have unmet emotional needs or distress, they experience an overall feeling of unhappiness. As tension escalates, security and survival are threatened. How different people respond to these troublesome situations reflect their level of coping and maturity. Emotionally healthy people endeavour to meet the demands of distressCHART 8-1

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ing situations while still coping with the typical issues that emerge in their lives. The ways in which people respond to uncomfortable stimuli reflect their exposure to various biologic, emotional, and sociocultural experiences. When stress interferes with a person’s ability to function comfortably and inhibits the effective management of personal needs, that person is at risk for emotional problems. The use of ineffective and unhealthy methods of coping is manifested by dysfunctional behaviours, thoughts, and feelings. These behaviours are aimed at relieving the overwhelming stress, even though they may cause further problems. Coping ability is strongly influenced by biologic or genetic factors, physical and emotional growth and development, family and childhood experiences, and learning. Typically, people revert to the strategies observed early in life that were modelled by family members, caregivers, and others to resolve conflicts. If these strategies were not adaptive, the person exhibits a range of unproductive behaviours. Dysfunctional behaviour in one person not only seriously affects that person’s emotional health but can also put others at risk for injury or death. As these destructive behaviours are repeated, a cyclic pattern becomes evident: impaired thinking, negative feelings, and more dysfunctional actions that prevent the person from meeting the demands of daily living. No universally accepted definition of what constitutes an emotional disorder exists, but many views and theories share the idea that a number of variables can interfere with emotional growth and development and impede successful adaptation to the environment. Most clinicians have adopted the statement from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM- 5-TR), which defines the term mental disorder as a group of behavioural or psychological symptoms or a pattern that manifests itself in significant distress, impaired functioning, or accentuated risk of enduring severe suffering or possible death (American Psychiatric Association, 2013). Risk factors for mental health problems are listed in Chart 8-2.

Canada’s National Mental Health Strategy Toward Recovery and Well-Being The Mental Health Commission of Canada is a nonprofit corporation created by the Federal Government to promote mental health. In 2009, after an extensive national consultation process, the commission declared the following goals to help all Canadians achieve the highest level of mental health and well-being possible: 1. People of all ages living with mental health problems and illnesses are actively engaged and supported in their journey of recovery and well-being. 2. Mental health is promoted, and mental health problems and illnesses are prevented whenever possible. 3. The mental health system responds to the diverse needs of all people in Canada. 4. The role of families in promoting well-being and providing care is recognized, and their needs are supported. 5. People have equitable and timely access to appropriate and effective programs, treatments, services, and supports that are seamlessly integrated around their needs. 6. Actions are informed by the best evidence based on multiple sources of knowledge, outcomes are measured, and research is advanced. 7. People living with mental health problems and illnesses are fully included as valued members of society.

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CHART 8-2

Risk Factors for Mental Health Problems Nonmodifiable Risk Factors • • • •

Age Gender Genetic background Family history

Modifiable Risk Factors • • • • • • • • • • • •

Marital status Family environment Housing problems Poverty or economic difficulties Physical health Nutritional status Stress level Social environment and activities Exposure to trauma Alcohol and drug misuse Environmental toxins or other pollutants Availability, accessibility, and cost of health services

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Patients seen in medical-surgical settings often struggle with psychosocial issues of anxiety, depression, loss, and grief. Abuse, addiction, chemical dependency, body image disturbances, and eating disorders are a few examples of issues that require extensive physical and emotional care to restore optimal functioning. The dual challenge for the health care team is to understand how the patient’s emotions influence physical conditions and to identify the best care for the patient experiencing underlying emotional and spiritual distress (Skillen, 2012).

Anxiety All people experience some degree of anxiety (a tense emotional state) as they face new, challenging, or threatening life situations. In clinical settings, fear of the unknown, unexpected news about one’s health, and impairment of bodily functions engenders anxiety. Although a mild level of anxiety can mobilize a person to take a position, act on the task that needs to be done, or learn to alter lifestyle habits, more severe anxiety can be paralyzing. Anxiety that escalates to a near panic state can be incapacitating. When patients receive unwelcome news about results of diagnostic studies, they are certain to experience anxiety. Different patients manifest physiologic, emotional, and behavioural signs and symptoms of anxiety in different ways.

Nursing Implications Early clinical observations of anxiety are essential components of nursing care (Chart 8-3). A high level of anxiety in a patient probably exacerbates physiologic distress. For example, a postoperative patient who is in pain may discover that anxiety intensifies the sensation of pain. A patient newly diagnosed with type 1 diabetes mellitus may be worried and fearful and therefore unable to focus on or complete essential self-care activities. Many medical conditions (e.g., a breast lump or heart condition) cause anxiety. Many assessment findings alert the nurse to patients with moderate to severe anxiety. All nurses must be vigilant about patients who worry excessively and deteriorate in emotional, social, or occupational functioning. If participation in the therapeutic regimen (e.g., administration of insulin) becomes a problem because of extreme anxiety, nursing interventions must be immediately initiated. Caring strategies emphasize ways for the patient to verbalize feelings and fears and to identify sources of anxiety. The need to teach and promote effective coping abilities and the use of relaxation techniques are the priorities of care. In some cases, antianxiety medication may be prescribed. Chart 8-4 provides a list of basic nursing principles that are useful to assist patients in managing severe anxiety. Chapter 9 presents additional information about stress and the relaxation response.

CHART 8-3

Assessing for Anxiety Be on the alert for the following assessment findings:

Physiologic Indicators • • • • • • • • • • • • • • •

Appetite change Headaches Muscle tension Fatigue or lethargy Weight change Cold and flu symptoms Digestive upsets Grinding teeth Palpitations Hypertension Restlessness Difficulty sleeping Skin irritations Injury prone Increased use of any alcohol or drugs

Emotional Indicators • • • • • • • • • • •

Forgetfulness Low productivity Feeling dull Poor concentration Negative attitude Confusion Whirling mind No new ideas Boredom Negative self-talk Anxiety

• • • • • • •

Frustration Depression Crying periods Irritability Worrying Feeling discouraged Nervous laughter

Relational Indicators • • • • • • • • • • •

Isolation Intolerance Resentment Loneliness Lashing out “Clamming up” Nagging Distrust Few friends No intimacy Using people

Spiritual Indicators • • • • • • • •

Emptiness Loss of meaning Doubt Unforgiving attitude Martyrdom Loss of direction Cynicism Apathy

human experience. Patients can suffer from posttraumatic stress disorder (PTSD), a condition that generates waves of anxiety, anger, aggression, depression, and suspicion; threatens a person’s sense of self; and interferes with daily functioning (Lasiuk & Hegadorn, 2006a,b). Specific examples of events that place people at risk for PTSD are rape, family violence, torture, terrorist attacks, fire, earthquake, CHART 8-4

Managing Anxiety • Listen actively and focus on having the patient discuss personal feelings.

• Use positive remarks and focus on the positive aspects of life in the “here and now.”

• Use appropriate touch (with patient permission) to demonstrate support.

• Discuss the importance of safety and the patient’s overall sense of well-being.

Posttraumatic Stress Disorder In medical-surgical settings, especially in emergency departments, burn units, and rehabilitation centres, nurses care for extremely anxious patients who have experienced overwhelming events that may be outside the range of usual

• Explain all procedures, policies, diagnostic studies, medications, treatments, or protocols for care.

• Explore coping strategies and work with the patient to

practice and use them effectively (e.g., breathing, progressive relaxation, visualization, imagery). • Use distraction as indicated to relax and prevent self from being overwhelmed.

CHAPTER 8

and military combat. Patients who have experienced a traumatic event are often frequent users of the health care system, seeking treatment for the overall emotional and physical trauma that they experienced. The physiologic responses of people who have been severely traumatized include increased activity of the sympathetic nervous system, increased plasma catecholamine levels, and increased urinary epinephrine and norepinephrine levels. People with PTSD may lose the ability to control their response to stimuli (Loseke, Gelles & Cavanaugh, 2005). The resulting excessive arousal can increase overall body metabolism and trigger emotional reactivity. In this situation, patients have difficulty sleeping, have an exaggerated startle response, and are excessively vigilant. Symptoms of PTSD can occur hours to years after the trauma is experienced. Acute PTSD is defined as the experience of symptoms for less than a 3-month period. Chronic PTSD is defined as the experience of symptoms lasting longer than 3 months. In the case of delayed PTSD, up to 6 months may elapse between the trauma and the manifestation of symptoms (American Psychiatric Association, 2013). For more information, see Chart 8-5.

Nursing Implications It is often thought that the incidence of PTSD is very low in the overall population. However, when high-risk groups are studied, the results indicate that more than 50% of study participants have PTSD (McKenny & Price, 2005). Therefore, it is important that nurses consider which of their patients are at risk for PTSD and be knowledgeable about the common symptoms associated with it. Older people are more susceptible to the physical effects of trauma and the effects of PTSD because of the neural inactivation associated with aging. One study reported that people with strong support networks were less likely to experience PTSD after a natural disaster than people without a strong support system (Acierno, Ruggiero, Kilpatrick, et al., 2006). The sensitivity and caring of the nurse creates the interpersonal relationship necessary to work with patients who have PTSD. These patients are physically compromised and are struggling emotionally with situations that are not considered part of normal human experience, situations that violate the commonly held perceptions of human social justice. Retired General Romeo D’Allaire (now Senator D’Allaire) was the Forces Commander of the United Nations troops in Rwanda. Despite his pleas for more troops to avert disaster, he was ignored by the international community, and a genocide occurred in which over 800,000 people were killed. In his book Shake Hands with the Devil: The Failure of Humanity in Rwanda, he describes how upon returning to Canada his mental health deteriorated, culminating in suicide attempts, a diagnosis of PTSD, a medical discharge from the Canadian Armed Forces, and dozens of therapy sessions and medications. He became the “public face” of PTSD when he was found inebriated on a park bench in Ottawa. He publically talks about this episode to help people understand more about PTSD.

Treatment of patients with PTSD includes several essential components: establishing a trusting relationship, addressing and working through the trauma experience, and teaching the coping skills needed for recovery and self-care. The patient’s progress can be influenced by the

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CHART 8-5

Assessing for Posttraumatic Stress Disorder (PTSD) Be on the alert for the following assessment findings:

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 behaviour, including suicide Thrill-seeking behaviours

Copel, L. C. (2000). Nurse’s clinical guide: Psychiatric and mental health care (2nd ed.). Springhouse, PA: Springhouse.

ability to cope with the various aspects of both the physical and the emotional distress.

Depression Depression is a common response to health issues and is an underdiagnosed condition, particularly in hospitalized patients (Seelig & Katon, 2008). People may become depressed as a result of injury or illness; may be suffering from an earlier loss that is compounded by a new health

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issue; or may seek health care for somatic manifestations of depression. The cause of depression is unknown but it includes the interaction of genetic, biological, social, and psychological factors (Lasiuk & Bickley, 2010). Clinical depression is distinguished from everyday feelings of sadness by its duration and severity (Lasiuk, 2012). Most people occasionally feel down or depressed, but these feelings are short-lived and do not result in impaired functioning. People who are clinically depressed 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 hiding their depression for months or years and astonish family members and others when they finally admit that they are seriously depressed. Many people experience depression but seek treatment for somatic concerns. The leading somatic concerns of patients struggling with depression are headache, backache, abdominal pain, fatigue, malaise, anxiety, and decreased desire or issues with sexual functioning (Varcarolis, Carson, & Shoemaker, 2006). It is estimated that depression is undiagnosed about half of the time, and masquerades as physical health problems (Townsend, 2005). People with depression also exhibit poor functioning with frequent absences from work and school. MacMillan, Patterson, & Wathen (2005) found that two questions can be used to assess for depression and may be as useful as longer questionnaires: “Over the past 2 weeks, have you felt down? Depressed? Or hopeless?” and “Over the past 2 weeks have you felt little interest or pleasure in doing things?” Specific symptoms of clinical depression include feelings of sadness, worthlessness, fatigue, 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. A diagnosis of clinical depression is made when a person presents with at least five of nine diagnostic criteria for depression (Chart 8-6). Unfortunately, only one of three people who are depressed is properly diagnosed and appropriately treated (American Psychiatric Association, 2013).

CHART 8-6

Diagnostic Criteria for Depression Based on the DSM-5-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. (2013). Diagnostic and statistical manual of mental disorders (DSM-5-TR) (5th ed.). Washington, DC: Author.

Talking with the patient about his or her fears, frustration, anger, and despair can help alleviate a sense of helplessness and lead to necessary treatment. Helping the patient learn to cope effectively with conflict, interpersonal issues, and grief and encouraging the patient to discuss actual and potential losses may hasten his or her recovery from depression. It may also be possible to help the patient identify and decrease negative self-talk and unrealistic expectations and show how these contribute to depression. The nurse monitors the patient for the onset of new concerns because depression adversely affects physical health and self-care activities (Chart 8-8). All patients with depression should be evaluated to determine if they would benefit from antidepressant therapy. In addition to the measures previously listed, psychoeducational programs, establishment of support systems, and counselling can reduce anxiety- and depressionrelated distress. Psychoeducational programs can help patients and their families understand depression, treatment options, and coping strategies. (In crisis situations, it is imperative that patients be referred to psychiatrists, psychiatric nurse specialists, advanced practice psychiatric mental health nurses, or crisis centres.) Explaining to

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. Chart 8-7 lists risk factors for depression. Depression can occur at any age, and it is diagnosed more frequently in women than in men. In older patients, nurses should be aware that decreased mental alertness or withdrawal-type responses may be indicative of depression. Consultation with an advanced practice psychiatric mental health nurse to assess and differentiate between dementia-like symptoms (Haase, 2010), and depression is often helpful.

CHART 8-7

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

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Chart 8-8. Loneliness and Social Support in MS Beal, C. C. & Stuifbergen, A. (2007). Loneliness in women with multiple sclerosis. Rehabilitation Nursing, 32 (4), 165–171. Purpose Women diagnosed with multiple sclerosis (MS) are at risk for loneliness due to the changes that frequently occur in their social activities and networks. This study was designed to (1) examine the relationship between loneliness, social support, functional limitations, self-rated health status, social responses to illness, and marital status, as well as to (2) determine the extent that the previously mentioned variables could predict loneliness. Design A secondary analysis examined data collected from 659 women in 1996. Participants, from the southwest region of the United States, were members of the National Multiple Sclerosis Society. The women provided information on age, gender, ethnicity, education, employment, marital status, and type of MS. The participants completed a longitudinal survey concerning health promotion behaviours and quality of life for people with MS. The researchers used descriptive statistics to describe the subjects. Pearson correlations and regression analysis were used to identify the variables that explained the variance for loneliness. Findings The subjects reported few problems with activities of daily living. Ninety-eight of the women (approximately 15%) revealed that they experienced fatigue, with 48% indicating that the fatigue was frequent or disabling. The majority of the participants reported that they were less social as a result of the MS because it was difficult to plan social activities. These women believed that other people did not

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 (Varcarolis et al., 2006).

Suicide In Canada, 2% of all deaths are due to suicide, and screening in primary care settings may help to reduce mortality (Stephen et al., 2010). It is estimated that 90% of those who died by suicide had a mental health illness (Langille, 2014). See Table 8-1 for number of suicide deaths by age group.

TABLE 8-1 Age Group Number of Deaths

Numbers of Suicide Deaths by Age Groups in Canada, 2009

15–24 25–44 45–64 ≥65 Total 60 yrs: 8–20 mg/dL About 10:1

Bladder Ultrasonography Bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder. It may be indicated for urinary frequency, inability to void after removal of an indwelling urinary catheter, measurement of postvoiding residual urine volume, inability to void postoperatively, or assessment of the need for catheterization during the initial stages of an intermittent catheterization training program. Portable, battery-operated devices are available for bedside use. The scan head is placed on the patient’s abdomen and directed toward the bladder. The device automatically calculates and displays urine volume.

Computed Tomography and Magnetic Resonance Imaging Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniques that provide excellent cross-sectional views of the kidney and urinary tract. They are used to evaluate genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease, and soft tissue abnormalities. The nurse should explain to the patient that a sedative may be prescribed. Claustrophobia is often a problem, especially with MRI. Patient preparation for the MRI includes removal of any metallic objects, such as jewelry or clothing with metallic clasps. Credit cards should be kept away from the MRI area because of their magnetic strips. MRI is contraindicated in patients with pacemakers, surgical clips, or any metallic objects anywhere in the body. Occasionally, an oral or intravenous radiopaque contrast material is used in CT scanning to

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CHART 44-6

Patient Care During Urologic Testing With Contrast Agents For some patients, contrast agents are nephrotoxic and allergenic. The following guidelines can help the nurse and other health care providers respond quickly in the event of a problem.

Nursing Actions for Room Preparation • Have emergency equipment and medications available in

case the patient has an anaphylactic reaction to the contrast agent. Emergency supplies include epinephrine, corticosteroids, vasopressors, oxygen, and airway and suction equipment.

Nursing Actions for Patient Preparation • Obtain the patient’s allergy history with emphasis on • •

•

•

allergy to iodine, shellfish, and other seafood, because many contrast agents contain iodine. Notify physician and radiologist if the patient is allergic or suspected to be allergic to iodine. Obtain health history. Contrast agents should be used with caution in older patients and patients who have diabetes mellitus, multiple myeloma, renal insufficiency, or volume depletion. Inform the patient that he or she may experience a temporary feeling of warmth, flushing of the face, and an unusual flavour (similar to that of seafood) in the mouth when the contrast agent is infused. Monitor patient closely for allergic reaction and monitor urine output.

enhance visualization. Nursing care guidelines for patient preparation and test precautions for any imaging procedure requiring a contrast agent (also called contrast medium) are explained in Chart 44-6.

Nuclear Scans Nuclear scans require injection of a radioisotope (a technetium 99m–labelled compound or iodine 123 [123I] hippurate) into the circulatory system; the isotope is then monitored as it moves through the blood vessels of the kidneys. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. Hypersensitivity to the radioisotope is rare. The technetium scan provides information about kidney perfusion. The 123I-hippurate renal scan provides information about kidney function, such as GFR. Nuclear scans are used to evaluate acute and chronic renal failure, renal masses, and blood flow before and after kidney transplantation. The radioisotope is injected at a specified time to achieve the proper concentration in the kidneys. After the procedure is completed, the patient is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys.

Intravenous Urography IV urography includes various tests such as excretory urography, intravenous pyelography (IVP), and infusion drip pyelography. A radiopaque contrast agent is adminis-

tered by IV. An IVP shows the kidneys, ureter, and bladder via x-ray imaging as the dye moves through the upper and then the lower urinary system. A nephrotomogram may be carried out as part of the study to visualize different layers of the kidney and the diffuse structures within each layer and to differentiate solid masses or lesions from cysts in the kidneys or urinary tract. IV urography may be used as the initial assessment of many suspected urologic conditions, especially lesions in the kidneys and ureters. It also provides an approximate estimate of renal function. After the contrast agent (sodium diatrizoate or meglumine diatrizoate) is administered by IV, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary systems. Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to opacify the renal parenchyma and fill the urinary tract. This examination method is useful when prolonged opacification of the drainage structures is desired so that tomograms (body-section radiography) can be made. Images are obtained at specified intervals after the start of the infusion. These images show the filled and distended collecting system. The patient preparation is the same as for excretory urography, except that fluids are not restricted.

Retrograde Pyelography In retrograde pyelography, catheters are advanced through the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected. Retrograde pyelography is usually performed if IV urography provides inadequate visualization of the collecting systems. It may also be used before extracorporeal shock wave lithotripsy and in patients with urologic cancer who need follow-up and have an allergy to IV contrast agents. Possible complications include infection, hematuria, and perforation of the ureter. Retrograde pyelography is used infrequently because of improved techniques in excretory urography.

Cystography Cystography aids in evaluating vesicoureteral reflux (backflow of urine from the bladder into one or both ureters) and in assessing for bladder injury. A catheter is inserted into the bladder, and a contrast agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder perforation stemming from bladder injury, but such leakage is usually harmless. Cystography can also be performed with simultaneous pressure recordings inside the bladder.

Voiding Cystourethrography Voiding cystourethrography uses fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder. It is commonly used as a diagnostic tool to identify vesicoureteral reflux. A urethral catheter is inserted, and a contrast agent is instilled into the bladder. When the bladder is full and the patient feels the urge to void, the catheter is removed, and the patient voids.

CHAPTER 44

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Renal Angiography A renal angiogram, or renal arteriogram, provides an image of the renal arteries. The femoral (or axillary) artery is pierced with a needle, and a catheter is threaded up through the femoral and iliac arteries into the aorta or renal artery. A contrast agent is injected to opacify the renal arterial supply. Angiography is used to evaluate renal blood flow in suspected renal trauma, to differentiate renal cysts from tumours, and to evaluate hypertension. It is used preoperatively for renal transplantation. Before the procedure, a laxative may be prescribed to evacuate the colon so that unobstructed x-rays can be obtained. Injection sites (groin for femoral approach or axilla for axillary approach) may be shaved. The peripheral pulse sites (radial, femoral, and dorsalis pedis) are marked for easy access during postprocedural assessment. The patient is informed that there may be a brief sensation of warmth along the course of the vessel when the contrast agent is injected. After the procedure, vital signs are monitored until stable. If the axillary artery was the injection site, blood pressure measurements are taken on the opposite arm. The injection site is examined for swelling and hematoma. Peripheral pulses are palpated, and the colour and temperature of the involved extremity are noted and compared with those of the uninvolved extremity. Cold compresses may be applied to the injection site to decrease edema and pain. Possible complications include hematoma formation, arterial thrombosis or dissection, false aneurysm formation, and altered renal function.

Urologic Endoscopic Procedures Endourology, or urologic endoscopic procedures, can be performed in one of two ways: using a cystoscope inserted into the urethra, or percutaneously, through a small incision. The cystoscopic examination is used to directly visualize the urethra and bladder. The cystoscope, which is inserted through the urethra into the bladder, has an optical lens system that provides a magnified, illuminated view of the bladder (Fig. 44-8). The use of a high-intensity light and interchangeable lenses allows excellent visualization and permits still and motion pictures to be taken. The cystoscope is manipulated to allow complete visualization of the urethra and bladder as well as the ureteral orifices and prostatic urethra. Small ureteral catheters can be passed through the cystoscope for assessment of the ureters and the pelvis of each kidney. The cystoscope also allows the urologist to obtain a urine specimen from each kidney to evaluate its function. Cup forceps can be inserted through the cystoscope for biopsy. Calculi may be removed from the urethra, bladder, and ureter using cystoscopy. If a lower tract cystoscopy is performed, the patient is usually conscious, and the procedure is usually no more uncomfortable than a catheterization. To minimize post-test urethral discomfort, viscous lidocaine is administered several minutes before the study. If the cystoscopy includes examination of the upper tracts, a sedative may be administered before the procedure.

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To light source

Bladder

Irrigant

Irrigant Ureteral orifice

FIGURE 44-8. Cystoscopic examination. A rigid or semirigid cysto-

scope is introduced into the bladder. The upper cord is an electric line for the light at the distal end of the cystoscope. The lower tubing leads from a reservoir of sterile irrigant that is used to inflate the bladder.

General anesthesia is usually administered to ensure that there are no involuntary muscle spasms when the scope is being passed through the ureters or kidney. The nurse describes the procedure to the patient and family to prepare them and to allay their fears. If an upper cystoscopy is to be performed, the patient is usually restricted to nothing by mouth (NPO) for several hours beforehand. Postprocedural management is directed at relieving any discomfort resulting from the examination. Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected. Moist heat to the lower abdomen and warm sitz baths are helpful in relieving pain and relaxing the muscles. After a cystoscopic examination, the patient with obstructive pathology may experience urine retention if the instruments used during the examination caused edema. The nurse carefully monitors the patient with prostatic hyperplasia for urine retention. Warm sitz baths and antispasmodic medication, such as flavoxate or flavoxate hydrochloride may be prescribed to relieve temporary urine retention caused by poor relaxation of the urinary sphincter; however, intermittent catheterization may be necessary for a few hours after the examination. The nurse monitors the patient for signs and symptoms of urinary tract infection. Because edema of the urethra secondary to local trauma may obstruct urine flow, the patient is also monitored for signs and symptoms of obstruction.

Biopsy Renal and Ureteral Brush Biopsy Brush biopsy techniques provide specific information when abnormal x-ray findings of the ureter or renal pelvis raise questions about whether a defect is a tumour, a

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stone, a blood clot, or an artefact. First, a cystoscopic examination is conducted. Then, a ureteral catheter is introduced, followed by a biopsy brush that is passed through the catheter. The suspected lesion is brushed back and forth to obtain cells and surface tissue fragments for histologic analysis. After the procedure, IV fluids may be administered to help clear the kidneys and prevent clot formation. Urine may contain blood (usually clearing in 24 to 48 hours) from oozing at the brushing site. Postoperative renal colic occasionally occurs and responds to analgesic agents.

Kidney Biopsy Biopsy of the kidney is used to help diagnose and evaluate the extent of kidney disease. Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. A small section of renal cortex is obtained either percutaneously (needle biopsy) or by open biopsy through a small flank incision. Before the biopsy is carried out, coagulation studies are conducted to identify any risk of postbiopsy bleeding. Contraindications to kidney biopsy include bleeding tendencies, uncontrolled hypertension, a solitary kidney, and morbid obesity (Salama & Cook, 2012).

Procedure The patient may be prescribed a fasting regimen 6 to 8 hours before the test. An IV line is established. A urine specimen is obtained and saved for comparison with the postbiopsy specimen. If a needle biopsy is to be performed, the patient is instructed to breathe in and hold that breath (to prevent the kidney from moving) while the needle is being inserted. The sedated patient is placed in a prone position with a sandbag under the abdomen. The skin at the biopsy site is infiltrated with a local anesthetic agent. The biopsy needle is introduced just inside the renal capsule of the outer quadrant of the kidney. The location of the needle may be confirmed by fluoroscopy or by ultrasound, in which case a special probe is used. With open biopsy, a small incision is made over the kidney, allowing direct visualization. Preparation for an open biopsy is similar to that for any major abdominal surgery.

Critical Thinking Exercises 1

Two days after major surgery your patient reports lower abdominal pain. Describe the assessment techniques appropriate to evaluate the pain. Review the possible causes, describe the actions you would take and the rationale for each action, and identify the evidence base that supports the actions. What criteria would you use to evaluate the strength of the evidence?

2 A 46-year-old patient with a history of smoking is admitted to the hospital for evaluation of urinary dysfunction and is scheduled for a urinary system MRI. Explain why the MRI is indicated for this patient and what, if any, precautions must be taken because the patient is trying to

stop smoking. What nursing observations and assessments are indicated because of the history of smoking? What patient teaching is appropriate before the MRI? 3 You make a home visit to an older female patient who is incontinent. Identify assessments and possible interventions you would use to evaluate and manage the incontinence. Identify the evidence for the assessments and nursing interventions you chose and the strength of that evidence.

REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS Boswell, W. D., Jadvar, H., & Palmer, S. L. (2012). Diagnostic kidney imaging. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 930–1005). Philadelphia, PA: Elsevier. Eliopoulos, C. (2014). Gerontological Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Holcombe, D. M., & Kern Feeley, N. (2013). Renal failure. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 663–690). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins. Israni, A. K., & Kasiske, B. L. (2012). Laboratory assessment of kidney disease: Glomerular filtration rate, urinalysis, and proteinuria. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 868–896). Philadelphia, PA: Elsevier. Miller, C. A. (2012). Nursing for wellness in older adults (6th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Salama, A. D., & Cook, H. T. (2012). The renal biopsy. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 1006–1015). Philadelphia, PA: Elsevier. Snyder, K. A., & Crusius, K. C. (2013). Patient assessment: Renal system. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 618–636). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Snyder, K. A., & Haas, K. (2013). Anatomy and physiology of the renal system. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 607–636). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS *Alexaitis, I., & Broome, B. (2013). Implementation of a nurse-driven protocol to prevent catheter associated urinary tract infections. Journal of Nursing Care Quality, 29 (3), 245–252. Castner, D. (2010). Understanding the stages of chronic kidney disease. Nursing, 40 (5), 25–31. Collins, M., & Claros, E. (2011). Recognizing the face of dehydration. Nursing, 41(8), 26–31. Keyock, K. L., & Newman, D. K. (2011). Understanding stress urinary incontinence. The Nurse Practitioner, 36 (10), 24–36. Larsen, B., & Post, G. J. (2013). LUTS: A practical guide to alleviating lower urinary tract symptoms. Journal of the American Academy of Physician Assistants, 26 (3), 26–30.

CHAPTER 44 Menaker, J., & Scalea, T. M. (2010). Geriatric Care in the surgical intensive care unit. Critical Care Medicine, 38 (9), S452–459. Mentes, J. C. (2013). The complexities of hydration issues in the elderly. Nutrition Today, 48 (4S), S10–S12. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) (2014). High blood pressure and kidney disease. Retrieved from http://kidney.niddk.nih.gov/KUDiseases/pubs/highblood/ #howcan O’Leary, M., & Dierich, M. (2010). Urinary tract dysfunction in neurological disorders: The nurses’ role in assessment and management. Journal of Neuroscience in Nursing, 42(2), E8–E23. Robinson, J. P., Bradway, C. W., Bunting-Perry, L., et al. (2013). Lower urinary tract symptoms in men with parkinson disease. Journal of Neuroscience Nursing, 45 (6), 382–392. Scemons, D. (2013). Urinary incontinence in adults. Nursing, 43(11), 52–60. Shultz, J. M. (2012). Rethink urinary incontinence in older women. Nursing, 42(11), 32–40.

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Sullivan, J. M. (2011). Caring for older adults after surgery. Nursing, 41(4), 48–51. Wilde, M. H., Bliss, D. A., Booth, J., et al. (2014). Self-management of urinary & fecal incontinence. American Journal of Nursing, 114(1), 38–45. Zuber, K., Liles, A. M., & Davies, J. (2013). Medication dosing in patients with chronic kidney disease. Journal of American Academy of Physician Assistants, 26 (10), 19–25.

RESOURCES American Association of Kidney Patients, www.aakp.org American Urological Association, www.auafoundation.org National Kidney Foundation, www.kidney.org National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, www.niddk.nih.gov The Kidney Foundation of Canada http://www.kidney.ca/ Kidney Cancer Research Network of Canada www.ncbi.nlm.nih.gov/ entrez/query.fcgi?db=OMIM

CHAPTER

45 Management of Patients With Renal Disorders Adapted by Lisa Rock

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the key factors associated with the development of renal disorders. 2. Differentiate between the causes of chronic kidney disease and acute and chronic renal failure. 3. Compare and contrast the pathophysiology, clinical manifestations, medical management, and nursing management for patients with renal disorders. 4. Describe the nursing management of patients with acute and chronic renal failure. 5. Compare and contrast the renal replacement therapies including hemodialysis, peritoneal dialysis, and kidney transplantation. 6. Describe the nursing management of the hospitalized patient on dialysis. 7. Develop a postoperative plan of nursing care and teaching plan for the patient undergoing kidney surgery and transplantation.

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The renal system helps regulate the body’s internal environment and is essential for the maintenance of life. Nurses working in any clinical setting may encounter patients with various renal disorders and thus need to be knowledgeable about these disorders. This chapter provides an overview of electrolyte imbalances that are common in patients with renal disorders. The main causes of kidney disease are discussed, together with management strategies to prevent damage and preserve renal function. Chronic kidney disease (CKD) and acute and chronic renal failure (CRF) are discussed, as is the care of patients with other renal conditions who require dialysis, transplantation, and kidney surgery.

FLUID AND ELECTROLYTE IMBALANCES IN RENAL DISORDERS Patients with renal disorders commonly experience fluid and electrolyte imbalances and require careful assessment

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and close monitoring for signs of potential problems. The patient whose fluid intake exceeds the ability of the kidneys to excrete fluid is said to have fluid overload. If fluid intake is inadequate, the patient is said to be volume depleted and may show signs and symptoms of fluid volume deficit. The fluid intake and output (I&O) record, a key monitoring tool, is used to document important fluid parameters, including the amount of fluid taken in (orally or parenterally), the volume of urine excreted, and other fluid losses (diarrhea, vomiting, diaphoresis). Patient weight is also important, and documenting trends in weight is a key assessment strategy essential for determining the daily fluid allowance and indicating signs of fluid overload or deficit.

!

NURSING ALERT

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.

Glossary acute nephritic syndrome: type of renal failure with glomerular inflammation acute renal failure: sudden rapid deterioration of kidney function that is sometimes reversible acute tubular necrosis: type of acute renal failure in which there is actual damage to the kidney tubules anuria: total urine output less than 50 mL in 24 hours arteriovenous fistula: type of vascular access for dialysis; created by surgically connecting an artery to a vein arteriovenous graft: type of surgically created vascular access for dialysis by which a piece of biologic, semibiologic, or synthetic graft material connects the patient’s artery to a vein azotemia: abnormal concentration of nitrogenous wastes in the blood chronic kidney disease: chronic progressive and irreversible diseases of the kidneys continuous ambulatory peritoneal dialysis: method of peritoneal dialysis whereby a patient manually performs four or five complete exchanges or cycles throughout the day continuous cyclic peritoneal dialysis: method of peritoneal dialysis in which a peritoneal dialysis machine (cycler) automatically performs exchanges, usually while the patient sleeps continuous renal replacement therapy: variety of methods used to replace normal kidney function by circulating the patient’s blood through a filter and returning it to the patient dialysate: solution that circulates through the dialyzer in hemodialysis and through the peritoneal membrane in peritoneal dialysis dialyzer: “artificial kidney” or dialysis machine; contains a semipermeable membrane through which particles of a certain size can pass

diffusion: movement of solutes (waste products) from an area of higher concentration to an area of lower concentration effluent: term used to describe the drained fluid from a peritoneal dialysis exchange end-stage renal disease: final stage of renal failure that results in retention of uremic waste products and the need for renal replacement therapies exchange (peritoneal dialysis): complete cycle of peritoneal dialysis includes fill, dwell, and drain phases glomerulonephritis: inflammation of the glomerular capillaries hemodialysis: procedure during which a patient’s blood is circulated through a dialyzer to remove waste products and excess fluid interstitial nephritis: inflammation within the renal tissue nephrosclerosis: hardening of the renal arteries nephrotic syndrome: type of renal failure with increased glomerular permeability and massive proteinuria nephrotoxic: any substance, medication, or action that destroys kidney tissue osmosis: movement of water through a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration peritoneal dialysis: procedure that uses the lining of the patient’s peritoneal cavity as the semipermeable membrane for exchange of fluid and solutes peritonitis: inflammation of the peritoneal membrane (lining of the peritoneal cavity) pyelonephritis: inflammation of the renal pelvis ultrafiltration: process whereby water is removed from the blood by means of a pressure gradient between the patient’s blood and the dialysate uremia: an excess of urea and other nitrogenous wastes in the blood urinary casts: proteins secreted by damaged kidney tubules

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Clinical Manifestations The signs and symptoms of common fluid and electrolyte disturbances that can occur in patients with renal disorders and their general management strategies are listed in Table 45-1. The nurse continually assesses, monitors, and informs appropriate members of the health care team if the patient exhibits any of these signs. Management strategies for fluid and electrolyte disturbances in renal disease are discussed in greater depth later in this chapter (see also Chapter 15).

Gerontologic Considerations Changes in kidney function with normal aging increase the susceptibility of older adults to kidney dysfunction and renal failure (Perico, Remuzzi, & Benigni, 2011). In addition, 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

TABLE 45-1

disorders. Therefore, acute problems need to be prevented, if possible, or recognized and treated quickly to avoid kidney damage, and nurses in all settings need to be alert for signs and symptoms of renal dysfunction in older adults. Older adults frequently take multiple prescription and over-the-counter medications. Because alterations in renal blood flow, glomerular filtration, and renal clearance increase the risk for medication-associated changes in renal function, precautions are indicated with all medications. When older adults undergo extensive diagnostic tests or when new medications (e.g., diuretic agents) are added, precautions must be taken to prevent dehydration, which can compromise marginal renal function and lead to renal failure (Mentes, 2013). With aging, the kidney is less able to respond to acute fluid and electrolyte changes. Older adults 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 pre-existing disorders and the misconception that they are normal changes of aging.

Common Fluid and Electrolyte Disturbances in Renal Disorders

Disturbance

Manifestations

General Management Strategies

Fluid volume deficit

Acute weight loss ≥5%, decreased skin turgor, dry mucous membranes, oliguria or anuria, increased hematocrit, blood urea nitrogen (BUN) level increased out of proportion to creatinine level, hypothermia Acute weight gain ≥5%, edema, crackles, shortness of breath, decreased BUN, decreased hematocrit, distended neck veins Nausea, malaise, lethargy, headache, abdominal cramps, apprehension, seizures Dry, sticky mucous membranes, thirst, rough dry tongue, fever, restlessness, weakness, disorientation Anorexia, abdominal distention, paralytic ileus, muscle weakness, ECG changes, dysrhythmias Diarrhea, colic, nausea, irritability, muscle weakness, ECG changes

Fluid challenge, fluid replacement orally or parenterally

Fluid volume excess

Sodium deficit Sodium excess Potassium deficit Potassium excess

Calcium deficit

Calcium excess

Bicarbonate deficit Bicarbonate excess Protein deficit Magnesium deficit

Magnesium excess

Phosphorus deficit Phosphorus excess

Abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek’s or Trousseau’s sign, tingling of fingers and around mouth, ECG changes Deep bone pain, flank pain, muscle weakness, depressed deep tendon reflexes, constipation, nausea and vomiting, confusion, impaired memory, polyuria, polydipsia, ECG changes Headache, confusion, drowsiness, increased respiratory rate and depth, nausea and vomiting, warm flushed skin Depressed respirations, muscle hypertonicity, dizziness, tingling of fingers and toes Chronic weight loss, emotional depression, pallor, fatigue, soft flabby muscles Dysphagia, muscle cramps, hyperactive reflexes, tetany, positive Chvostek’s or Trousseau’s sign, tingling of fingers, dysrhythmias, vertigo Facial flushing, nausea and vomiting, sensation of warmth, drowsiness, depressed deep tendon reflexes, muscle weakness, respiratory depression, cardiac arrest Deep bone pain, flank pain, muscle weakness and pain, paresthesia, apprehension, confusion, seizures Tetany, tingling of fingers and around mouth, muscle spasms, soft tissue calcification

Fluid and sodium restriction, diuretics, dialysis

Diet, normal saline or hypertonic saline solutions Fluids, diuretics, dietary restriction Diet, oral or parenteral potassium replacement therapy Dietary restriction, diuretics, IV glucose, insulin and sodium bicarbonate, cation-exchange resin, calcium gluconate, dialysis Diet, oral or parenteral calcium salt replacement

Fluid replacement, etidronate, pamidronate, mithramycin, calcitonin, glucocorticoids, phosphate salts Bicarbonate replacement, dialysis Fluid replacement if volume depleted; ensure adequate chloride Diet, dietary supplements, hyperalimentation, albumin Diet, oral or parenteral magnesium replacement therapy Calcium gluconate, mechanical ventilation, dialysis

Diet, oral or parenteral phosphorus supplementation therapy Diet restriction, phosphate binders, normal saline solution, IV dextrose solution, and insulin

CHAPTER 45

RENAL DISORDERS Chronic Kidney Disease Chronic kidney disease (CKD) is an abnormality of kidney structure or function for 3 months or more and is identified by the glomerular filtration rate (GFR) and other markers that indicate kidney damage (Kidney Disease Improving Global Outcomes [KDIGO], 2012). CKD is associated with decreased quality of life, increased health care expenditures, and premature death. Untreated CKD can result in end-stage renal disease (ESRD) and necessitate renal replacement therapy (dialysis or kidney transplantation). Risk factors include cardiovascular disease, diabetes, hypertension, and obesity (KDIGO, 2012). At the end of 2010, there were an estimated 39,352 people in Canada living with ESRD (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014). Diabetes is the primary cause of ESRD in Canada. The second leading cause is hypertension, followed by glomerulonephritis; polycystic kidney disease, hereditary, or congenital disorders; and systemic lupus erythematosus (Hannon, Pooler, & Porth, 2010).

Pathophysiology In the early stages of CKD there can be significant damage to the kidneys without signs or symptoms. The pathophysiology of CKD is not yet clearly understood, but the damage to the kidneys is thought to be caused by prolonged acute inflammation that is not organ specific and thus has subtle systemic manifestations.

Stages of Chronic Kidney Disease CKD has been classified into five stages by the National Kidney Foundation (NKF) (Chart 45-1). Stage 5 results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions and renal replacement therapies are required to sustain life. Screening and early intervention are important, as not all patients progress to stage 5 CKD. Patients with CKD are at increased risk for cardiovascular disease, the leading cause of morbidity and mortality (Holcombe & Kern Feeley, 2013). Treatment of hypertension, anemia, and hyperglycemia and detection of proteinuria all help to slow disease progression and improve patient outcomes (Castner, 2010).

Clinical Manifestations Elevated serum creatinine levels indicate underlying kidney disease; as the creatinine level increases, symptoms of CKD begin. Anemia, due to decreased erythropoietin production by the kidney; metabolic acidosis; and abnormalities in calcium and phosphorus herald the development of CKD. Fluid retention, evidenced by both edema and congestive heart failure, develops. As the disease progresses, abnormalities in electrolytes occur, heart failure worsens, and hypertension becomes more difficult to control.

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CHART 45-1

Stages of Chronic Kidney Disease Stages are based on the glomerular filtration rate (GFR). The normal GFR is 125 mL/min/1.73 m2.

Stage 1

GFR ≥ 90 mL/min/1.73 m2 Kidney damage with normal or increased GFR

Stage 2

GFR = 60–89 mL/min/1.73 m2 Mild decrease in GFR

Stage 3

GFR = 30–59 mL/min/1.73 m2 Moderate decrease in GFR

Stage 4

GFR = 15–29 mL/min/1.73 m2 Severe decrease in GFR

Stage 5

GFR < 15 mL/min/1.73 m2 Kidney failure (end-stage renal disease [ESRD])

Assessment and Diagnostic Findings The GFR is the amount of plasma filtered through the glomeruli per unit of time. Creatinine clearance is a measure of the amount of creatinine the kidneys are able to clear in a 24-hour period. Normal values differ in men and women. Calculation of GFR, an important assessment perimeter in CKD, is discussed in Chapter 44.

Medical Management The management of patients with CKD includes treatment of the underlying causes. Regular clinical and laboratory assessment is important to keep the blood pressure (BP) below 130/80 mm Hg. Medical management also includes early referral for initiation of renal replacement therapies as indicated by the patient’s renal status. Prevention of complications is accomplished by controlling cardiovascular risk factors; treating hyperglycemia; treating anemia; smoking cessation, weight loss, and exercise programs as needed; and reduction in salt and alcohol intake.

Nephrosclerosis Nephrosclerosis (hardening of the renal arteries) is most often due to prolonged hypertension and diabetes. Nephrosclerosis is a major cause of CKD and ESRD secondary to many disorders.

Pathophysiology There are two forms of nephrosclerosis: malignant (accelerated) and benign. Malignant nephrosclerosis is often associated with significant hypertension (diastolic blood pressure

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higher than 130 mm Hg). It usually occurs in young adults and twice as often in men compared to women. Damage is caused by decreased blood flow to the kidney resulting in patchy necrosis of the renal parenchyma. Over time, fibrosis occurs and glomeruli are destroyed. The disease process progresses rapidly. Without dialysis, more than half of patients die from uremia (an excess of urea and other nitrogenous wastes in the blood) in a few years. Benign nephrosclerosis can be found in older adults, associated with atherosclerosis and hypertension.

Assessment and Diagnostic Findings 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.

Medical Management Treatment of nephrosclerosis is aggressive antihypertensive therapy. An angiotensin-converting enzyme (ACE) inhibitor, alone or in combination with other antihypertensive medications, significantly reduces its incidence (Castner, 2010). See Chapter 33 for additional information on hypertension.

PRIMARY GLOMERULAR DISEASES Diseases that destroy the glomerulus of the kidney are the third most common cause of stage 5 CKD. In these disorders, the glomerular capillaries are primarily involved. Antigen–antibody complexes form in the blood and become trapped in the glomerular capillaries (the filtering portion of the kidney), inducing an inflammatory response. Immunoglobulin G (IgG), the major immunoglobulin (antibody) found in the blood, can be detected in the glomerular capillary walls. The major clinical manifestations of glomerular injury include proteinuria, hematuria, decreased GFR, decreased excretion of sodium, edema, and hypertension (Chart 45-2).

CHART 45-2

Terms Typically Used When Describing Glomerular Disease Primary: Disease is mainly in glomeruli Secondary: Glomerular diseases that are the consequence of systemic disease Idiopathic: Cause is unknown Acute: Occurs over days or weeks Chronic: Occurs over months or years Rapidly progressing: Constant loss of renal function with minimal chance of recovery Diffuse: Involves all glomeruli Focal: Involves some glomeruli Segmental: Involves portions of individual glomeruli Membranous: Evidence of thickened glomerular capillary walls Proliferative: Number of glomerular cells involved is increasing

skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein–Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). In some patients, antigens outside the body (e.g., medications, foreign serum) initiate the process, resulting in antigen–antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen.

Physiology/Pathophysiology Antigen (group A beta-hemolytic streptococcus)

Antigen–antibody product

Deposition of antigen–antibody complex in glomerulus

Increased production of epithelial cells lining the glomerulus

Acute Nephritic Syndrome The acute nephritic syndrome is the clinical manifestation of glomerular inflammation (Hannon et al., 2010). Glomerulonephritis is an inflammation of the glomerular capillaries that can occur in acute and chronic forms.

Leukocyte infiltration of the glomerulus

Thickening of the glomerular filtration membrane

Pathophysiology Primary glomerular diseases include postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, membrane proliferative glomerulonephritis, and membranous glomerulonephritis. Postinfectious causes are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks (Fig. 45-1). It may also follow impetigo (infection of the

Scarring and loss of glomerular filtration membrane

Decreased glomerular filtration rate (GFR) FIGURE 45-1. Sequence of events in acute nephritic syndrome.

CHAPTER 45

Clinical Manifestations The primary presenting features of an acute glomerular inflammation are hematuria, oliguria, edema, azotemia, an abnormal concentration of nitrogenous wastes in the blood, and proteinuria decreased GFR (Hannon et al., 2010). The hematuria may be microscopic (identifiable only through microscopic examination) or macroscopic (visible to the eye). The urine may appear cola-coloured because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. Glomerulonephritis may be mild and the hematuria discovered incidentally through a routine urinalysis, or the disease may be severe, with acute renal failure (ARF) and oliguria. Some degree of edema and hypertension is present in most patients. Marked proteinuria due to the increased permeability of the glomerular membrane may also occur, with associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty casts in the urine. Blood urea nitrogen (BUN) and serum creatinine levels may increase as urine output decreases. In addition, anemia may be present. In the more severe form of the disease, patients also complain of headache, malaise, and flank pain. Older adults may experience circulatory overload with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema. Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder.

Assessment and Diagnostic Findings In acute nephritic syndrome, the kidneys become large, edematous, and congested. All renal tissues including the glomeruli, tubules, and blood vessels are affected to varying degrees. Patients with an IgA nephropathy have an elevated serum IgA and low to normal complement levels. Electron microscopy and immunofluorescent analysis help identify the nature of the lesion; however, a kidney biopsy may be needed for definitive diagnosis. (See Chapter 44 for discussion of kidney biopsy.) If the patient improves, the amount of urine increases and the urinary protein and sediment diminish. The percentage of adults who recover is unknown. Some patients develop severe uremia (an excess of urea and other nitrogenous wastes in the blood) within weeks and require dialysis for survival. Others, after a period of apparent recovery, insidiously develop chronic glomerulonephritis.

Complications Complications of acute glomerulonephritis include hypertensive encephalopathy, heart failure, and pulmonary edema. Hypertensive encephalopathy is a medical emergency, and therapy is directed toward reducing the blood pressure without impairing renal function. This can occur in acute nephritic syndrome or preeclampsia with chronic hypertension of greater than 140/90 mm Hg. Rapidly progressive glomerulonephritis is characterized by a rapid decline in renal function. Without treatment, ESRD develops in a matter of weeks or months. Signs and symptoms are similar to those of acute glomerulonephritis (hematuria and proteinuria), but the course of the disease is more

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severe and rapid. Crescent-shaped cells accumulate in Bowman’s space, disrupting the filtering surface. Plasma exchange (plasmapheresis) and treatment with high-dose corticosteroids and cytotoxic agents have been used to reduce the inflammatory response. Dialysis is initiated in acute glomerulonephritis if signs and symptoms of uremia are severe. The prognosis for patients with acute nephritic syndrome is excellent and rarely causes CKD (Hannon et al., 2010).

Medical Management Management consists primarily of treating symptoms, attempting to preserve kidney function, and treating complications promptly. Treatment may include corticosteroids, antihypertensives, and controlling proteinuria. Pharmacologic therapy depends on the cause of acute glomerulonephritis. If residual streptococcal infection is suspected, penicillin is the agent of choice; however, other antibiotic agents may be prescribed. Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN) develop. Sodium is restricted when the patient has hypertension, edema, and heart failure.

Nursing Management Although most patients with acute uncomplicated glomerulonephritis are cared for as outpatients, nursing care is important in every setting.

Providing Care in the Hospital In a hospital setting, carbohydrates are given liberally to provide energy and reduce the catabolism of protein. I&O are carefully measured and recorded. Fluids are given based on the patient’s fluid losses and daily body weight. Insensible fluid loss through the lungs (300 mL) and skin (600 mL) is considered when estimating fluid loss (see Chapter 15). If treatment is effective, diuresis will begin, resulting in decreased edema and blood pressure. Proteinuria and microscopic hematuria may persist for many months; in fact, 20% of patients have some degree of persistent proteinuria or decreased GFR 1 year after presentation (Hannon et al., 2010). Other nursing interventions focus on patient education about the disease process, explanations of laboratory and other diagnostic tests, and preparation for safe and effective self-care at home (Castner, 2010).

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patient education is directed toward symptom management and monitoring for complications. Fluid and diet restrictions must be reviewed with the patient to avoid worsening of edema and hypertension. The patient is instructed verbally and in writing to notify the physician if symptoms of renal failure occur (e.g., fatigue, nausea, vomiting, diminishing urine output) or at the first sign of any infection. CONTINUING CARE. The importance of follow-up evaluations of blood pressure, urinalysis for protein, and BUN and serum creatinine levels to determine if the disease has progressed is stressed to the patient. A referral for home care may be indicated; a visit from a home care

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nurse provides an opportunity for careful assessment of the patient’s progress and detection of early signs and symptoms of renal insufficiency. If corticosteroids, immunosuppressant agents, or antibiotic medications are prescribed, the home care nurse or nurse in the outpatient setting uses the opportunity to review the dosage, desired actions, and adverse effects of medications and the precautions to be taken.

Chronic Glomerulonephritis Chronic glomerulonephritis may be due to repeated episodes of acute nephritic syndrome, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, or hemodynamically mediated glomerular sclerosis. Secondary glomerular diseases that can have systemic effects include lupus erythematosus, Goodpasture’s syndrome (caused by antibodies to the glomerular basement membrane), diabetic glomerulosclerosis, and amyloidosis.

Pathophysiology The kidneys are reduced to as little as one fifth their normal size (consisting largely of fibrous tissue). The cortex layer shrinks to 1 to 2 mm in thickness or less. Bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular. Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are thickened. The resulting severe glomerular damage can progress to stage 5 CKD and require renal replacement therapies.

Clinical Manifestations The symptoms of chronic glomerulonephritis vary. Some patients with severe disease have no symptoms at all for many years (Hannon et al., 2010). The condition may be discovered when hypertension or elevated BUN and serum creatinine levels are detected. Most patients report general symptoms, such as loss of weight and strength, increasing irritability, and an increased need to urinate at night (nocturia). Headaches, dizziness, and digestive disturbances are also common. As chronic glomerulonephritis progresses, signs and symptoms of CKD and CRF may develop. The patient appears poorly nourished, with a yellow-grey pigmentation of the skin and periorbital and peripheral (dependent) edema. Blood pressure may be normal or severely elevated. Retinal findings include hemorrhage, exudate, narrowed tortuous arterioles, and papilledema. Anemia causes pale mucous membranes. Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and symptoms of heart failure may be present (Stephen, Skillen, Day, et al., 2010). Crackles can be heard in the bases of the lungs. Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with a pericardial friction rub and pulsus paradoxus (difference in blood pressure during inspiration and expiration of greater than 10 mm Hg).

Assessment and Diagnostic Findings A number of laboratory abnormalities occur. Urinalysis reveals a fixed specific gravity of about 1.010, variable proteinuria, and urinary casts (proteins secreted by damaged kidney tubules). As renal failure progresses and the GFR falls below 50 mL/min, the following changes occur: • Hyperkalemia due to decreased potassium excretion, acidosis, catabolism, and excessive potassium intake from food and medications • Metabolic acidosis from decreased acid secretion by the kidney and inability to regenerate bicarbonate • Anemia secondary to decreased erythropoiesis (production of RBCs) • Hypoalbuminemia with edema secondary to protein loss through the damaged glomerular membrane • Increased serum phosphorus level due to decreased renal excretion of phosphorus • Decreased serum calcium level (calcium binds to phosphorus to compensate for elevated serum phosphorus levels) • Mental status changes • Impaired nerve conduction due to electrolyte abnormalities and uremia Chest x-rays may show cardiac enlargement and pulmonary edema. The electrocardiogram (ECG) may be normal or may indicate left ventricular hypertrophy associated with hypertension and signs of electrolyte disturbances, such as tall, tented (or peaked) T waves associated with hyperkalemia. Computed tomography (CT) and magnetic resonance imaging (MRI) scans show a decrease in the size of the renal cortex.

Medical Management Management of symptoms guides the treatment. If the patient has hypertension, efforts are made to reduce the blood pressure with sodium and water restriction, antihypertensive agents, or both. Weight is monitored daily, and diuretic medications are prescribed to treat fluid overload. Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good nutritional status. Adequate calories are provided to spare protein for tissue growth and repair. Urinary tract infections (UTIs) must be treated promptly to prevent further renal damage. Dialysis is initiated early in the course of the disease to keep the patient in optimal physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of complications of renal failure. The course of dialysis is smoother if treatment begins before the patient develops complications.

Nursing Management Whether the patient is hospitalized or cared for in the home, the nurse observes the patient for common fluid and electrolyte disturbances in renal disease (Table 45-1). Changes in fluid and electrolyte status and in cardiac and neurologic status are reported promptly to the physician. Anxiety levels are often extremely high for both the patient and family. Throughout the course of the disease and treatment, the

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nurse gives emotional support by providing opportunities for the patient and family to verbalize their concerns, have their questions answered, and explore their options.

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Physiology/Pathophysiology Damaged glomerular capillary membrane

TEACHING PATIENTS SELF-CARE. The nurse has a major

role in teaching the patient and family about the prescribed treatment plan and the risks associated with noncompliance. Instructions to the patient include explanations and scheduling for follow-up evaluations: blood pressure, urinalysis for protein and casts, and laboratory studies of BUN and serum creatinine levels. If long-term dialysis is needed, the nurse teaches the patient and family about the procedure, how to care for the access site, dietary restrictions, and other necessary lifestyle modifications. These topics are discussed later in this chapter. Periodic hospitalization, visits to the outpatient clinic or office, and home care referrals provide the nurse in each setting with the opportunity for careful assessment of the patient’s progress and continued education about changes to report to the primary health care provider (worsening signs and symptoms of renal failure, such as nausea, vomiting, and diminished urine output). Specific teaching may include explanations about recommended diet and fluid modifications and medications (purpose, desired effects, adverse effects, dosage, and administration schedule). CONTINUING CARE. Periodic laboratory evaluations of creatinine clearance and BUN and serum creatinine levels are carried out to assess residual renal function and the need for dialysis or transplantation. If dialysis is initiated, the patient and family require considerable assistance and support in dealing with therapy and its long-term implications. The patient and family are reminded of the importance of participation in health promotion activities, including health screening. The patient is instructed to inform all health care providers about the diagnosis of glomerulonephritis so that all medical management, including pharmacologic therapy, is based on altered renal function.

Nephrotic Syndrome Nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria (Hannon et al., 2010). Clinical findings include a marked increase in protein (particularly albumin) in the urine (proteinuria), a decrease in albumin in the blood (hypoalbuminemia), diffuse edema, high serum cholesterol, and low-density lipoproteins (hyperlipidemia). The syndrome is apparent in any condition that seriously damages the glomerular capillary membrane and results in increased glomerular permeability to plasma proteins. Although the liver is capable of increasing the production of albumin, it cannot keep up with the daily loss of albumin through the kidneys. Thus, hypoalbuminemia results (Fig. 45-2).

Pathophysiology Nephrotic syndrome occurs with many intrinsic renal diseases and systemic diseases that cause glomerular damage.

Loss of plasma protein (albumin)

Stimulates synthesis of lipoproteins

Hypoalbuminemia

Hyperlipidemia

Decreased oncotic pressure

Generalized edema (fluid moves from vascular space to extracellular compartment)

Activation of renin–angiotensin system

Sodium retention

Edema

FIGURE 45-2. Sequence of events in nephrotic syndrome.

It is not a specific glomerular disease but a constellation of clinical findings that result from the glomerular damage (Hannon et al., 2010).

Clinical Manifestations The major manifestation of nephrotic syndrome is edema. It is usually soft and pitting and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). Patients may also exhibit irritability, headache, and malaise.

Assessment and Diagnostic Findings Proteinuria (predominately albumin) exceeding 3.5 g/day is the hallmark of the diagnosis of nephrotic syndrome (Hannon et al., 2010). Protein electrophoresis and immunoelectrophoresis may be performed on the urine to categorize the type of proteinuria. The urine may also contain increased white blood cells (WBCs) as well as granular and epithelial casts. A needle biopsy of the kidney may be performed for histologic examination of renal tissue to confirm the diagnosis.

Complications Complications of nephrotic syndrome include infection (due to a deficient immune response), thromboembolism (especially of the renal vein), pulmonary emboli, ARF (due to hypovolemia), and accelerated atherosclerosis (due to hyperlipidemia).

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Medical Management Treatment is focused on treating the underlying disease state causing proteinuria, slowing progression of CKD, and relieving symptoms. Typical treatment includes diuretics for edema, ACE inhibitors to reduce proteinuria, and lipid-lowering agents for hyperlipidemia.

Nursing Management In the early stages of nephrotic syndrome, nursing management is similar to that of the patient with acute glomerulonephritis, but as the condition worsens, management is similar to that of the patient with ESRD (see the following section). Patients with nephrotic syndrome need adequate instruction about the importance of following all medication and dietary regimens so that their condition can remain stable as long as possible. Patients must be made aware of the importance of communicating any health-related change to their health care providers as soon as possible so that appropriate medication and dietary changes can be made before further changes occur within the glomeruli.

POLYCYSTIC KIDNEY DISEASE Pathophysiology Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys. When cysts form in the kidneys, they are filled with fluid, destroying the nephrons. PKD cysts can profoundly enlarge the kidneys while replacing much of the normal structure, resulting in reduced kidney function and leading to kidney failure. PKD can also cause cysts in the liver and problems in other organs, such as blood vessels in the brain and heart. The number of cysts as well as the complications they cause help distinguish PKD from the usually harmless “simple” cysts that can form in the kidneys in later years of life. In the United States, PKD and cystic diseases are the fifth leading cause of kidney failure. Two major inherited forms of PKD exist: • Autosomal dominant PKD is the most common inherited form. Symptoms usually develop between the ages of 30 and 40, but they can begin earlier, even in childhood. About 90% of all PKD cases are autosomal dominant PKD. • Autosomal recessive PKD is a rare inherited form. Symptoms of autosomal recessive PKD begin in the earliest months of life or in utero. When autosomal dominant PKD causes kidneys to fail, which usually happens after many years, the patient requires dialysis or kidney transplantation. About one half of people with the most common type of PKD progress to CKD stage 5, requiring renal replacement.

Clinical Manifestations Signs and symptoms of PKD result from loss of renal function and the increasing size of the kidneys as the cysts

grow. Renal damage can result in hematuria, polyuria (large amounts of urine), hypertension, development of renal calculi and associated UTIs, and proteinuria. The growing cysts are noted with reports of abdominal fullness and flank pain (back and lower sides).

Assessment and Diagnostic Findings Since PKD is a genetic disease, careful evaluation of family history is necessary. Palpation of the abdomen will often reveal enlarged cystic kidneys. Diagnosis is usually made with ultrasound imaging of the kidney (Hannon et al., 2010).

Medical Management PKD has no cure and treatment is largely supportive including blood pressure control, pain control, and antibiotics to resolve infections. Once the kidneys fail, renal replacement therapy is indicated. Genetic testing and counselling may be indicated.

RENAL CANCER Cancer of the kidney accounts for 3,656 new cases (3.8%) in men and 2,285 new cases (2.5%) in women in Canada in 2013. (Canadian Cancer Society’s Steering Committee, 2013). The incidence of all stages of kidney cancer has increased in the last two decades in Canada. Tobacco use continues to be a significant risk factor for renal carcinoma (Chart 45-3). The most common type of renal carcinoma arises from the renal epithelium and accounts for more than 85% of all kidney tumours. These tumours may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One quarter of patients have metastatic disease at the time of diagnosis. Although enhanced imaging techniques account for improved detection of early-stage kidney cancer, symptoms may not be present until the tumour reaches a considerable size (Hannon et al., 2010).

Clinical Manifestations Many renal tumours produce no symptoms and are discovered on a routine physical examination as a palpable abdominal mass. The classic signs and symptoms, which occur in only 10% of patients, include hematuria, pain, CHART 45-3

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

CHAPTER 45

and a mass in the flank (Canadian Cancer Society, 2014). The usual sign that first calls attention to the tumour 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 tumour into the perirenal area, or hemorrhage into the kidney tissue. Colicky pains occur if a clot or mass of tumour cells passes down the ureter. Symptoms from metastasis may be the first manifestations of renal tumour and may include unexplained weight loss, increasing weakness, and anemia.

Assessment and Diagnostic Findings The diagnosis of a renal tumour may require intravenous (IV) 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 tumour as well as for older 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 tumour before metastasis occurs.

Surgical Management NEPHRECTOMY. A radical nephrectomy is the preferred treatment if the tumour can be removed. This includes removal of the kidney (and tumour), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes. Laparoscopic nephrectomy can be performed for removal of the kidney with a small tumour. This procedure incurs less morbidity and a shorter recovery time. Radiation therapy, hormonal therapy, or chemotherapy may be used along with surgery. Immunotherapy may also be helpful. For patients with bilateral tumour or cancer of a functional single kidney, nephron-sparing surgery (partial nephrectomy) may be considered. Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron-sparing surgery is excellent, and operative morbidity and mortality are low. Patients with upper tract transitional cell carcinoma may benefit from laparoscopic nephroureterectomy. Although it is a lengthier surgical procedure, it has the same efficacy and is better tolerated by patients than open nephroureterectomy. RENAL ARTERY EMBOLIZATION. In patients with metastatic renal carcinoma, the renal artery may be occluded to impede the blood supply to the tumour and thus kill the tumour cells. After angiographic studies are completed, a catheter is advanced into the renal artery, and embolizing materials (e.g., Gelfoam, autologous blood clot, steel coils) are injected into the artery and carried with the arterial blood flow to occlude the tumour vessels mechanically. This decreases the local blood supply, making removal of

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the kidney (nephrectomy) easier. It also stimulates an immune response because infarction of the renal cell carcinoma releases tumour-associated antigens that enhance the patient’s response to metastatic lesions. The procedure may also reduce the number of tumour cells entering the venous circulation during surgical manipulation. After renal artery embolization and tumour 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 gastrointestinal (GI) symptoms. Pain is treated with parenteral analgesic agents, and acetaminophen (Tylenol) is administered to control fever. Antiemetic medications, restriction of oral intake, and IV fluids are used to treat the GI symptoms.

Pharmacologic Therapy Currently, no pharmacologic agents are in widespread use for treatment of renal cell carcinoma, which is refractory to most chemotherapeutic agents. However, depending on the stage of the tumour, percutaneous partial or radical nephrectomy may be followed by treatment with chemotherapeutic agents. Radiation therapy may be used for palliation in patients who are not candidates for surgery. Treatment with biologic response modifiers such as interleukin-2 (IL-2) is effective. IL-2, a protein that regulates cell growth, is used alone or in combination with lymphokineactivated killer cells (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 tumours. Temsirolimus (Torisel) is administered by IV infusion on a weekly basis to treat advanced renal cell carcinoma (Wood, 2010).

Nursing Management The patient with a renal tumour usually undergoes extensive diagnostic and therapeutic procedures. Treatment includes surgery, radiation therapy, and medications. 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 patient’s position during surgery, and the nature of the surgical procedure, pain and muscle soreness are common. Pharmacologic management often includes immunosuppressant agents; therefore, patients are monitored for infection (Aschenbrenner, 2007). The patient requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. The patient and family require assistance and support to cope with the diagnosis and uncertain prognosis. (See this chapter for discussion of postoperative care of the patient undergoing kidney surgery and Chapter 17 for discussion of care of the patient with cancer.)

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The nurse teaches the patient to inspect and care for the incision and perform other general postoperative care including activity and

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lifting restrictions, driving, and pain management. Instructions are provided about when to notify the physician about problems (e.g., fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs). The nurse encourages the patient to eat a healthy 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 diagnosis, treatment, 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 treatment plan or chemotherapy protocol, what to expect with each visit, and when to notify the physician. Evaluation of remaining renal function (creatinine clearance, BUN and serum 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 indicated services and resources.

RENAL FAILURE Renal failure results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid–base disturbances. Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. In 2012, 5,431 patients were diagnosed with endstage kidney diseases. This is more than double what was found in 1993 (Canadian Institute for Health Information [CIHI], 2013).

Acute Renal Failure Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of ARF, a wide range of potentially lifethreatening metabolic complications can occur, including metabolic acidosis as well as fluid and electrolyte imbalances. Treatment is aimed at replacing renal function temporarily to minimize potentially lethal complications and reduce potential causes of increased renal injury with the goal of minimizing long-term loss of renal function. ARF is a problem seen in hospitalized patients and those in outpatient settings. A widely accepted criterion for ARF is a decreased GFR and accumulation of BUN and serum creatinine. Further classification can be made using the Risk, Injury, Failure, Loss, End stage (RIFLE) classification system (Holcombe & Kern Feeley, 2013; Yaklin, 2011).

Pathophysiology Although the pathogenesis of ARF and oliguria is not always known, many times there is a specific underlying problem. Some of the factors may be reversible if identified and treated promptly, before kidney function is impaired. This is true of the following conditions that reduce blood flow to the kidney and impair kidney function: (1) hypovolemia; (2) hypotension; (3) reduced cardiac output and heart failure; (4) obstruction of the kidney or lower urinary tract by tumour, blood clot, or kidney stone; and (5) bilateral obstruction of the renal arteries or veins. If these conditions are treated and corrected before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other signs may be reversed. Although renal stones are not a common cause of ARF, some types may increase the risk for ARF. Some hereditary stone diseases (see Chapter 46), primary struvite stones, and infection-related urolithiasis associated with anatomic and functional urinary tract anomalies and spinal cord injury may cause recurrent bouts of obstruction as well as crystal-specific damage to tubular epithelial cells and interstitial renal cells.

Categories of Acute Renal Failure The major categories of ARF are prerenal (hypoperfusion of kidney), intrarenal (actual damage to kidney tissue), and postrenal (obstruction to urine flow). Prerenal ARF, which occurs in 60% to 70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN) is the most common type of intrinsic ARF. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances. CKD, diabetes, heart failure, hypertension, and cirrhosis can lead to ATN (Ali & Gray-Vickrey, 2011; Holcombe & Kern Feeley, 2013). Postrenal ARF usually results from obstruction distal to the kidney. Pressure rises in the kidney tubules and eventually, the GFR decreases. Common causes of each type of ARF are summarized in Chart 45-4.

Phases of Acute Renal Failure There are four phases of ARF: initiation, oliguria, diuresis, and recovery. • The initiation period begins with the initial insult and ends when oliguria develops. • The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.

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CHART 45-4

Causes of Acute Renal Failure Prerenal Failure

Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia) • Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE inhibitors) • Infectious processes such as: Acute pyelonephritis Acute glomerulonephritis

• Volume depletion resulting from:

Hemorrhage Renal losses (diuretics, osmotic diuresis) Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) • Impaired cardiac efficiency resulting from: Myocardial infarction Heart failure Dysrhythmias Cardiogenic shock • Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause vasodilation

Postrenal Failure • Urinary tract obstruction, including: Calculi (stones) Tumours Benign prostatic hyperplasia Strictures Blood clots

Intrarenal Failure • Prolonged renal ischemia resulting from:

Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)

Some patients have decreased renal function with increasing nitrogen retention, yet actually excrete normal amounts of urine (2 L/day or more). This is the nonoliguric form of renal failure and occurs predominantly after exposure of the patient to nephrotoxic agents, burns, traumatic injury, and the use of halogenated anesthetic agents. • The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. Laboratory values stabilize and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. • The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory valTABLE 45-2

ues return to the patient’s normal level. Although a permanent 1% to 3% reduction in the GFR is common, it is not clinically significant.

Clinical Manifestations Almost every system of the body is affected with failure of the normal renal regulatory mechanisms. The patient may appear critically ill and lethargic. The skin and mucous membranes are dry from dehydration. Central nervous system signs and symptoms include drowsiness, headache, muscle twitching, and seizures. Table 45-2 summarizes common clinical characteristics in all three categories of ARF.

Assessment and Diagnostic Findings Assessment of the patient with ARF includes evaluation for changes in the urine, diagnostic tests that evaluate the

Comparing Clinical Characteristics of Acute Renal Failure Categories

Characteristics

Prerenal

Intrarenal

Postrenal

Etiology Blood urea nitrogen value

Parenchymal damage Increased

Obstruction Increased

Creatinine Urine output

Hypoperfusion Increased (out of normal 20:1 proportion to creatinine) Increased Decreased

Increased Varies, often decreased

Urine sodium

Decreased to 40 mEq/L

Urinary sediment Urine osmolality Urine specific gravity

Normal, few hyaline casts Increased to 500 mOsm Increased

Abnormal casts and debris About 350 mOsm similar to serum Low normal

Increased Varies, may be decreased, or sudden anuria Varies, often decreased to 20 mEq/L or less Usually normal Varies, increased or equal to serum Varies

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kidney contour, and a variety of laboratory values. See Chapter 44 for information about the normal characteristics of urine, diagnostic findings, and laboratory values in the renal system. In ARF, urine output varies from scanty to a normal volume, hematuria may be present, and the urine has a low specific gravity (compared with a normal value of 1.010 to 1.025). One of the earliest manifestations of tubular damage is the inability to concentrate the urine (Hannon et al., 2010). Patients with prerenal azotemia have a decreased amount of sodium in the urine (less than 20 mEq/L) and normal urinary sediment. Patients with intrarenal azotemia usually have urinary sodium levels greater than 40 mEq/L with urinary casts and other cellular debris. Ultrasonography is a critical component of the evaluation of patients with renal failure. A renal sonogram or a CT or MRI scan may show evidence of anatomic changes. The BUN level increases steadily at a rate dependent on the degree of catabolism (breakdown of protein), renal perfusion, and protein intake. Serum creatinine levels are useful in monitoring kidney function and disease progression and increase with glomerular damage. With a decline in the GFR, oliguria, and anuria, patients are at high risk for hyperkalemia. Protein catabolism results in the release of cellular potassium into the body fluids, causing severe hyperkalemia (high serum potassium levels). Hyperkalemia may lead to dysrhythmias, such as ventricular tachycardia and cardiac arrest. Sources of potassium include normal tissue catabolism, dietary intake, blood in the GI tract, or blood transfusion and other sources (e.g., IV infusions, potassium penicillin, and extracellular shift in response to metabolic acidosis). Progressive metabolic acidosis occurs in renal failure because patients cannot eliminate the daily metabolic load of acid-type substances produced by the normal metabolic processes. In addition, normal renal buffering mechanisms fail. This is reflected by a decrease in the serum CO2-combining power and blood pH. There may be an increase in blood phosphate concentrations; calcium levels may be low due to decreased absorption of calcium from the intestine and as a compensatory mechanism for the elevated blood phosphate levels. Anemia is another common laboratory finding in ARF, as a result of reduced erythropoietin production, uremic GI lesions, reduced RBC lifespan, and blood loss from the GI tract.

Prevention ARF has a high mortality rate that ranges from 25% to 90%. Factors that influence mortality include increased age, comorbid conditions, and pre-existing renal and vascular diseases (Dirkes, 2011). Therefore, prevention of ARF is essential (Chart 45-5). A careful history is obtained to identify exposure to nephrotoxic agents or environmental toxins. The kidneys are susceptible to the adverse effects of medications because the kidneys are repeatedly exposed to substances in the blood. Patients taking nephrotoxic medications (e.g., aminoglycosides, gentamicin, tobramycin, colistimethate, polymyxin B, amphotericin B, vancomycin, amikacin, cyclosporine) should be monitored closely for changes in renal function. BUN and serum creatinine levels should be obtained at baseline within 24 hours after

CHART 45-5

Preventing Acute Renal Failure 1. Provide adequate hydration to patients at risk for dehydration including: Before, during, and after surgery Patients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, intravenous pyelograms), especially older patients who may have marginal renal reserve Patients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy 2. Prevent and treat shock promptly with blood and fluid replacement. 3. Monitor central venous and arterial pressures and hourly urine output of critically ill patients to detect the onset of renal failure as early as possible. 4. Treat hypotension promptly. 5. Continually assess renal function (urine output, laboratory values) when appropriate. 6. Take precautions to ensure that the appropriate blood is administered to the correct patient in order to avoid severe transfusion reactions, which can precipitate renal failure. 7. Prevent and treat infections promptly. Infections can produce progressive renal damage. 8. Pay special attention to wounds, burns, and other precursors of sepsis. 9. To prevent infections from ascending in the urinary tract, give meticulous care to patients with indwelling catheters. Remove catheters as soon as possible. 10. To prevent toxic drug effects, closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys.

initiation of these medications and at least twice a week while the patient is receiving them. Any agent that reduces renal blood flow (e.g., long-term analgesic use) may cause renal insufficiency. Chronic use of analgesic agents, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), may cause interstitial nephritis (inflammation within the renal tissue) and papillary necrosis. Patients with heart failure or cirrhosis with ascites are at particular risk for NSAID-induced renal failure. Increased age, pre-existing renal disease, and the simultaneous administration of several nephrotoxic agents increase the risk for kidney damage. Radiocontrast-induced nephropathy (RIN) is a major cause of hospital-acquired ARF. Patients undergo more than 1 million radiocontrast studies in the United States annually; of these approximately 150,000 will experience RIN, and at least 1% of these will require dialysis and experience a prolonged hospital stay (Barreto, 2007). This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify patients at high risk. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of RIN (Jorgensen, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent RIN (Isaac, 2012).

CHAPTER 45

Gerontologic Considerations About half of all patients who develop ARF during hospitalization are older than 60 years. The etiology of ARF in older adults includes prerenal causes such as dehydration, intrarenal causes such as nephrotoxic agents (e.g., medications, contrast agents), and complications of major surgery (Holcombe & Kern Feeely, 2013). Suppression of thirst, enforced bed rest, lack of access to drinking water, and confusion all contribute to the older patient’s failure to consume adequate fluids and may lead to dehydration, further compromising already decreased renal function. ARF in older adults is also often seen in the community setting. Nurses in the ambulatory setting need to be aware of the risk. All medications need to be monitored for potential side effects that could result in damage to the kidney either through reduced circulation or nephrotoxicity. Outpatient procedures that require fasting or a bowel preparation may cause dehydration and therefore require careful monitoring.

Medical Management The kidneys have a remarkable ability to recover from insult. The objectives of treatment of ARF are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur. Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing renal replacement therapy. Prerenal azotemia is treated by optimizing renal perfusion, whereas postrenal failure is treated by relieving the obstruction. Intrarenal azotemia is treated with supportive therapy, with removal of causative agents, aggressive management of prerenal and postrenal failure, and avoidance of associated risk factors. Shock and infection, if present, are treated promptly (see Chapter 16). Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and the clinical status of the patient. The parenteral and oral intake and the output of urine, gastric drainage, stools, wound drainage, and perspiration are calculated and are used as the basis for fluid replacement. The insensible fluid produced through the normal metabolic processes and lost through the skin and lungs is also considered in fluid management. Fluid excesses can be detected by the clinical findings of dyspnea, tachycardia, and distended neck veins. The patient’s lungs are auscultated for moist crackles. Because pulmonary edema may be caused by excessive administration of parenteral fluids, extreme caution must be used to prevent fluid overload. The development of generalized edema is assessed by examining the presacral and pretibial areas several times daily. Mannitol (Osmitrol), furosemide (Lasix), or ethacrynic acid (Edecrin) may be prescribed to initiate diuresis. Adequate renal blood flow in patients with prerenal causes of ARF may be restored by IV fluids or transfusions of blood products. If ARF is caused by hypovolemia secondary to hypoproteinemia, an infusion of albumin may be prescribed. Dialysis may be initiated to prevent complications of ARF, such as hyperkalemia, metabolic acidosis,

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pericarditis, and pulmonary edema. Dialysis corrects many biochemical abnormalities; allows for liberalization of fluid, protein, and sodium intake; diminishes bleeding tendencies; and promotes wound healing. Hemodialysis (a procedure that circulates the patient’s blood through a dialyzer to remove waste products and excess fluid), peritoneal dialysis (PD) (a procedure that uses the patient’s peritoneal membrane [the lining of the peritoneal cavity] as the semipermeable membrane to exchange fluid and solutes), or a variety of continuous renal replacement therapies (CRRTs) (methods used to replace normal kidney function by circulating the patient’s blood through a hemofilter) may be performed. These and other treatment modalities for patients with renal dysfunction are discussed later in this chapter.

Pharmacologic Therapy Hyperkalemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with renal disturbances. Therefore, the patient is monitored for hyperkalemia through serial serum electrolyte levels (potassium value greater than 5.5 mmol/L), ECG changes (tall, tented, or peaked T waves), and changes in clinical status (see Chapter 15). Other symptoms of hyperkalemia include irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness. Muscle weakness may present as slurred speech, difficulty breathing, paresthesia, and paralysis. As the potassium level increases, both cardiac and other muscular function declines, making this a true medical emergency (Mount & Zandi-Nejad, 2012). The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If a Kayexalate retention enema is administered (the colon is the major site of potassium exchange), a rectal catheter with a balloon may be used to facilitate retention if necessary. The patient should retain the Kayexalate for 30 to 45 minutes to promote potassium removal. Afterward, a cleansing enema may be prescribed to remove remaining medication as a precaution against fecal impaction. If the patient is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells. Salbutamol sulfate (Ventolin HFA) by nebulizer can lower plasma potassium concentration by 0.3 to 0.85 mmol/L (Elliot, Ronksley, Clase, et al., 2010). The shift of potassium into the intracellular space is temporary, so arrangements for dialysis need to be made on an emergent basis. Since many medications are eliminated through the kidneys, dosages must be reduced when a patient has ARF. Examples of commonly used agents that require adjustment are antibiotic medications (especially aminoglycosides), digoxin, ACE inhibitors, and magnesium-containing agents. In addition, many medications have been used in patients with ARF in an attempt to improve patient outcomes. Diuretic agents are often used to control fluid volume, but they have not been shown to improve recovery from ARF (Dirkes, 2011).

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In patients with severe acidosis, the arterial blood gases and serum bicarbonate levels (CO2-combining power) must be monitored because the patient may require sodium bicarbonate therapy or dialysis. If respiratory problems develop, appropriate ventilatory measures must be instituted. The elevated serum phosphate level may be controlled with phosphate-binding agents (e.g., calcium or lanthanum carbonate) that help prevent a continuing rise in serum phosphate levels by decreasing the absorption of phosphate from the intestinal tract.

Nutritional Therapy ARF causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements). If the patient gains or does not lose weight or develops hypertension, fluid retention should be suspected. Nutritional support is based on the underlying cause of ARF, the catabolic response, the type and frequency of renal replacement therapy, comorbidities, and nutritional status. Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms. Caloric requirements are met with highcarbohydrate meals, because carbohydrates have a protein-sparing effect (i.e., in a high-carbohydrate diet, protein is not used for meeting energy requirements but is “spared” for growth and tissue healing). Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted. The oliguric phase of ARF may last 10 to 20 days and is followed by the diuretic phase, at which time urine output begins to increase, signalling that kidney function is returning. Results of blood chemistry tests are used to determine the amounts of sodium, potassium, and water needed for replacement, along with assessment for overhydration or underhydration. Following the diuretic phase, the patient is placed on a high-protein, high-calorie diet and is encouraged to resume activities gradually.

Nursing Management The nurse has an important role in caring for the patient with ARF. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the patient’s progress and response to treatment, and provides physical and emotional support. In addition, the nurse keeps family members informed about the patient’s condition, helps them understand the treatments, and provides psychological support. Although the development of ARF may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract).

Monitoring Fluid and Electrolyte Balance Because of the serious fluid and electrolyte imbalances that can occur with ARF, the nurse monitors the patient’s serum electrolyte levels and physical indicators of these complications during all phases of the disorder. Hyperka-

lemia is the most immediate life-threatening imbalance seen in ARF. Parenteral fluids, all oral intake, and all medications are screened carefully to ensure that hidden sources of potassium are not inadvertently administered or consumed. IV solutions must be carefully selected based on the patient’s fluid and electrolyte status. The patient’s cardiac function and musculoskeletal status are monitored closely for signs of hyperkalemia. The nurse monitors fluid status by paying careful attention to fluid intake (IV medications should be administered in the smallest volume possible), urine output, apparent edema, distention of the jugular veins, alterations in heart sounds and breath sounds, and increasing difficulty in breathing. Accurate daily weights, as well as I&O records, are essential. Indicators of deteriorating fluid and electrolyte status are reported immediately to the physician, and preparation is made for emergency treatment. Severe fluid and electrolyte disturbances may be treated with hemodialysis, PD, or CRRT.

Reducing Metabolic Rate The nurse takes steps to reduce the patient’s metabolic rate. Bed rest may be indicated to reduce exertion and the metabolic rate during the most acute stage of the disorder. Fever and infection, both of which increase the metabolic rate and catabolism, are prevented or treated promptly.

Promoting Pulmonary Function Attention is given to pulmonary function, and the patient is assisted to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. Drowsiness and lethargy may prevent the patient from moving and turning without encouragement and assistance.

Preventing Infection Asepsis is essential with invasive lines and catheters to minimize the risk of infection and increased metabolism. An indwelling urinary catheter is avoided whenever possible due to the high risk of UTI associated with its use but may be required to provide ongoing data required to monitor fluid I&O.

Providing Skin Care The skin may be dry or susceptible to breakdown as a result of edema; therefore, meticulous skin care is important. In addition, excoriation and itching of the skin may result from the deposit of irritating toxins in the patient’s tissues. Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and the fingernails trimmed to avoid excoriation are often comforting and prevent skin breakdown.

Providing Psychosocial Support The patient with ARF may require treatment with hemodialysis, PD, or CRRT. The length of time that these treatments are necessary varies with the cause and extent of damage to the kidneys. The patient and family need assistance, explanation, and support during this period. The purpose of the treatment is explained to the patient and family by the physician. However, high levels of anxiety and

CHAPTER 45

fear may necessitate repeated explanation and clarification by the nurse. The family members may initially be afraid to touch and talk to the patient during these procedures but should be encouraged and assisted to do so. In an intensive care setting, many of the nurse’s functions are devoted to the technical aspects of patient care; however, it is essential that the psychological needs and other concerns of the patient and family be addressed. Continued assessment of the patient for complications of ARF and precipitating causes is essential.

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more sensitive indicator of renal function than BUN. The BUN is affected not only by renal disease but also by protein intake in the diet, catabolism (tissue and RBC breakdown), parenteral nutrition, and medications such as corticosteroids.

Sodium and Water Retention

When a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis, the patient has moved into the fifth or final stage of CKD, also referred to as CRF or ESRD.

The kidney cannot concentrate or dilute the urine normally in ESRD. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. Hypertension may also result from activation of the renin–angiotensin–aldosterone axis and the concomitant increased aldosterone secretion. Other patients have a tendency to lose sodium and run the risk of developing hypotension and hypovolemia. Vomiting and diarrhea may cause sodium and water depletion, which worsens the uremic state.

Pathophysiology

Acidosis

As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more pronounced the symptoms are. The rate of decline in renal function and progression of ESRD is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions.

Metabolic acidosis occurs in ESRD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH 3−) and to reabsorb sodium bicarbonate (HCO3−). There is also decreased excretion of phosphates and other organic acids.

CHRONIC RENAL FAILURE (END-STAGE RENAL DISEASE)

Clinical Manifestations Because virtually every body system is affected in ESRD, patients exhibit a number of signs and symptoms (Broscious & Castagnola, 2006). The severity of these signs and symptoms depends in part on the degree of renal impairment, other underlying conditions, and the patient’s age. Cardiovascular disease is the predominant cause of death in patients with ESRD (Holcombe & Kern Feeley, 2013). Peripheral neuropathy, a disorder of the peripheral nervous system, is present in some patients. Patients complain of severe pain and discomfort. Restless leg syndrome and burning feet can occur in the early stage of uremic peripheral neuropathy (Holcombe & Kern Feeley, 2013). The precise mechanisms for many of these systemic signs and symptoms have not been identified. However, it is generally thought that the accumulation of uremic waste products is the probable cause. Chart 45-6 summarizes the systemic signs and symptoms. Cardiovascular disease is the predominant cause of death in patients with ESRD.

Assessment and Diagnostic Findings Glomerular Filtration Rate As the GFR decreases (due to nonfunctioning glomeruli), the creatinine clearance decreases, while the serum creatinine and BUN levels increase. Serum creatinine is a

Anemia Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient’s tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs (Muzzy & Snyder, 2013). In ESRD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.

Calcium and Phosphorus Imbalance Another abnormality seen in ESRD is a disorder in calcium and phosphorus metabolism (Hannon et al., 2010). Serum calcium and phosphate levels have a reciprocal relationship in the body: As one increases, the other decreases. With a decrease in filtration through the glomerulus of the kidney, there is an increase in the serum phosphate level and a reciprocal or corresponding decrease in the serum calcium level. The decreased serum calcium level causes increased secretion of parathormone from the parathyroid glands. However, in renal failure, the body does not respond normally to the increased secretion of parathormone; as a result, calcium leaves the bone, often producing bone changes and bone disease as well as calcification of major blood vessels in the body. In addition, the active metabolite of vitamin D (1,25-dihydroxycholecalciferol) normally manufactured by the kidney decreases as renal failure progresses (Hannon et al., 2010). Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance. There is also evidence of calcification of blood vessels.

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CHART 45-6

Assessing for End-Stage Renal Disease Be alert for the following signs and symptoms:

Pulmonary

Neurologic

• • • • • • • •

• • • • • • • • • •

Weakness and fatigue Confusion Inability to concentrate Disorientation Tremors Seizures Asterixis Restlessness of legs Burning of soles of feet Behaviour changes

Integumentary • • • • • • •

Grey-bronze skin colour Dry, flaky skin Pruritus Ecchymosis Purpura Thin, brittle nails Coarse, thinning hair

Cardiovascular • • • • • • • • • •

Hypertension Pitting edema (feet, hands, sacrum) Periorbital edema Pericardial friction rub Engorged neck veins Pericarditis Pericardial effusion Pericardial tamponade Hyperkalemia Hyperlipidemia

Crackles Thick, tenacious sputum Depressed cough reflex Pleuritic pain Shortness of breath Tachypnea Kussmaul-type respirations Uremic pneumonitis

Gastrointestinal • • • • • • •

Ammonia odour to breath (“uremic fetor”) Metallic taste Mouth ulcerations and bleeding Anorexia, nausea, and vomiting Hiccups Constipation or diarrhea Bleeding from gastrointestinal tract

Hematologic • Anemia • Thrombocytopenia

Reproductive • • • •

Amenorrhea Testicular atrophy Infertility Decreased libido

Musculoskeletal • • • • • •

Muscle cramps Loss of muscle strength Renal osteodystrophy Bone pain Bone fractures Foot drop

Complications

Medical Management

Potential complications of CRF that concern the nurse and necessitate a collaborative approach to care include the following:

The goal of management is to maintain kidney function and homeostasis for as long as possible. All factors that contribute to ESRD and all factors that are reversible (e.g., obstruction) are identified and treated. Management is accomplished primarily with medications and diet therapy, although dialysis may also be needed to decrease the level of uremic waste products in the blood and to control electrolyte balance.

• Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) • Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis • Hypertension due to sodium and water retention and malfunction of the renin–angiotensin–aldosterone system • Anemia due to decreased erythropoietin production, decreased RBC lifespan, bleeding in the GI tract from irritating toxins and ulcer formation, and blood loss during hemodialysis • Bone disease and metastatic and vascular calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels

Pharmacologic Therapy Complications can be prevented or delayed by administering prescribed phosphate-binding agents, calcium supplements, antihypertensive and cardiac medications, antiseizure medications, and erythropoietin Eprex. CALCIUM AND PHOSPHORUS BINDERS. Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. If calcium is high or the calcium–phosphorus product exceeds 55 mg/dL, a polymeric phosphate binder such as sevelamer

CHAPTER 45

hydrochloride (Renagel) may be prescribed (Muzzy & Snyder, 2013). These medications bind dietary phosphorus in the intestinal tract. All binding agents must be administered with food to be effective. Magnesium-based antacids are avoided to prevent magnesium toxicity. ANTIHYPERTENSIVE AND CARDIOVASCULAR AGENTS.

Hypertension is managed by intravascular volume control and a variety of antihypertensive agents. Heart failure and pulmonary edema may also require treatment with fluid restriction, low-sodium diets, diuretic agents, inotropic agents such as digoxin (Lanoxin) or dobutamine (Dobutrex), and dialysis. The metabolic acidosis of ESRD usually produces no symptoms and requires no treatment; however, sodium bicarbonate supplements or dialysis may be needed to correct the acidosis if it causes symptoms (Holcombe & Kern Feeley, 2013). ANTISEIZURE AGENTS. Neurologic abnormalities may occur, so the patient must be observed for early evidence of slight twitching, headache, delirium, or seizure activity. If seizures occur, the onset of the seizure is recorded along with the type, duration, and general effect on the patient. The physician is notified immediately. IV diazepam (Valium) or phenytoin (Dilantin) is usually administered to control seizures. The side rails of the bed should be raised and padded to protect the patient. The nursing management of the patient with seizures is discussed in Chapter 62. ERYTHROPOIETIN. Anemia associated with ESRD is treated with recombinant human erythropoietin (Eprex). Patients with anemia (hemoglobin less than 110 g/L) present with nonspecific symptoms, such as malaise, general fatigability, and decreased activity tolerance. Erythropoietin therapy is initiated to achieve a hemoglobin level of 110 to 120 g/L. Erythropoietin is administered intravenously or subcutaneously three times a week in ESRD. It may take 2 to 6 weeks for the hematocrit to increase; therefore, the medication is not indicated for patients who need immediate correction of severe anemia. Management involves adjustment of heparin to prevent clotting of the lines during hemodialysis treatments, frequent monitoring of hemoglobin and periodic assessment of serum iron and transferrin levels. Because adequate stores of iron are necessary for an adequate response to erythropoietin, supplementary iron may be prescribed. The patient’s blood pressure and serum potassium level are monitored to detect hypertension and increasing serum potassium levels, which may occur with therapy and the increasing RBC mass. The occurrence of hypertension requires initiation or adjustment of the patient’s antihypertensive therapy. Hypertension that cannot be controlled is a contraindication to recombinant erythropoietin therapy. Patients who have received erythropoietin therapy have reported decreased levels of fatigue, increased feelings of well-being, better tolerance of dialysis, higher energy levels, and improved exercise tolerance. In addition, this therapy has decreased the need for transfusion and its associated risks, including bloodborne infectious disease, antibody formation, and iron overload.

Nutritional Therapy Dietary intervention is necessary with deterioration of renal function and includes careful regulation of protein

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intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. At the same time, adequate caloric intake and vitamin supplementation must be ensured. Protein is restricted because urea, uric acid, and organic acids—the breakdown products of dietary and tissue proteins—accumulate rapidly in the blood when there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats). High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. Usually, the fluid allowance per day is 500 to 600 mL more than the previous day’s 24-hour urine output. Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin supplementation is necessary because a proteinrestricted diet does not provide the necessary complement of vitamins. In addition, the patient on dialysis may lose water-soluble vitamins during the dialysis treatment. Hyperkalemia is usually prevented by ensuring adequate dialysis treatments with potassium removal and careful monitoring of diet, medications, and fluids for their potassium content. Sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin, may be needed for acute hyperkalemia.

Dialysis The patient with increasing symptoms of renal failure is referred to a dialysis and transplantation centre early in the course of progressive renal disease. Dialysis is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment. In Canada, for 2010, the number of patients receiving dialysis was 23,188 (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014).

Nursing Management The patient with ESRD requires astute nursing care to avoid the complications of reduced renal function and the stresses and anxieties of dealing with a life-threatening illness. Nursing care is directed toward assessing fluid status and identifying potential sources of imbalance, implementing a dietary program to ensure proper nutritional intake within the limits of the treatment regimen, and promoting positive feelings by encouraging increased self-care and greater independence. It is extremely important to provide explanations and information to the patient and family concerning ESRD, treatment options, and potential complications. A great deal of emotional support is needed by the patient and family because of the numerous changes experienced. Specific interventions, along with rationale and evaluation criteria, are presented in more detail in the plan of nursing care for the patient with CRF (Chart 45-7).

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The nurse plays an important role in teaching the patient with ESRD. Because of the extensive teaching needed, the home care nurse, dialysis nurse, and nurses in the hospital and outpatient settings all provide ongoing education and reinforcement (text continued on page 1424)

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 45-7. The Patient With Chronic Renal Failure

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water Goal: Maintenance of ideal body weight without excess fluid 1. Assess fluid status: a. Daily weight b. Intake and output balance c. Skin turgor and presence of edema d. Distention of neck veins e. Blood pressure, pulse rate, and rhythm f. Respiratory rate and effort 2. Limit fluid intake to prescribed volume. 3. Identify potential sources of fluid: a. Medications and fluids used to take or administer medications: oral and intravenous b. Foods 4. Explain to patient and family rationale for fluid restriction. 5. Assist patient to cope with the discomforts resulting from fluid restriction. 6. Provide or encourage frequent oral hygiene.

1. Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

• Demonstrates no rapid weight changes

• Maintains dietary and fluid restrictions

• Exhibits normal skin turgor without edema

2. Fluid restriction will be determined on basis of weight, urine output, and response to therapy. 3. Unrecognized sources of excess fluids may be identified.

• Exhibits normal vital signs • Exhibits no neck vein distention • Reports no difficulty breathing or shortness of breath

• Performs oral hygiene frequently • Reports decreased thirst • Reports decreased dryness of oral mucous membranes

4. Understanding promotes patient and family cooperation with fluid restriction. 5. Increasing patient comfort promotes compliance with dietary restrictions. 6. Oral hygiene minimizes dryness of oral mucous membranes.

Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous membranes Goal: Maintenance of adequate nutritional intake 1. Assess nutritional status: a. Weight changes b. Laboratory values (serum electrolyte, BUN, creatinine, protein, transferrin, and iron levels) 2. Assess patient’s nutritional dietary patterns: a. Diet history b. Food preferences c. Calorie counts 3. Assess for factors contributing to altered nutritional intake: a. Anorexia, nausea, or vomiting b. Diet unpalatable to patient c. Depression d. Lack of understanding of dietary restrictions e. Stomatitis 4. Provide patient’s food preferences within dietary restrictions. 5. Promote intake of high-biologicvalue protein foods: eggs, dairy products, meats.

1. Baseline data allow for monitoring of changes and evaluating effectiveness of interventions. 2. Past and present dietary patterns are considered in planning meals.

3. Information about other factors that may be altered or eliminated to promote adequate dietary intake is provided.

4. Increased dietary intake is encouraged. 5. Complete proteins are provided for positive nitrogen balance needed for growth and healing.

• Consumes protein of high biologic value

• Chooses foods within dietary restrictions that are appealing

• Consumes high-calorie foods within dietary restrictions

• Explains in own words rationale for • • • • •

dietary restrictions and relationship to urea and creatinine levels Takes medications on schedule that does not produce anorexia or feeling of fullness Consults written lists of acceptable foods Reports increased appetite at meals Exhibits no rapid increases or decreases in weight Demonstrates normal skin turgor without edema; wound healing and acceptable plasma albumin levels

CHAPTER 45

Plan of Nursing Care NURSING INTERVENTIONS 6. Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals. 7. Alter schedule of medications so that they are not given immediately before meals. 8. Explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels. 9. Provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium. 10. Provide pleasant surroundings at meal-times. 11. Weigh patient daily. 12. Assess for evidence of inadequate protein intake: a. Edema formation b. Delayed wound healing c. Decreased serum albumin levels

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Management of Patients With Renal Disorders

Chart 45-7. The Patient With Chronic Renal Failure, Continued

RATIONALE

EXPECTED OUTCOMES

6. Reduces source of restricted foods and proteins and provides calories for energy, sparing protein for tissue growth and healing. 7. Ingestion of medications just before meals may produce anorexia and feeling of fullness. 8. Promotes patient understanding of relationships between diet and urea and creatinine levels to renal disease. 9. Lists provide a positive approach to dietary restrictions and a reference for patient and family to use when at home. 10. Unpleasant factors that contribute to patient’s anorexia are eliminated. 11. Allows monitoring of fluid and nutritional status. 12. Inadequate protein intake can lead to decreased albumin and other proteins, edema formation, and delay in wound healing.

Nursing Diagnosis: Deficient knowledge regarding condition and treatment Goal: Increased knowledge about condition and related treatment 1. Assess understanding of cause of renal failure, consequences of renal failure, and its treatment: a. Cause of patient’s renal failure b. Meaning of renal failure c. Understanding of renal function d. Relationship of fluid and dietary restrictions to renal failure e. Rationale for treatment (hemodialysis, peritoneal dialysis, transplantation) 2. Provide explanation of renal function and consequences of renal failure at patient’s level of understanding and guided by patient’s readiness to learn. 3. Assist patient to identify ways to incorporate changes related to illness and its treatment into lifestyle. 4. Provide oral and written information as appropriate about: a. Renal function and failure b. Fluid and dietary restrictions c. Medications d. Reportable problems, signs, and symptoms e. Follow-up schedule f. Community resources g. Treatment options

1. Provides baseline for further explanations and teaching.

• Verbalizes relationship of cause of renal failure to consequences

• Explains fluid and dietary restrictions • • •

2. Patient can learn about renal failure and treatment as he or she becomes ready to understand and accept the diagnosis and consequences. 3. Patient can see that his or her life does not have to revolve around the disease. 4. Provides patient with information that can be used for further clarification at home.

•

as they relate to failure of kidney’s regulatory functions States in own words relationship of renal failure and need for treatment Asks questions about treatment options, indicating readiness to learn Verbalizes plans to continue as normal a life as possible Uses written information and instructions to clarify questions and seek additional information

continued >

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 45-7. The Patient With Chronic Renal Failure, Continued

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure Goal: Participation in activity within tolerance 1. Assess factors contributing to activity intolerance: a. Fatigue b. Anemia c. Fluid and electrolyte imbalances d. Retention of waste products e. Depression 2. Promote independence in self-care activities as tolerated; assist if fatigued. 3. Encourage alternating activity with rest. 4. Encourage patient to rest after dialysis treatments.

1. Indicates factors contributing to severity of fatigue.

• Participates in increasing levels of activity and exercise

• Reports increased sense of well-being • Alternates rest and activity • Participates in selected self-care activities

2. Promotes improved self-esteem. 3. Promotes activity and exercise within limits and adequate rest. 4. Adequate rest is encouraged after dialysis treatments, which are exhausting to many patients.

Nursing Diagnosis: Risk for situational low self-esteem related to dependency, role changes, change in body image, and change in sexual function Goal: Improved self-esteem 1. Assess patient’s and family’s responses and reactions to illness and treatment. 2. Assess relationship of patient and significant family members. 3. Assess usual coping patterns of patient and family members. 4. Encourage open discussion of concerns about changes produced by disease and treatment: a. Role changes b. Changes in lifestyle c. Changes in occupation d. Sexual changes e. Dependence on health care team 5. Explore alternate ways of sexual expression other than sexual intercourse. 6. Discuss role of giving and receiving love, warmth, and affection.

1. Provides data about problems encountered by patient and family in coping with changes in life. 2. Identifies strengths and supports of patient and family. 3. Coping patterns that may have been effective in past may be harmful in view of restrictions imposed by disease and treatment. 4. Encourages patient to identify concerns and steps necessary to deal with them.

• Identifies previously used coping

styles that have been effective and those no longer possible due to disease and treatment (alcohol or drug use; extreme physical exertion) • Patient and family identify and verbalize feelings and reactions to disease and necessary changes in their lives • Seeks professional counselling, if necessary, to cope with changes resulting from renal failure • Reports satisfaction with method of sexual expression

5. Alternative forms of sexual expression may be acceptable. 6. Sexuality means different things to different people, depending on stage of maturity.

Collaborative Problems: Hyperkalemia; pericarditis, pericardial effusion, and pericardial tamponade; hypertension; anemia; bone disease and metastatic calcifications

Goal: Absence of complications

Hyperkalemia 1. Monitor serum potassium levels. Notify physician if level greater than 5.5 mEq/L, and prepare to treat hyperkalemia. 2. Assess patient for muscle weakness, diarrhea, ECG changes (tall-tented T waves and widened QRS).

1. Hyperkalemia causes potentially life-threatening changes in the body. 2. Cardiovascular signs and symptoms are characteristic of hyperkalemia.

• Patient has normal potassium level • Experiences no muscle weakness or diarrhea

• Exhibits normal ECG pattern • Vital signs are within normal limits

CHAPTER 45

Plan of Nursing Care NURSING INTERVENTIONS

●

Chart 45-7. The Patient With Chronic Renal Failure, Continued

RATIONALE

Pericarditis, Pericardial Effusion, and Pericardial Tamponade 1. About 30%–50% of patients with 1. Assess patient for fever, chest pain, chronic renal failure develop periand a pericardial friction rub (signs carditis due to uremia; fever, chest of pericarditis) and, if present, notify pain, and a pericardial friction rub physician. are classic signs. 2. Pericardial effusion is a common 2. If patient has pericarditis, assess for fatal sequela of pericarditis. Signs the following every 4 hours: of an effusion include a paradoxical a. Paradoxical pulse >10 mm Hg pulse (>10 mm Hg drop in blood b. Extreme hypotension pressure during inspiration) and c. Weak or absent peripheral pulses signs of shock due to compression d. Altered level of consciousness of the heart by a large effusion. Care. Bulging neck veins diac tamponade exists when the patient is severely compromised hemodynamically. 3. Cardiac ultrasound is useful in visu3. Prepare patient for cardiac ultraalizing pericardial effusions and sound to aid in diagnosis of pericarcardiac tamponade. dial effusion and cardiac tamponade. 4. Cardiac tamponade is a life-threat4. If cardiac tamponade develops, preening condition, with a high morpare patient for emergency pericartality rate. Immediate aspiration of diocentesis. fluid from the pericardial space is essential. 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. 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.

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EXPECTED OUTCOMES

• 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

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 the need to alter therapy.

• Blood pressure within normal limits • Reports no headaches, visual prob-

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 skin colour

lems, or seizures

• Edema is absent • Demonstrates compliance with dietary and fluid restrictions

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. continued >

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 45-7. The Patient With Chronic Renal Failure, Continued

RATIONALE

Bone Disease and Metastatic Calcifications 1. 1. Administer the following medications as prescribed: phosphate binders, calcium supplements, vitamin D supplements. 2. 2. Monitor serum lab values as indicated (calcium, phosphorus, aluminum levels) and report abnormal findings to physician. 3. 3. Assist patient with an exercise program.

EXPECTED OUTCOMES

Chronic renal failure causes numerous physiologic changes affecting calcium, phosphorus, and vitamin D metabolism. Hyperphosphatemia, hypocalcemia, and excess aluminum accumulation are common in chronic renal failure. Bone demineralization increases with immobility.

while monitoring the patient’s progress and compliance with the treatment regimen. A referral to a nutritionist is made because of the dietary changes required. The patient is taught how to check the vascular access device for patency and appropriate precautions, such as avoiding venipuncture and blood pressure measurements on the arm with the access device. In addition, the patient and family need to know what problems to report to the health care provider. These include the following: • Worsening signs and symptoms of renal failure (nausea, vomiting, change in usual urine output [if any], ammonia odour on breath) • Signs and symptoms of hyperkalemia (muscle weakness, diarrhea, abdominal cramps) • Signs and symptoms of access problems (clotted fistula or graft, infection) These signs and symptoms of decreasing renal function, in addition to increasing BUN and serum creatinine levels, may indicate a need to alter the dialysis prescription. The dialysis nurses also provide ongoing education and support at each treatment visit. CONTINUING CARE. The importance of follow-up examinations and treatment is stressed to the patient and family because of changing physical status, renal function, and dialysis requirements. Referral for home care provides the home care nurse with the opportunity to assess the patient’s environment and emotional status and the coping strategies used by the patient and family to deal with the changes in family roles often associated with chronic illness. The home care nurse also assesses the patient for further deterioration of renal function and signs and symptoms of complications resulting from the primary renal disorder, the resulting renal failure, and effects of treatment strategies (e.g., dialysis, medications, dietary restrictions). Patients need education and reinforcement of the dietary restrictions required, including fluid, sodium, potassium, and protein restriction. Reminders about the need for health promotion activities and health screening are an important part of nursing care for the patient with renal failure.

• 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

Gerontologic Considerations Diabetes, hypertension, chronic glomerulonephritis, interstitial nephritis, and urinary tract obstruction are the causes of ESRD in the older adult. The signs and symptoms of renal disease in the older adult are often 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. Patients often develop signs and symptoms of nephrotic syndrome, such as edema and proteinuria. Hemodialysis and PD are used effectively in treating older patients. The number of older patients initiating dialysis has dramatically increased in the past decade (Kurella, Covinsky, Collins, et al., 2007). Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the older patients. However, the outcome is comparable to that of younger patients. Some older patients elect not to undergo dialysis or transplantation. 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 have dialysis or transplantation.

RENAL REPLACEMENT THERAPIES The use of renal replacement therapies becomes necessary when the kidneys can no longer remove wastes, maintain electrolytes, and regulate fluid balance. This can occur rapidly or over a long period of time and the need for replacement therapy can be acute (short term) or chronic (long term). The main renal replacement therapies include the various types of dialysis and kidney transplantation.

Dialysis Types of dialysis include hemodialysis, CRRT, and PD. Acute dialysis is indicated when there is a high and increasing level

CHAPTER 45

of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion. It may also be used to remove medications or toxins (poisoning or medication overdose) from the blood or for edema that does not respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia (Mosenkis, Kirk, & Berns, 2006). Chronic or maintenance dialysis is indicated in advanced CKD and ESRD in the following instances: the presence of uremic signs and symptoms affecting all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid restriction, and a general lack of well-being. An urgent indication for dialysis in patients with renal failure is pericardial friction rub. The decision to initiate dialysis should be reached only after thoughtful discussion among the patient, family, physician, and others as appropriate. Many potentially life-threatening issues are associated with the need for dialysis. The nurse can assist the patient and family by answering their questions, clarifying the information provided, and supporting their decision. Successful kidney transplantation eliminates the need for dialysis. Not only is the quality of life much improved in patients with ESRD who undergo transplantation, but also physiologic function is improved as well. Patients who undergo renal transplantation from living donors before dialysis is initiated generally have longer survival of the transplanted kidney than patients who receive transplantation after dialysis treatment is initiated.

Hemodialysis Hemodialysis is used for patients who are acutely ill and require short-term dialysis (days to weeks) and for patients with advanced CKD and ESRD who require long-term or permanent renal replacement therapy. Hemodialysis prevents death but does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys. Most patients receive intermittent hemodialysis that involves treatments three times a week with the average treatment duration of 3 to 4 hours in an outpatient setting. Hemodialysis can also be performed at home by the patient and a caregiver. With home dialysis, treatment time and frequency can be adjusted to meet optimal patient needs. The objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to remove excess water. A dialyzer (also referred to as an artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, where toxins are filtered out and removed and the blood is returned to the patient. Diffusion, osmosis, and ultrafiltration are the principles on which hemodialysis is based (see Chapter 15). The toxins and wastes in the blood are removed by diffusion— that is, they move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. The dialysate is a solution made up of all the important electrolytes in their ideal extracellular concentrations.

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Management of Patients With Renal Disorders

1425

The electrolyte level in the patient’s blood can be brought under control by properly adjusting the dialysate bath. The semipermeable membrane impedes the diffusion of large molecules, such as RBCs and proteins. Excess water is removed from the blood by osmosis, in which water moves from an area of low concentration potential (the blood) to an area of high concentration potential (the dialysate bath). In ultrafiltration, water moves under high pressure to an area of lower pressure. This process is much more efficient than osmosis at water removal and is accomplished by applying negative pressure or a suctioning force to the dialysis membrane. Because patients with renal disease usually cannot excrete water, this force is necessary to remove fluid to achieve fluid balance. The body’s buffer system is maintained using a dialysate bath made up of bicarbonate (most common) or acetate, which is metabolized to form bicarbonate. The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit. Cleansed blood is returned to the body. By the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal, and the buffer system has been replenished.

Dialyzers Dialyzers are hollow-fibre devices containing thousands of tiny strawlike tubes that carry the blood through the dialyzer. The tubes are porous and act as a semipermeable membrane allowing toxins, fluid, and electrolytes to pass through. The constant flow of the solution maintains the concentration gradient to facilitate the exchange of wastes from the blood through the semipermeable membrane into the dialysate solution, where they are removed and discarded (Fig. 45-3). Dialyzers have undergone many technologic changes in performance and biocompatibility. High-flux dialysis uses highly permeable membranes to increase the clearance of low- and mid-molecular-weight molecules. These special membranes are used with higher than traditional rates of flow for the blood entering and exiting the dialyzer (500 to 550 mL/min). High-flux dialysis increases the efficiency of treatments while shortening their duration and reducing the need for heparin.

Vascular Access Access to the patient’s vascular system must be established to allow blood to be removed, cleansed, and returned to the patient’s vascular system at rates between 300 and 800 mL/min. Several types of access are available.

Vascular Access Devices Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting a double-lumen, noncuffed, large-bore catheter into the subclavian, internal jugular, or femoral vein by the physician (Fig. 45-4). This method of vascular access involves some risk (e.g., hematoma, pneumothorax, infection, thrombosis of the subclavian vein, inadequate flow). The catheter is removed when no longer needed (e.g., because the patient’s condition has

1426

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Urinary Tract Function

Vascular access to circulation

Arterial blood

Venous blood

Blood port

Blood pressure monitor

Semipermeable membrane

Dialysate fluid out

Blood pump

Clot and bubble trap

Dialysate fluid out

Dialysate fluid in

B

Blood port

Dialysate fluid in

A FIGURE 45-3. Hemodialysis system. A, Blood from an artery is pumped into (B) a dialyzer where it flows

through the cellophane tubes, which act as the semipermeable membrane (inset). The dialysate, which has the same chemical composition as the blood except for urea and waste products, flows in around the tubules. The waste products in the blood diffuse through the semipermeable membrane into the dialysate.

improved or another type of access has been established). Double-lumen, cuffed catheters may also be inserted, usually by either a surgeon or interventional radiologist, into the internal jugular vein of the patient. Since these catheters have cuffs under the skin, the insertion site heals, sealing the wound and reducing the risk for ascending infection. This feature makes these catheters safe for longer-term use. Infection rates, however, remain high and septicemia continues to be a common cause for hospital admission.

Arteriovenous Fistula The preferred method of permanent access is an arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by joining (anastomosing) an artery to a vein, either side to side or end to side (Fig. 45-5A). Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer. The arterial segment of the fistula is used for arterial flow to the dialyzer and the venous segment for reinfusion of the dialyzed blood. This access will need time (2 to 3 months) to “mature” before it can be used. As the AVF matures, the venous segment dilates due to the increased blood flow coming directly from the artery. Once sufficiently dilated it will then accommodate two large-bore (14-, 15-, or 16-gauge) nee-

dles that are inserted for each dialysis treatment. The patient is encouraged to perform hand exercises to increase the size of these vessels (i.e., squeezing a rubber ball for forearm fistulas) to accommodate the large-bore needles. Once established, this access has the longest useful life and thus is the best option for vascular access for the chronic hemodialysis patient.

Arteriovenous Graft An arteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic, or synthetic graft material between an artery and vein (Fig. 45-5B). Usually a graft is created when the patient’s vessels are not suitable for creation of an AVF. Patients with compromised vascular systems (e.g., from diabetes) will require a graft because their native vessels are not suitable for creation of an AVF. Grafts are usually placed in the arm but may be placed in the thigh or chest area. Stenosis, infection, and thrombosis are the most common complications that result in loss of this access. It is not at all uncommon to see a dialysis patient with numerous “old” or “nonfunctioning” accesses present on their arms. The patient is asked to identify which is the current access in use and it is checked carefully for the presence of a bruit and thrill.

CHAPTER 45

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Management of Patients With Renal Disorders

1427

Complications

Internal jugular vein Subclavian vein

Catheter Catheter cuff

Aortic arch

Superior vena cava Left atrium

“Red” adapter

Right ventricle

“Blue” adapter FIGURE 45-4. Double-lumen, cuffed hemodialysis catheter used in acute hemodialysis. The red adapter is attached to a blood line through which blood is pumped from the patient to the dialyzer. After the blood passes through the dialyzer (artificial kidney), it returns to the patient through the blue adapter.

!

NURSING ALERT

Failure of the permanent dialysis access (fistula or graft) accounts for most hospital admissions of patients undergoing chronic hemodialysis. Thus, protection of the access is of high priority.

Cephalic vein Radial artery

A

Median cubital vein Radial artery Graft

B

FIGURE 45-5. A, Arteriovenous fistulas are created by anastomosing a

patient’s vein to an artery. This illustrates a side-to-side anastomosis. B, Arteriovenous grafts are established by placing synthetic tubing between the artery and vein.

While hemodialysis can prolong life indefinitely, it does not alter the natural course of the underlying CKD, nor does it completely replace kidney function. The CKD complications previously discussed will continue to worsen and require more aggressive treatment. With the initiation of dialysis, disturbances of lipid metabolism (hypertriglyceridemia) are accentuated and contribute to cardiovascular complications. Heart failure, coronary heart disease, angina, stroke, and peripheral vascular insufficiency may occur and can incapacitate the patient. Cardiovascular disease remains the leading cause of death in patients receiving dialysis (Vasundhara, Kozman, Liu, et al., 2014). Anemia is compounded by blood lost during hemodialysis. Gastric ulcers may result from the physiologic stress of chronic illness, medication, and pre-existing medical conditions (e.g., diabetes). Patients with uremia report a metallic taste and nausea when they require dialysis. Vomiting may occur during the hemodialysis treatment when rapid fluid shifts and hypotension occur. These contribute to the malnutrition seen in patients on dialysis. Worsening calcium metabolism and renal osteodystrophy can result in bone pain and fractures, interfering with mobility. As time on dialysis continues, calcification of major blood vessels has been reported and linked to hypertension and other vascular complications. Phosphorus deposits in the skin can occur and cause itching. Many dialysis patients experience fatigue while undergoing hemodialysis. Up to 85% of people undergoing hemodialysis experience major sleep problems that further complicate their overall health status (Horigan, Rocchiccioli, & Trimm, 2012). Early-morning or lateafternoon dialysis may be a risk factor for developing sleep disturbances. Other complications of dialysis treatment may include the following: • Episodes of shortness of breath often occur as fluid accumulates between dialysis treatments. • Hypotension may occur during the treatment as fluid is removed. Nausea and vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension. • Painful muscle cramping may occur, usually late in dialysis as fluid and electrolytes rapidly leave the extracellular space. • Exsanguination may occur if blood lines separate or dialysis needles become dislodged. • Dysrhythmias may result from electrolyte and pH changes or from removal of antiarrhythmic medications during dialysis. • Air embolism is rare but can occur if air enters the vascular system. • Chest pain may occur in patients with anemia or arteriosclerotic heart disease. • Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is more likely to occur in ARF or when BUN levels are very high, exceeding 54 mmol/L.

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Urinary Tract Function

Nursing Management The nurse in the dialysis unit has an important role in monitoring, supporting, assessing, and educating the patient. During dialysis, the patient, the dialyzer, and the dialysate bath require constant monitoring because numerous complications are possible, including clotting of the circuit, air embolism, inadequate or excessive ultrafiltration hypotension, cramping, vomiting, blood leaks, contamination, and access complications. Nursing care of the patient and maintenance of the vascular access device are especially important and are discussed later in this chapter in the section titled Special Considerations: Nursing Management of the Hospitalized Patient on Dialysis.

Promoting Pharmacologic Therapy Many medications are removed from the blood during hemodialysis; therefore, dosage or timing of the medication administration may require adjustment. Medications that are water soluble are readily removed during hemodialysis treatment and those that are fat soluble or adhere to other substances (like albumin) are not dialyzed out very well. This is the reason some drug overdoses are treated with emergency hemodialysis and others are not. Patients undergoing hemodialysis who require medications (e.g., cardiac glycosides, antibiotic agents, antiarrhythmic medications, antihypertensive agents) are monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation. Antihypertensive therapy, often part of the regimen of patients on dialysis, is one example when communication, teaching, and evaluation can make a difference in patient outcomes. The patient must know when and when not to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after the dialysis treatment.

Promoting Nutritional and Fluid Therapy Diet is important for patients on hemodialysis because of the effects of uremia. Goals of nutritional therapy are to minimize uremic symptoms and fluid and electrolyte imbalances; to maintain good nutritional status through adequate protein, calorie, vitamin, and mineral intake; and to enable the patient to eat a palatable and enjoyable diet. Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur, leading to weight gain, heart failure, and pulmonary edema. With the initiation of hemodialysis, the patient usually requires some restriction of dietary protein, sodium, potassium, and fluid intake. Protein intake is restricted to about 1.2 to 1.3 g/kg ideal body weight per day; therefore, protein must be of high biologic quality. Sodium is usually restricted to 2 to 3 g/day; fluids are restricted to an amount equal to the daily urine output plus 500 mL/day. The goal for patients on hemodialysis is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg (Welch & Perkins, 2006). Potassium restriction depends

on the amount of residual renal function and the frequency of dialysis. Dietary restriction is an unwelcome change in lifestyle for many patients with CRF. Patients can feel stigmatized in social situations because there may be few food choices available for their diet. If the restrictions are ignored, life-threatening complications, such as hyperkalemia and pulmonary edema, may result. Thus, the patient may feel punished for responding to basic human drives to eat and drink. The nurse who cares for a patient with symptoms or complications resulting from dietary indiscretion must avoid harsh, judgmental, or punitive tones when communicating with him or her. Regular education with reinforcement is needed to achieve this difficult change in life style (Castner, 2010) (Chart 45-8).

Meeting Psychosocial Needs Patients requiring long-term hemodialysis are often concerned about the unpredictability of the illness and the disruption of their lives. They often have financial problems, difficulty holding a job, waning sexual desire and impotence, depression from being chronically ill, and fear of dying. Younger patients worry about marriage, having children, and the burden that they bring to their families. The regimented lifestyle that frequent dialysis treatments and restrictions in food and fluid intake impose is often demoralizing to the patient and family. Dialysis alters the lifestyle of the patient and family. The amount of time required for dialysis and physician visits and being chronically ill can create conflict, frustration, guilt, and depression. It may be difficult for the patient, spouse, and family to express anger and negative feelings. The nurse needs to give the patient and family the opportunity to express feelings of anger and concern about the limitations that the disease and treatment impose, possible financial problems, and job insecurity. If anger is not expressed, it may be directed inward and lead to depression, despair, and attempts at suicide (suicide is more prevalent in patients on dialysis); however, if anger is projected outward to other people, it may destroy already threatened family relationships. Although these feelings are normal in this situation, they are often profound and overwhelming. Counselling and psychotherapy may be necessary. Depression may require treatment with antidepressant agents. Referring the patient and family to a mental health provider with expertise in the care of patients receiving dialysis may also be helpful. Clinical nurse specialists, psychologists, and social workers may be helpful in assisting the patient and family to cope with the changes brought about by renal failure and its treatment. The “sense of loss” that the patient experiences cannot be underestimated because every aspect of a “normal life” is disrupted. Some patients use denial to deal with the overwhelming array of medical problems (e.g., infections, hypertension, anemia, neuropathy). Staff who are tempted to label the patient as noncompliant must consider the impact of renal failure and its treatment on the patient and family and the coping strategies that they may use. Palliative care principles that focus on symptom control are becoming increasingly important as greater attention is focused on quality-of-life issues (Kane, Vinen, & Murtagh, 2013).

CHAPTER 45

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Management of Patients With Renal Disorders

1429

NURSING RESEARCH PROFILE

Chart 45-8. Hemodialysis and Nonadherence Belguzar, K., Kayser, C., & Kilic, S. (2007). Nonadherence with diet and fluid restrictions and perceived social support in patients receiving hemodialysis. Journal of Nursing Scholarship, 39 (3), 243–248. Purpose Nonadherence to diet and fluid restrictions has adverse consequences for patients receiving hemodialysis. The purpose of this study was to describe nonadherence with diet and fluid restrictions and the level of perceived social support in hemodialysis patients. Nonadherence often occurs when a person’s behaviour conflicts with medical advice regarding taking medications, following diets, or other lifestyle changes. Design This descriptive study surveyed 160 patients on hemodialysis in three centres in Turkey. Participants were asked about personal characteristics, and data were collected using the Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) and Multidimensional Scale of Perceived Social Support (MSP). Data were collected during the patient’s regularly scheduled dialysis session. The DDFQ is a four-item

Patients and their families should be encouraged to discuss end-of-life options and have developed advanced directives or living wills.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Preparing a patient for hemodialysis is challenging. Often the patient does not fully comprehend the impact of dialysis, and learning needs may go unrecognized. Good communication between dialysis staff and home care nurses is essential. Assessment helps identify the learning needs of the patient and family members. In many cases, the patient is discharged home before learning needs and readiness to learn can be thoroughly evaluated; therefore, hospital-based nurses, dialysis staff, and home care nurses must work together to provide appropriate teaching that meets the patient’s and family’s changing needs and readiness to learn. The diagnosis of CRF and the need for dialysis often overwhelm the patient and family. In addition, many patients with ESRD have depressed mentation, a shortened attention span, a decreased level of concentration, and altered perception. Therefore, teaching must occur in brief, 10- to 15-minute sessions, with time added for clarification, repetition, reinforcement, and questions from the patient and family. The nurse needs to convey a nonjudgmental attitude to enable the patient and family to discuss options and their feelings about those options. Team conferences are helpful for sharing information and providing every team member the opportunity to discuss the needs of the patient and family. HOME HEMODIALYSIS. Most patients who undergo hemodialysis do so in an outpatient setting, but home hemodialysis is an option for some. Home hemodialysis requires a highly motivated patient who is willing to take

self-report questionnaire that assesses the frequency of nonadherence to diet and fluid restrictions for the previous 14 days. The MSP is a 12-item scale used to assess emotional support and the degree of satisfaction with perceived social support from family, friends, and significant others. Findings Adherence to fluid restriction is a difficult and stressful aspect of hemodialysis treatment, and most patients in this study showed some degree of nonadherence to fluid restrictions (68%) and diet (58%). Participants perceived total social support as low. Nonadherence was most common with younger patients, those who were married, and those with lower levels of perceived social support. Nursing Implications Nurses working in hemodialysis centres need to consider social support and how it affects adherence in patients receiving hemodialysis. The results of this study suggest that younger, married patients may require assistance to develop the levels of social support needed to adhere to fluid and diet restrictions between hemodialysis sessions.

responsibility for the procedure and is able to adjust each treatment to meet the body’s changing needs. It also requires the commitment and cooperation of a caregiver to assist the patient. However, many patients are not comfortable imposing on others this way and do not wish to subject family members to the feeling that their home is being turned into a clinic. The health care team never forces a patient to use home hemodialysis because this treatment requires significant changes in the home and family. Home hemodialysis must be the patient’s and family’s decision because full cooperation and participation are required (Peters, 2014). The patient undergoing home hemodialysis and the caregiver assisting that patient must be trained to prepare, operate, and disassemble the dialysis machine; maintain and clean the equipment; administer medications (e.g., heparin) into the machine lines; and handle emergency problems (hemodialysis dialyzer rupture, electrical or mechanical problems, hypotension, shock, and seizures). Because home hemodialysis places primary responsibility for the treatment on the patient and the family member, they must understand and be capable of performing all aspects of the hemodialysis procedure (Chart 45-9). Before home hemodialysis is initiated, the home environment, household and community resources, and ability and willingness of the patient and family to carry out this treatment are assessed. The home is surveyed to see if electrical outlets, plumbing facilities, and storage space are adequate. Modifications may be needed to enable the patient and assistant to perform dialysis safely and to deal with emergencies. Once home hemodialysis is initiated, the home care nurse must visit periodically to evaluate compliance with the recommended techniques, to assess the patient for complications, to reinforce previous teaching, and to provide reassurance.

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CHART 45-9

HOME CARE CHECKLIST •

Hemodialysis Patient

Caregiver

• Discuss renal failure and its effects on the body.

✔

✔

• Describe the cause of renal failure and why hemodialysis is necessary.

✔

✔

• Describe the basic principles of hemodialysis.

✔

✔

• Discuss common problems that may occur during hemodialysis and their prevention

✔

✔

• Demonstrate knowledge about prescribed medications and the reason for their use, potential

✔

✔

• Acknowledge dietary and fluid restrictions, rationale, and consequences of noncompliance.

✔

✔

• Describe commonly measured laboratory values, results, and implications.

✔

✔

• List guidelines for prevention and detection of fluid overload, meaning of “dry” weight, and how

✔

✔

• Demonstrate vascular access care, how to check patency, signs and symptoms of infection, and

✔

✔

• Discuss strategies for detection, management, and relief of pruritus, neuropathy, and other

✔

✔

• Develop strategies to manage or reduce anxiety and maintain independence.

✔

✔

• Coordinate financial arrangements for dialysis and strategies to identify and obtain resources.

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

and management.

side effects, guidelines on when to notify physician, and the schedule of medications on dialysis and nondialysis days.

to weigh self.

prevention of complications.

complications of renal failure.

CONTINUING CARE. The health care team’s goal in treating patients with CRF is to maximize their vocational potential, functional status, and quality of life. To facilitate renal rehabilitation, appropriate follow-up and monitoring by members of the health care team (physicians, dialysis nurses, social worker, psychologist, home care nurses, and others as appropriate) are essential to identify and resolve problems early on. Many patients with CRF can resume relatively normal lives, doing the things that are important to them: travelling, exercising, working, or actively participating in family activities. If appropriate interventions are available early in the course of dialysis, the potential for better health improves, and the patient can remain active in family and community life. Outcome goals for renal rehabilitation include employment for those able to work, improved physical functioning of all patients, improved understanding about adaptation and options for living well, increased control over the effects of kidney disease and dialysis, and resumption of activities enjoyed before dialysis.

Continuous Renal Replacement Therapies CRRTs may be indicated for patients with acute or CRF who are too clinically unstable for traditional hemodialysis, for patients with fluid overload secondary to oliguric (low urine output) renal failure, and for patients whose kidneys cannot handle their acutely high metabolic or

nutritional needs. CRRT does not produce rapid fluid shifts, does not require dialysis machines or dialysis personnel to carry out the procedures, and can be initiated quickly. Several types of CRRT are available and widely used in critical care units (Fig. 45-6). The methods are similar as they require access to the circulation and blood to pass through an artificial filter. A hemofilter (an extremely porous blood filter containing a semipermeable membrane) is used in all types.

Continuous Venovenous Hemofiltration Continuous venovenous hemofiltration (CVVH) is used to manage ARF. Blood from a double-lumen venous catheter is pumped (using a small blood pump) through a hemofilter and then returned to the patient through the same catheter. CVVH provides continuous slow fluid removal (ultrafiltration); therefore, hemodynamic effects are mild and better tolerated by patients with unstable conditions. CVVH does not require arterial access, and critical care nurses can set up, initiate, maintain, and terminate the system.

Continuous Venovenous Hemodialysis Continuous venovenous hemodialysis (CVVHD) is similar to CVVH. Blood is pumped from a double-lumen venous

CHAPTER 45

FIGURE 45-6. Devices for administering continuous renal replacement therapy (CRRT) offer an integrated fluid warmer for the heating of infusion and dialysate fluids, a weighing system to reduce the possibility of error in assessing fluid balance, and a battery backup that allows treatments to continue when the patient is moved. A, Diapact CRRT System, B-Braun Medical, Inc., Bethlehem, PA. B, PRISMA, Gambro Corporation, Lakewood, CO.

A

catheter through a hemofilter and returned to the patient through the same catheter. In addition to the benefits of ultrafiltration, CVVHD uses a concentration gradient to facilitate the removal of uremic toxins and fluid. No arterial access is required, hemodynamic effects are usually mild, and critical care nurses can set up, initiate, maintain, and terminate the system (Muzzy & Snyder, 2013). Examples of less frequently used CRRT include slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAVH), and continuous arteriovenous hemodialysis (CAVHD) (Martin & Jurschak, 2007).

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B

centration (the blood stream) to an area of lesser concentration (the dialysate fluid) through a semipermeable membrane (the peritoneum). This movement of solute from the blood into the dialysate fluid is called clearance. Since substances cross the peritoneal membrane at different rates, adjustments in dwell time and amount of fluid

Dialysate

Peritoneal Dialysis The goals of peritoneal dialysis (PD) are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance. PD may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation. Patients who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis experience fewer of these problems with the slower rate of PD. Therefore, patients with diabetes or cardiovascular disease, many older patients, and those who may be at risk for adverse effects of systemic heparin are likely candidates for PD. In addition, severe hypertension, heart failure, and pulmonary edema not responsive to usual treatment regimens have been successfully treated with PD. In PD, the peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals (Fig. 45-7). Once the sterile solution is in the peritoneal cavity, uremic toxins such as urea and creatinine begin to be cleared from the blood. Diffusion and osmosis occur as waste products move from an area of higher con-

Skin

Drainage

Subcutaneous fat Muscle Peritoneum Bowel

FIGURE 45-7. In peritoneal dialysis and in acute intermittent perito-

neal dialysis, dialysate is infused into the peritoneal cavity by gravity, after which the clamp on the infusion line is closed. After a dwell time (when the dialysate is in the peritoneal cavity), the drainage tube is unclamped and the fluid drains from the peritoneal cavity, again by gravity. A new container of dialysate is infused as soon as drainage is complete. The duration of the dwell time depends on the type of peritoneal dialysis.

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used are made to facilitate the process. Ultrafiltration (water removal) occurs in PD through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration. PD usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.

Procedure As with other forms of treatment, the decision to begin PD is made by the patient and family in consultation with the physician. The patient may be acutely ill, thus requiring short-term treatment to correct severe disturbances in fluid and electrolyte status, or may have ESRD and need to receive ongoing treatments.

Preparing the Patient The nurse’s preparation of the patient and family for PD depends on the patient’s physical and psychological status, level of alertness, previous experience with dialysis, and understanding of and familiarity with the procedure. The nurse explains the procedure to the patient and assists in obtaining signed consent. Baseline vital signs, weight, and serum electrolyte levels are recorded. Evaluation of the abdomen for placement of the catheter is done to facilitate self-care. Typically the catheter is placed on the nondominant side to allow the patient easier access to the catheter connection site when exchanges are done. The patient is encouraged to empty the bladder and bowel to reduce the risk of puncture of internal organs during the insertion procedure. Broad-spectrum antibiotic agents may be administered to prevent infection. The peritoneal catheter can be inserted in interventional radiology, in the operating room, or at the bedside. Depending on the situation, this will need to be explained to the patient and family.

Preparing the Equipment In addition to assembling the equipment for PD, the nurse consults with the physician to determine the concentration of dialysate to be used and the medications to be added to it. Heparin may be added to prevent fibrin formation and resultant occlusion of the peritoneal catheter. Potassium chloride may be prescribed to prevent hypokalemia. Antibiotics may be added to treat peritonitis (inflammation of the peritoneal membrane) caused by infection. Regular insulin may be added for patients with diabetes. Aseptic technique is imperative whenever medications are added. Before medications are added, the dialysate is warmed to body temperature to prevent patient discomfort and abdominal pain and to dilate the vessels of the peritoneum to increase urea clearance. Solutions that are too cold cause pain, cramping, and vasoconstriction and reduce clearance. Dry heating (heating cabinet, incubator, or heating pad) is recommended. Methods not recommended include soaking the bags of solution in warm water (can introduce bacteria to the exterior of the bags of solution and increase the chance of peritonitis) and use of a microwave to heat the fluid (increases the danger of burning the peritoneum). Immediately before initiating dialysis, using aseptic technique, the nurse assembles the administration set and tubing. The tubing is filled with the prepared dialysate to

reduce the amount of air entering the catheter and peritoneal cavity, which could increase abdominal discomfort and interfere with instillation and drainage of the fluid.

Inserting the Catheter Ideally, the peritoneal catheter is inserted in the operating room or radiology suite to maintain surgical asepsis and minimize the risk of contamination. However, in some circumstances, the physician may insert the rigid stylet catheter at the bedside using strict asepsis. Whenever a rigid catheter is used, careful securing and close observation for bowel perforation is essential to minimize complications. Catheters for long-term use (e.g., Tenckhoff, Swan, or Cruz) are usually soft and flexible and made of silicone with a radiopaque strip to permit visualization on x-ray. These catheters have three sections: (1) an intraperitoneal section, with numerous openings and an open tip to let dialysate flow freely; (2) a subcutaneous section that passes from the peritoneal membrane and tunnels through muscle and subcutaneous fat to the skin; and (3) an external section for connection to the dialysate system. Most of these catheters have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. One cuff is placed just distal to the peritoneum, and the other cuff is placed subcutaneously. The subcutaneous tunnel (5 to 10 cm long) further protects against bacterial infection (Fig. 45-8).

Performing the Exchange Peritoneal dialysis involves a series of exchanges or cycles. An exchange is defined as the infusion (fill), dwell, and drainage of the dialysate. This cycle is repeated throughout the course of the dialysis. The dialysate is infused by gravity into the peritoneal cavity. A period of about 5 to 10 minutes is usually required to infuse 2 to 3 L of fluid. The prescribed dwell, or equilibration, time allows diffusion and osmosis to occur. At the end of the dwell time, the drainage portion of the exchange begins. The tube is unclamped and the solution drains from the peritoneal cavity by gravity through a closed system. Drainage is usually completed in 10 to 20 minutes. The drainage fluid is normally colourless or straw-coloured and should not be cloudy. Bloody drainage may be seen in the first few exchanges after insertion of a new catheter but should not occur after that time. The number of cycles or exchanges and their frequency are prescribed based on monthly laboratory values and presence of uremic symptoms. The removal of excess water during PD occurs because dialysate has a high dextrose concentration, making it hypertonic. An osmotic gradient is created between the blood and the dialysate solution. Dextrose solutions of 1.5%, 2.5%, and 4.25% are available in several volumes, from 1,000 mL to 3,000 mL. The higher the dextrose concentration, the greater the osmotic gradient and the more water will be removed. Selection of the appropriate solution is based on the patient’s fluid status.

Complications Most complications of PD are minor, but several, if unattended, can have serious consequences.

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Fresh peritoneal dialysate

Peritoneal cavity

Cuff

Silicone catheter

Collecting tube

Skin

Subcutaneous tissue Position of bag to receive dialysate drainage

Rectus muscle

A

B

C

FIGURE 45-8. Continuous ambulatory peritoneal dialysis. A, The peritoneal catheter is implanted through

the abdominal wall. B, Dacron cuffs and a subcutaneous tunnel provide protection against bacterial infection. C, Dialysate flows by gravity through the peritoneal catheter into the peritoneal cavity. After a prescribed period of time, the fluid is drained by gravity and discarded. New solution is then infused into the peritoneal cavity until the next drainage period. Dialysis thus continues on a 24-hour-a-day basis, during which the patient is free to move around and engage in his or her usual activities.

Acute Complications PERITONITIS. Peritonitis is the most common and serious complication of PD. The first sign of peritonitis is cloudy dialysate drainage fluid. Diffuse abdominal pain and rebound tenderness occur much later. Hypotension and other signs of shock may also occur with advancing infection. The patient with peritonitis may be treated as an inpatient or outpatient (most common), depending on the severity of the infection and the patient’s clinical status. Drainage fluid is examined for cell count; Gram stain and culture are used to identify the organism and guide treatment. Antibiotic agents (aminoglycosides or cephalosporins) are usually added to subsequent exchanges until Gram stain or culture results are available for appropriate antibiotic determination. Intraperitoneal administration of antibiotics is as effective as IV administration and therefore most often used. Antibiotic therapy continues for 10 to 14 days. Careful selection and calculation of the antibiotic dosage are needed to prevent nephrotoxicity and further compromise of residual renal function. Regardless of which organism causes peritonitis, the patient with peritonitis loses large amounts of protein through the peritoneum. Acute malnutrition and delayed healing may result. Therefore, attention must be given to detecting and promptly treating peritonitis. LEAKAGE. Leakage of dialysate through the catheter site may occur immediately after the catheter is inserted. Usually, the leak stops spontaneously if dialysis is withheld for several days, giving the tissue surrounding the cuffs located on the abdominal catheter a chance to infiltrate the Dacron and seal the insertion tunnel. It also allows the exit site time to heal. During this time, it is important to

reduce factors that might delay healing, such as undue abdominal muscle activity and straining during bowel movement. In many cases, leakage can be avoided by using small volumes (500 mL) of dialysate, gradually increasing the volume up to 2,000 to 3,000 mL. BLEEDING. A bloody effluent (drainage) may be observed occasionally, especially in young, menstruating women. (The hypertonic fluid pulls blood from the uterus, through the opening in the fallopian tubes, and into the peritoneal cavity.) Bleeding is also common during the first few exchanges after a new catheter insertion because some blood enters the abdominal cavity following insertion. In many cases, no cause can be found for the bleeding, although catheter displacement from the pelvis has occasionally been associated with bleeding. Some patients have had bloody effluent after an enema or from minor trauma. Invariably, bleeding stops in 1 to 2 days and requires no specific intervention. More frequent exchanges and the addition of heparin to the dialysate during this time may be necessary to prevent blood clots from obstructing the catheter.

Long-Term Complications Hypertriglyceridemia is common in patients undergoing long-term PD, suggesting that the therapy may accelerate atherogenesis. Despite this, the use of cardioprotective medications is relatively uncommon, and many patients have suboptimal blood pressure control. Given the high burden of disease in these patients, beta-blockers and ACE inhibitors should be used to control hypertension or protect the heart, and the use of aspirin and statins should be considered.

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Other complications that may occur with long-term PD include abdominal hernias (incisional, inguinal, diaphragmatic, and umbilical), probably resulting from continuously increased intra-abdominal pressure. The persistently elevated intra-abdominal pressure also aggravates symptoms of hiatal hernia and hemorrhoids. Low back pain and anorexia from fluid in the abdomen and a constant sweet taste related to glucose absorption may also occur. Mechanical problems occasionally occur and may interfere with instillation or drainage of the dialysate. Formation of clots in the peritoneal catheter and constipation are factors that may contribute to these problems.

Approaches Peritoneal dialysis can be performed using several different approaches: acute intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), and continuous cyclic peritoneal dialysis (CCPD).

Acute Intermittent Peritoneal Dialysis Indications for acute intermittent PD, a variation of PD, include uremic signs and symptoms (nausea, vomiting, fatigue, altered mental status), fluid overload, acidosis, and hyperkalemia. Although PD is not as efficient as hemodialysis in removing solute and fluid, it permits a more gradual change in the patient’s fluid volume status and in waste product removal. Therefore, it may be the treatment of choice for the hemodynamically unstable patient. It can be carried out manually (the nurse warms, spikes, and hangs each container of dialysate) or by a cycler machine. Exchange times range from 30 minutes to 2 hours. A common routine is hourly exchanges consisting of a 10-minute infusion, a 30-minute dwell time, and a 20-minute drain time. Maintaining the PD cycle is a nursing responsibility. Strict aseptic technique is maintained when changing solution containers and emptying drainage containers. Vital signs, weight, I&O, laboratory values, and patient status are frequently monitored. The nurse uses a flow sheet to document each exchange and records vital signs, dialysate concentration, medications added, exchange volume, dwell time, dialysate fluid balance for each exchange (fluid lost or gained), and cumulative fluid balance. The nurse also carefully assesses skin turgor and mucous membranes to evaluate fluid status and monitor the patient for edema. If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock. The nurse monitors for complications, including peritonitis, bleeding, respiratory difficulty, and leakage of peritoneal fluid. Abdominal girth may be measured periodically to determine if the patient is retaining large amounts of dialysis solution. In addition, the nurse must ensure that the PD catheter remains secure and that the dressing remains dry. Physical comfort measures, frequent turning, and skin care are provided. The patient

and family are educated about the procedure and are kept informed about progress (fluid loss, weight loss, laboratory values). Emotional support and encouragement are given to the patient and family during this stressful and uncertain time.

Continuous Ambulatory Peritoneal Dialysis CAPD is performed at home by the patient or a trained caregiver who is usually a family member. The procedure allows the patient reasonable freedom and control of daily activities but requires a serious commitment to be successful. Chart 45-10 discusses suitability for CAPD. CAPD works on the same principles as other forms of PD: diffusion and osmosis. Less extreme fluctuations in the patient’s laboratory values occur with CAPD than with intermittent PD or hemodialysis because the dialysis is constantly in progress. The serum electrolyte levels usually remain in the normal range. PROCEDURE. The patient performs exchanges four or five times a day, 24 hours a day, 7 days a week, at intervals scheduled throughout the day. Different manufacturers supply different equipment. Most commonly used is a Y-shaped system, in which a bag containing dialysate solution comes connected to one branch of the “Y” and a sterile empty bag is connected to the second branch. This leaves the third part of the “Y” open and available for connection to the transfer set on the PD catheter. To perform an exchange, the patient (or person doing the exchange) washes his or her hands, dons a mask, and then removes the cap from the transfer set while maintaining sterility. The open end of the “Y” set is connected to the end of the transfer set and the dialysate infused where it will dwell. After the dialysate is infused, the patient clamps off the transfer set and the tubing set, disconnects the tubing set, and applies a new cap to the transfer set, making it a closed system. The patient drains the fluid (effluent) from the peritoneal cavity through the catheter (over about 20 to 30 minutes) into an empty bag. Once the effluent has been fully drained, fresh fluid is instilled into the peritoneal cavity. The longer the dwell time, the better the clearance of uremic toxins is. If dwell time is excessive, the patient will absorb some of the effluent back into the body simply because the osmotic gradient is lost. Once equilibrium is reached, the movement of fluid and toxins stops. COMPLICATIONS. To reduce the risk of peritonitis, the patient (and all caregivers) must use meticulous care to avoid contaminating the catheter, fluid, or tubing and to avoid accidentally disconnecting the catheter from the tubing. Whenever a connection/disconnection is made, hands must be washed and a mask worn by anyone within 6 ft of the area to avoid contamination with airborne bacteria. Excess manipulation should be avoided and meticulous care of the catheter entry site is provided using a standardized protocol.

Continuous Cyclic Peritoneal Dialysis Continuous cyclic peritoneal dialysis (CCPD) uses a machine called a cycler to provide the exchanges. It is programmed as to how much fluid to use and how long and how many exchanges need to be done. Since it is programmed, it also keeps track of the total amounts removed and will sound an alarm if limits are not met. It requires

CHAPTER 45

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Management of Patients With Renal Disorders

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CHART 45-10

Considerations in CAPD Although CAPD is not suitable for all patients with end-stage renal disease (ESRD), it is a viable therapy for those who can perform self-care and exchanges and who can fit therapy into their own routines. Often, patients report having more energy and feeling healthier once they begin CAPD. Nurses can be instrumental in helping patients with ESRD find the dialysis therapy that best suits their lifestyle. Those considering CAPD need to understand the advantages and disadvantages along with the indications and contraindications for this form of therapy.

Advantages • Freedom from a dialysis machine • Control over daily activities • Opportunities to avoid dietary restrictions, increase fluid intake, raise serum hematocrit values, improve blood pressure control, avoid venipuncture, and gain a sense of well-being

Disadvantages • Continuous dialysis 24 hours a day, 7 days a week

Indications • Patient’s willingness, motivation, and ability to perform dialysis at home

• Strong family or community support system (essential for success), particularly if the patient is an older adult

that a person set up and break down the system for use, which typically takes about 15 minutes. CCPD combines overnight intermittent PD with a prolonged dwell time during the day. The peritoneal catheter is connected to a cycler machine every evening, usually just before the patient goes to sleep for the night. Because the machine is very quiet, the patient can sleep, and the extra long tubing allows the patient to move and turn normally during sleep. In the morning, the patient disconnects from the cycler. Sometimes dialysate is left in the abdominal cavity for a longer day dwell cycle. This day exchange is drained during the day either by using a “Y” set or reattaching to the cycler. This process is done every day to achieve the effects of dialysis required. CCPD has a lower infection rate than other forms of PD because there are fewer opportunities for contamination with bag changes and tubing disconnections. It also allows the patient to be free from exchanges throughout the day, making it possible to engage in work and activities of daily living more freely.

Nursing Management Meeting Psychosocial Needs In addition to the complications of PD previously described, patients who elect to do PD may experience altered body image because of the presence of the abdominal catheter, bag, tubing, and cycler. Waist size increases from 2.5 to 5 cm (or more) with fluid in the abdomen. This affects

• Special problems with long-term hemodialysis, such as dys-

functional or failing vascular access devices, excessive thirst, severe hypertension, postdialysis headaches, and severe anemia requiring frequent transfusion • Interim therapy while awaiting kidney transplantation • ESRD secondary to diabetes because hypertension, uremia, and hyperglycemia are easier to manage with CAPD than with hemodialysis

Contraindications • Adhesions from previous surgery (adhesions reduce clearance of solutes) or systemic inflammatory disease

• Chronic backache and pre-existing disk disease, which

could be aggravated by the continuous pressure of dialysis fluid in the abdomen • Risk of complications, for example, in patients receiving immunosuppressive medications, which impede healing of the catheter site, and in patients with a colostomy, ileostomy, nephrostomy, or ileal conduit because of the risk of peritonitis. The risk for complications is not an absolute contraindication for CAPD therapy. • Diverticulitis because CAPD has been associated with rupture of the diverticulum • Severe arthritis or poor hand strength necessitating assistance in performing the exchange. However, blind or partially blind patients and those with other physical limitations can learn to perform CAPD.

clothing selection and may make the patient feel “fat.” Body image may be so altered that patients do not want to look at or care for the catheter for days or weeks. The nurse may arrange for the patient to talk with other patients who have adapted well to PD. Although some patients have no psychological problems with the catheter–they think of it as their lifeline and as a life-sustaining device–other patients feel they are doing exchanges all day long and have no free time, particularly in the beginning. They may experience depression because they feel overwhelmed with the responsibility of self-care. Patients undergoing PD may also experience altered sexuality patterns and sexual dysfunction. The patient and partner may be reluctant to engage in sexual activities, partly because of the catheter being psychologically “in the way” of sexual performance. The peritoneal catheter, drainage bag, and about 2 L of dialysate may interfere with the patient’s sexual function and body image as well. In patients on CCPD, the presence of the dialysis cycler in the bedroom and the continual connection during the sleeping hours can also cause interference with intimacy. Although these problems may resolve with time, some problems may warrant special counselling. Questions by the nurse about concerns related to sexuality and sexual function often provide the patient with a welcome opportunity to discuss these issues and a first step toward their resolution.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients are taught as inpatients or outpatients to perform PD once their condition

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CHART 45-11

HOME CARE CHECKLIST •

Peritoneal Dialysis (CAPD or CCPD) Patient

Caregiver

• Discuss basic information about normal kidney function.

✔

✔

• Discuss basic information about the disease process.

✔

✔

• Discuss the basic principles of peritoneal dialysis.

✔

✔

• Demonstrate catheter and exit site care.

✔

✔

• Demonstrate measurement of vital signs and weight measurement.

✔

✔

• Discuss monitoring and management of fluid balance.

✔

✔

• Discuss basic principles of aseptic technique.

✔

✔

• Demonstrate the CAPD exchange procedure using aseptic technique (CCPD patients should

✔

✔

• Demonstrate cycler setup procedure and maintenance if on CCPD.

✔

✔

• Discuss complications of peritoneal dialysis; prevention, recognition, and management of

✔

✔

• Demonstrate procedure for adding medications to the dialysis solution.

✔

✔

• Demonstrate procedure for obtaining sterile dialysis fluid samples.

✔

✔

• Discuss routine laboratory tests needed and implications of results.

✔

✔

• Discuss medications: name of medications, their actions, potential side effects, and when to

✔

✔

• Discuss ordering, storage, and inventory of dialysis supplies.

✔

✔

• Describe plan for follow-up care.

✔

✔

• Demonstrate maintenance of home dialysis records.

✔

✔

• Describe actions in case of emergency.

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

also demonstrate exchange procedure in case of failure or unavailability of cycling machine).

complications.

• Discuss dietary restrictions. contact physician.

is medically stable. Training usually takes 5 days to 2 weeks. Patients are taught according to their own learning ability and knowledge level and only as much at one time as they can handle without feeling uncomfortable or becoming overwhelmed. Education topics for the patient and family who will be performing PD at home are described in Chart 45-11. The use of an adult learning theory–based curriculum may decrease peritonitis and exit site infection rates. Because of protein loss with continuous PD, the patient is instructed to eat a high-protein, well-balanced diet. The patient is also encouraged to increase his or her daily fibre intake to help prevent constipation, which can impede the flow of dialysate into or out of the peritoneal cavity. Many patients gain 1.5 to 2.5 kg within a month of initiating PD, so they may be asked to limit their carbohydrate intake to avoid excessive weight gain. Potassium, sodium, and fluid restrictions are not usually needed. Patients commonly lose about 2 to 3 L of fluid over and above the volume of dialysate infused into the abdomen during a 24-hour period, permitting a normal fluid intake even in an anephric patient (a patient without kidneys).

CONTINUING CARE. Follow-up care through phone calls, visits to the outpatient department, and continuing home care assists patients in the transition to home and promotes their active participation in their own health care. Patients often depend on checking with the nurse to see if they are making the correct choices about dialysate or control of blood pressure, or simply to discuss a problem. Patients may be seen by the PD team as outpatients once a month or more often if needed. The exchange procedure is evaluated at that time to see that strict aseptic technique is being used. Blood chemistry values are followed closely to make certain the therapy is adequate for the patient. If a referral is made for home care, the home care nurse assesses the home environment and suggests modifications to accommodate the equipment and facilities needed to carry out PD. In addition, the nurse assesses the patient’s and family’s understanding of PD and evaluates their technique in performing PD. Assessments include checking for changes related to renal disease, complications such as peritonitis, and treatment-related problems such as heart failure, inadequate drainage, and weight gain or loss. The nurse continues to reinforce and clarify teaching about PD

CHAPTER 45

and renal disease and assesses the patient’s and family’s progress in coping with the procedure. This is also an opportunity to remind patients about the need to participate in appropriate health promotion activities and health screening (e.g., gynecologic examinations, colonoscopy). Because of the projected high numbers of older adult patients who will develop ESRD, the nursing home or extended care facility is likely to become an increasingly important site for both rehabilitation and long-term management of patients with renal failure.

Special Considerations: Nursing Management of the Hospitalized Patient on Dialysis Whether undergoing hemodialysis or PD, the patient may be hospitalized for treatment of complications related to the dialysis treatment, the underlying renal disorder, or health problems not related to renal dysfunction or its treatment.

Protecting Vascular Access When the patient undergoing hemodialysis is hospitalized for any reason, care must be taken to protect the vascular access. The nurse assesses the vascular access for patency and takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access must be avoided as well. The bruit, or “thrill,” over the venous access site must be evaluated at least every 8 hours. Absence of a palpable thrill or audible bruit may indicate blockage or clotting in the vascular access. Clotting can occur if the patient has an infection anywhere in the body (serum viscosity increases) or if the blood pressure has dropped. When blood flow is reduced through the access for any reason (hypotension, application of blood pressure cuff or tourniquet), the access can clot. If a patient has a hemodialysis catheter or implanted hemodialysis access device, the nurse must observe for signs and symptoms of infection such as redness, swelling, drainage from the exit site, fever, and chills. The nurse must assess the integrity of the dressing and change it as needed. Patients with renal disease are more prone to infection; therefore, infection control measures must be used for all procedures.

Taking Precautions During Intravenous Therapy When the patient needs IV therapy, the rate of administration must be as slow as possible and should be strictly controlled by a volumetric infusion pump. Because patients on dialysis cannot excrete water, rapid or excessive administration of IV fluid can result in pulmonary edema. Accurate I&O records are essential.

Monitoring Symptoms of Uremia As metabolic end products accumulate, symptoms of uremia worsen. Patients whose metabolic rate accelerates (those receiving corticosteroid medications or parenteral nutrition, those with infections or bleeding disorders,

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Management of Patients With Renal Disorders

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those undergoing surgery) accumulate waste products more quickly and may require daily dialysis. These same patients are more likely than other patients receiving dialysis to experience complications.

Detecting Cardiac and Respiratory Complications Cardiac and respiratory assessment must be conducted frequently. As fluid builds up, fluid overload, heart failure, and pulmonary edema develop. Crackles in the bases of the lungs may indicate pulmonary edema. Pericarditis may result from the accumulation of uremic toxins. If not detected and treated promptly, this serious complication may progress to pericardial effusion and cardiac tamponade. Pericarditis is detected by the patient’s report of substernal chest pain (if the patient can communicate), low-grade fever (often overlooked), and pericardial friction rub. A pulsus paradoxus (a decrease in blood pressure of more than 10 mm Hg during inspiration) is often present. When pericarditis progresses to effusion, the friction rub disappears, heart sounds become distant and muffled, ECG waves show very low voltage, and the pulsus paradoxus worsens. The effusion may progress to life-threatening cardiac tamponade, noted by narrowing of the pulse pressure in addition to muffled or inaudible heart sounds, crushing chest pain, dyspnea, and hypotension. Although pericarditis, pericardial effusion, and cardiac tamponade can be detected by chest x-ray, they should also be detected through astute nursing assessment. Because of their clinical significance, assessment of the patient for these complications is a priority.

Controlling Electrolyte Levels and Diet Electrolyte alterations are common, and potassium changes can be life-threatening. All IV solutions and medications to be administered are evaluated for their electrolyte content. Serum laboratory values are assessed daily. If blood transfusions are required, they may be administered during hemodialysis, if possible, so that excess potassium can be removed. Dietary intake must also be monitored. The patient’s frustrations related to dietary restrictions typically increase if the hospital food is unappetizing. The nurse needs to recognize that this may lead to dietary indiscretion and hyperkalemia. Hypoalbuminemia is an indicator of malnutrition in patients undergoing long-term or maintenance dialysis. Although some patients can be treated with adequate nutrition alone, some patients remain hypoalbuminemic for reasons that are poorly understood.

Managing Discomfort and Pain Complications such as pruritus and pain secondary to neuropathy must be managed. Antihistamine agents, such as diphenhydramine hydrochloride (Benadryl), are commonly used, and analgesic medications may be prescribed. However, because elimination of the metabolites of medications occurs through dialysis rather than through renal excretion, medication dosages may need to be adjusted. Keeping the skin clean and well moisturized using bath oils, superfatted soap, and creams or lotions helps promote comfort and reduce itching. Teaching the patient to

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keep the nails trimmed to avoid scratching and excoriation also promotes comfort.

Monitoring Blood Pressure Hypertension in renal failure is common. It is usually the result of fluid overload and, in part, oversecretion of renin. Many patients undergoing dialysis receive some form of antihypertensive therapy and require ongoing teaching about its purpose and adverse effects. The trial-and-error approach that may be necessary to identify the most effective antihypertensive agent and dosage may confuse the patient if no explanation is provided. Antihypertensive agents must be withheld before dialysis to avoid hypotension due to the combined effect of the dialysis and the medication. Typically these patients require single or multiple antihypertensive agents to achieve normal blood pressure, thus adding to the total number of medications needed on an ongoing basis.

Preventing Infection Patients with ESRD commonly have low WBC counts (and decreased phagocytic ability), low RBC counts (anemia), and impaired platelet function. Together, these pose a high risk for infection and potential for bleeding after even minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common.

Caring for the Catheter Site Patients receiving CAPD usually know how to care for the catheter site; however, the hospital stay is an opportunity to assess catheter care technique and correct misperceptions or deviations from recommended technique. Recommended daily or three-or-four-times-weekly routine catheter site care is typically performed during showering or bathing. The exit site should not be submerged in bath water. The most common cleaning method is soap and water; liquid soap is recommended. During care, the nurse and patient need to make sure that the catheter remains secure to avoid tension and trauma. The patient may wear a gauze or semitransparent dressing over the exit site.

Administering Medications All medications and the dosage prescribed for any patient on dialysis must be closely monitored to avoid those that are toxic to the kidneys and may threaten remaining renal function. Medications are also scrutinized for potassium and magnesium content, because medications containing potassium or magnesium must be avoided. Care must be taken to evaluate all problems and symptoms that the patient reports without automatically attributing them to renal failure or to dialysis therapy.

Providing Psychological Support Patients undergoing dialysis for a while may begin to reevaluate their status, the treatment modality, their satisfaction with life, and the impact of these factors on their families and support systems. Nurses must provide opportunities for these patients to express their feelings and

reactions and to explore options. The decision to begin dialysis does not require that dialysis be continued indefinitely, and it is not uncommon for patients to consider discontinuing treatment. These feelings and reactions must be taken seriously, and the patient should have the opportunity to discuss them with the dialysis team as well as with a psychologist, psychiatrist, psychiatric nurse, trusted friend, or spiritual advisor. The patient’s informed decision about discontinuing treatment, after thoughtful deliberation, should be respected.

KIDNEY SURGERY A patient may undergo surgery to remove obstructions that affect the kidney (tumours or calculi), to insert a tube for draining the kidney (nephrostomy, ureterostomy), or to remove the kidney involved in unilateral kidney disease, renal carcinoma, or kidney transplantation.

Management of Patients Undergoing Kidney Surgery Preoperative Considerations Surgery is performed only after a thorough evaluation of renal function. Patient preparation to ensure that optimal renal function is maintained is essential. Fluids are encouraged to promote increased excretion of waste products before surgery unless contraindicated because of preexisting renal or cardiac dysfunction. If kidney infection is present preoperatively, broad-spectrum antimicrobial agents may be prescribed to prevent bacteremia. Antibiotic agents must be given with extreme care because many are toxic to the kidneys. Coagulation studies (prothrombin time, partial thromboplastin time, platelet count) may be indicated if the patient has a history of bruising and bleeding. The preoperative preparation is similar to that described in Chapter 19. Because many patients facing kidney surgery are apprehensive, the nurse encourages the patient to recognize and verbalize concerns. Confidence is reinforced by establishing a relationship of trust and by providing expert care. Patients faced with the prospect of losing a kidney may think that they will be dependent on dialysis for the rest of their lives. It is important to teach the patient and family that normal function may be maintained by a single healthy kidney.

Perioperative Concerns Renal surgery requires various patient positions to expose the surgical site adequately. Three surgical approaches are common: flank, lumbar, and thoracoabdominal (Fig. 45-9). During surgery, plans are carried out for managing altered urinary drainage. These may include inserting a nephrostomy or other drainage tube.

Postoperative Management Because the kidney is a highly vascular organ, hemorrhage and shock are the chief complications of renal surgery.

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Management of Patients With Renal Disorders

Incision Kidney

FIGURE 45-9. Patient positioning and incisional approaches (A, flank; B, lumbar; C, thoracoabdominal) for kidney surgery are associated with significant postoperative discomfort.

A Flank approach

Fluid and blood component replacement is frequently necessary in the immediate postoperative period to treat intraoperative blood loss. Abdominal distention and paralytic ileus are fairly common after renal and ureteral surgery and are thought to be due to a reflex paralysis of intestinal peristalsis and manipulation of the colon or duodenum during surgery. Abdominal distention is relieved by decompression through a nasogastric tube (see Chapter 39 for treatment of paralytic ileus). Oral fluids are permitted when the passage of flatus is noted. If infection occurs, antibiotics are prescribed after a culture reveals the causative organism. The toxic effects that antibiotic agents have on the kidneys (nephrotoxicity) must be kept in mind when assessing the patient. Lowdose heparin therapy may be initiated postoperatively to prevent thromboembolism in patients who had any type of urologic surgery.

Nursing Management In addition to those interventions listed in this section, Chart 45-12 provides a plan of nursing care for the patient undergoing kidney surgery.

Providing Immediate Postoperative Care Immediate postoperative care of the patient who has undergone surgery of the kidney includes assessment of all body systems. Respiratory and circulatory status, pain level, fluid and electrolyte status, and patency and adequacy of urinary drainage systems are assessed. RESPIRATORY STATUS. As with any surgery, the use of anesthesia increases the risk for respiratory complications. Noting the location of the surgical incision assists the nurse in anticipating respiratory problems and pain. Respiratory status is assessed by monitoring the rate, depth, and pattern of respirations. The location of the incision frequently causes pain on inspiration and coughing; therefore, the patient tends to splint the chest wall and take shallow respirations. Auscultation is performed to assess normal and adventitious breath sounds. CIRCULATORY STATUS AND BLOOD LOSS. The patient’s vital signs and arterial or central venous pressure are monitored. Skin colour and temperature and urine output pro-

Incision Kidney

B Lumbar approach

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Incision Kidney

C

Thoracoabdominal approach

vide information about circulatory status. The surgical incision and drainage tubes are observed frequently to help detect unexpected blood loss and hemorrhage. PAIN. Postoperative pain is a major problem for the patient because of the location of the surgical incision and patient’s position on the operating table to permit access to the kidney. The location and severity of pain are assessed before and after analgesic medications are administered. Abdominal distention, which increases discomfort, is also noted. URINARY DRAINAGE. Urine output and drainage from tubes inserted during surgery are monitored for amount, colour, and type or characteristics. Decreased or absent drainage is promptly reported to the physician because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines.

Monitoring and Managing Potential Complications Bleeding is a major complication of kidney surgery. If undetected and untreated it can result in hypovolemia and hemorrhagic shock. The nurse’s role is to observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Frequent monitoring of vital signs (initially monitored at least at hourly intervals) and urinary output is necessary for early detection of these complications. If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack. Bleeding may be suspected when the patient experiences fatigue and when urine output is less than 30 mL/h. As bleeding persists, late signs of hypovolemia occur, such as cool skin, flat neck veins, and change in level of consciousness or responsiveness. Transfusions of blood components are indicated, along with surgical repair of the bleeding vessel. Pneumonia may be prevented through use of an incentive spirometer, adequate pain control, and early ambulation. (text continued on page 1442)

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 45-12. Care of Patient Undergoing Kidney Surgery

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Ineffective airway clearance related to pain of high abdominal or flank incision, abdominal discomfort, and immobility; risk for ineffective breathing pattern related to high abdominal incision Goal: Improved airway clearance 1. Administer analgesic agent as prescribed. 2. Splint incision with hands or pillow to assist patient in coughing. 3. Assist patient to change positions frequently. 4. Encourage use of incentive spirometer if indicated or prescribed. 5. Assist with and encourage early ambulation.

1. Enables patient to take deep breaths and cough 2. Splints incision and promotes adequate cough and prevention of atelectasis 3. Promotes drainage and inflation of all lobes of the lungs 4. Encourages adequate deep breaths

• Takes deep breaths and coughs

5. Mobilizes pulmonary secretions

•

• • •

• • • •

adequately when encouraged and assisted Exhibits respiratory rate of 12–18 breaths/min Exhibits normal breath sounds without adventitious sounds Exhibits full thoracic excursion without shallow respirations Uses incentive spirometer with encouragement Splints incision while taking deep breaths and coughing Reports progressively less pain and discomfort with coughing and deep breaths Exhibits normal blood gas levels and chest x-ray Exhibits normal body temperature with no signs of atelectasis or pneumonia on assessment

Nursing Diagnosis: Acute pain and discomfort related to surgical incision, positioning, and stretching of muscles during kidney surgery Goal: Relief of pain and discomfort 1. Assess level of pain. 2. Administer analgesic agents as prescribed. 3. Splint incision with hands or pillow during movement or deep breathing and coughing exercises. 4. Assist and encourage early ambulation.

1. Provides baseline for later evaluation of pain relief strategies 2. Promotes pain relief 3. Minimizes sensation of pulling or tension on incision and provides sense of support to the patient 4. Promotes resumption of muscle activity exercise

• Reports relief of severe pain and discomfort

• Takes analgesia as prescribed • Exercises aching muscles within recommendations

• Uses distraction, relaxation exercises, and imagery to relieve pain

• Exhibits no behavioural manifesta-

tions of pain and discomfort (e.g., restlessness, perspiration, verbal expressions of pain) • Participates in deep breathing and coughing exercises • Gradually increases physical activity and exercise

Nursing Diagnosis: Fear and anxiety related to diagnosis, outcome of surgery, and alteration in urinary function Goal: Reduction of fear and anxiety 1. Assess patient’s anxiety and fear before surgery if possible. 2. Assess patient’s knowledge about procedure and expected surgical outcome preoperatively. 3. Evaluate the meaning of alterations resulting from surgical procedure for the patient and family or partner.

1. Provides a baseline for postoperative assessment 2. Provides a basis for further teaching

• Verbalizes reactions and feelings to staff

• Shares reactions and feelings with family or partner

3. Enables understanding of patient’s reactions and responses to expected and unexpected results of surgery

• Grieves appropriately for self and for changes in role and function

• Identifies information needed to

promote own adaptation and coping

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Plan of Nursing Care

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Management of Patients With Renal Disorders

Chart 45-12. Care of Patient Undergoing Kidney Surgery, Continued

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

4. Encourage patient to verbalize reactions, feelings, and fears.

4. Affirms patient’s understanding of and ultimate resolution of feelings and fears 5. Enables patient and partner to receive mutual support and reduces sense of isolation from each other 6. Provides support from another person who has encountered the same or a similar surgical procedure and an example of how others have coped with the alteration

• Participates in activities and events in

5. Encourage patient to share feelings with spouse or partner. 6. Offer and arrange for visit from member of support group (e.g., ostomy group, if indicated).

immediate environment

• Accepts visit from ostomy group if indicated

• Identifies support person or support group

Nursing Diagnosis: Impaired urinary elimination related to urinary drainage; risk for infection related to altered urinary drainage Goal: Maintenance of urinary elimination; infection-free urinary tract 1. Assess urinary drainage system immediately. 2. Assess adequacy of urinary output and patency of drainage system. 3. Use asepsis and hand hygiene when providing care and manipulating drainage system. 4. Maintain closed urinary drainage system. 5. If irrigation of the drainage system is necessary, use sterile gloves and sterile irrigating solution and a closed drainage and irrigation system. 6. If irrigation is necessary and prescribed, perform it gently with sterile saline and the prescribed amount of irrigating fluid. 7. Assist patient in turning and moving in bed and when ambulating to prevent displacement or inadvertent removal of urinary stent or ureteral catheters if in place. 8. Observe urine colour, volume, odour, and components. 9. Minimize trauma and manipulation of catheter, drainage system, and urethra. 10. Clean catheter gently with soap during bath, avoiding any to-andfro movement of catheter. 11. Anchor drainage tube.

12. Maintain adequate fluid intake.

1. Provides basis for further assessment and action 2. Provides baseline

• Exhibits adequate urinary output and

3. Prevents or reduces risk of contamination of urinary drainage system

• Demonstrates normal laboratory

4. Reduces risk of bacterial contamination and infection 5. Permits irrigation when necessary while maintaining closed drainage system, minimizing risk of infection

• •

6. Maintains patency of the catheter or drainage system and prevents sudden increases in pressure in the urinary tract that may cause trauma, pressure on sutures or urinary tract structures, and pain 7. Prevents trauma from accidental displacement of urinary stent or ureteral catheter necessitating repeated instrumentation of the urinary tract (e.g., cystoscopy) to replace them 8. Provides information about adequacy of urine output, condition and patency of drainage system, and debris in urine 9. Reduces risk of contamination of drainage system and eliminates site of bacterial invasion 10. Removes debris and encrustations without causing trauma to or contamination of urethra 11. Prevents movement or slipping of drainage tube, minimizing trauma to and contamination of urethra or catheter 12. Promotes adequate urine output and prevents urinary stasis

patent drainage system

• Exhibits urinary output consistent with fluid intake

• • • • • • • • • • •

values: BUN, serum creatinine levels, urine specific gravity, and osmolality Exhibits sterile urine on urine culture Exhibits clear, dilute urine without debris or encrustation in the drainage system States rationale for avoiding manipulation of catheter, drainage, or irrigation system Exhibits normal placement of urinary stent or ureteral catheters until removed by physician Maintains closed urinary drainage system Exhibits normal body temperature without signs or symptoms of urinary tract infection Cleans catheter with soap and water Consumes adequate fluid intake (six to eight glasses of water or more per day, unless contraindicated) Urinary drainage system remains in place until physician removes or discontinues it Maintains urinary drainage system without infection or obstruction Maintains urinary diversion as instructed Maintains self-care so that environment is odour-free States rationale for close follow-up and maintains recommended schedule of appointments with health care providers

continued >

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Plan of Nursing Care

Chart 45-12. Care of Patient Undergoing Kidney Surgery, Continued

NURSING INTERVENTIONS

RATIONALE

13. Assist with and encourage early ambulation while ensuring placement of urinary drainage system.

13. Minimizes cardiovascular and pulmonary complications while preventing loss, dislodging, or disruption of drainage system 14. Knowledge and understanding of the drainage system or urinary diversion are essential to prevent infection and other complications

14. If patient is to be discharged with urinary drainage system (catheter) in place or a urinary diversion, instruct patient and family member in care.

EXPECTED OUTCOMES

Nursing Diagnosis: Risk for imbalanced fluid volume related to surgical fluid loss, altered urinary output, parenteral fluid administration Goal: Normal fluid balance will be maintained 1. Weigh patient daily. 2. Take accurate intake and output measurements. 3. Place all parenteral therapy on an infusion pump. 4. Monitor amount and characteristics of urine. 5. Monitor vital signs: temperature, pulse, respirations, and blood pressure. 6. Auscultate heart and lungs every shift.

1. Daily weight is the most sensitive indicator of fluid loss or gain 2. Detects fluid retention due to poor cardiac or renal output 3. Ensures that the patient does not receive excess or insufficient intravenous fluids 4. Assists in early detection of possible complications of surgery or tube insertion 5. When fluid volume or cardiac output is altered, vital signs are affected 6. When fluid volume is increased because of poor cardiac or renal output, fluid accumulates in the lungs. Also, heart sounds change as heart failure develops; frequent auscultation ensures early detection.

Early signs of pneumonia include fever, increased heart and respiratory rates, and adventitious breath sounds. Preventing infection is the rationale for using asepsis when changing dressings and handling and preparing catheters, other drainage tubes, central venous catheters, and IV catheters for administration of fluids. Insertion sites are monitored closely for signs and symptoms of inflammation: redness, drainage, heat, and pain. Special care must be taken to prevent UTI, which is associated with the use of indwelling urinary catheters. Catheters and other invasive tubes are removed as soon as they are no longer needed. Antibiotics are commonly administered postoperatively to prevent infection. If antibiotic agents are prescribed, serum creatinine and BUN values must be monitored closely because many antibiotic agents are toxic to the kidney or can accumulate to toxic levels if renal function is decreased. Preventing fluid imbalance is critical when caring for a patient undergoing kidney surgery, because both fluid loss and fluid excess are possible adverse effects of the surgery. Fluid loss may occur during surgery as a result of excessive urinary drainage when the obstruction is removed, or it may occur if diuretic agents are used. Such loss may also

• Patient’s weight will be within 2–3 lb of patient’s baseline

• Intake that exceeds output will be detected early

• The exact amount of solution is

infused with no adverse effects resulting from overinfusion or underinfusion • Urine is clear and absent of blood, pus, or any foreign substances • Temperature, pulse, respiration, and blood pressure are normal • Normal heart and lung sounds are present

occur with GI losses, with diarrhea resulting from antibiotic use, or with nasogastric drainage. When postoperative IV therapy is inadequate to match the output or fluids lost, a fluid deficit results. Fluid excess, or overload, may result from cardiac effects of anesthesia, administration of excessive amounts of fluids, or the patient’s inability to excrete fluid because of changes in renal function. Decreased urine output may be an indication of fluid excess. Astute assessment skills are needed to detect early signs of fluid excess (such as weight gain, pedal edema, urine output below 30 mL/h, and slightly elevated pulmonary wedge pressure, if available) before they become severe (appearance of adventitious breath sounds, shortness of breath). Fluid excess may be treated with fluid restriction and administration of furosemide (Lasix) or other diuretic agents. If renal insufficiency is present, these medications may prove ineffective; therefore, dialysis may be necessary to prevent heart failure and pulmonary edema. Deep venous thrombosis (DVT) may occur postoperatively because of surgical manipulation of the iliac vessels during surgery or prolonged immobility. Antiembolism stockings are applied, and the patient is monitored closely for signs and symptoms of thrombosis and encouraged to

CHAPTER 45

exercise the legs. Heparin may be administered postoperatively to reduce the risk of thrombosis.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. If the patient has a drainage system in place, measures are taken to ensure that both the patient and family understand the importance of maintaining the system correctly at home and preventing infection. Verbal and written instructions and guidelines are provided to the patient and family at the time of hospital discharge. The patient may be asked to demonstrate management of the drainage system to ensure understanding. The importance of strategies to prevent postoperative complications (UTI and obstruction, DVT, atelectasis, and pneumonia) is stressed to the patient and family. Those signs, symptoms, problems, and questions that should be referred to the physician or other primary health care provider are reviewed by the nurse with the patient and family. CONTINUING CARE. The need for postoperative assessment and care after renal surgery continues regardless of the setting: the home, subacute care unit, outpatient clinic or office, or rehabilitation facility. Referral for home care is indicated for the patient going home with a urinary drainage system in place. During the home visit, the home care nurse reviews the instructions and guidelines given to the patient at hospital discharge. The nurse assesses the patient’s ability to carry out the instructions in the home and answers questions that the patient or family has about management of the drainage system and the surgical incision. In addition, the home care nurse obtains vital signs and assesses the patient for signs and symptoms of UTI and obstruction. The nurse also ensures that pain is adequately controlled and that the patient is complying with recommendations. The home care nurse encourages adequate fluid intake and increased levels of activity. Together the nurse, patient, and family review the signs, symptoms, problems, and questions that should be referred to the physician or other primary health care provider. If the patient has a drainage tube in place, the nurse assesses the site and the patency of the system and monitors the patient for complications, such as DVT, bleeding, or pneumonia. Because it is easy for the patient, family, and health care team to focus on the patient’s immediate disorder to the exclusion of other health issues, the nurse reminds the patient and family about the importance of participating in health promotion activities, including health screening.

KIDNEY TRANSPLANTATION Kidney transplantation has become the treatment of choice for most patients with ESRD. At the end of 2012, 1,358 Canadians underwent kidney transplantation: 713 from deceased donors and 392 from living donors. Another 3,428 were waiting for a kidney transplant in 2012 (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014). 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.

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CHART 45-13

Kidney 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 on renewal.

In addition, the cost of maintaining a successful transplantation is one third the cost of dialysis treatment. Kidney transplantation is an elective procedure, not an emergency life-saving procedure. Therefore, patients should be in the best possible condition prior to transplantation. Kidney transplantation involves transplanting a kidney from a living donor or deceased donor to a recipient who no longer has renal function (Chart 45-13). A living donor is a person who is alive at the time of donation and may or may not be related to the recipient. A deceased or cadaveric transplant comes from someone who has died and donated his or her organs. Transplantation from wellmatched living donors who are related to the patient (those with compatible ABO and human leukocyte antigens) is slightly more successful than from cadaver donors. Prior to either receiving or donating an organ, an extensive medical evaluation is performed. Not everyone is suitable for a kidney transplant. Contraindications include recent malignancy, active or chronic infection, severe irreversible extrarenal disease (e.g., inoperable cardiac disease, chronic lung disease, severe peripheral vascular disease), active autoimmune disease (e.g., HIV, hepatitis B and C), morbid obesity (body mass index greater than 35), current substance abuse, inability to give informed consent, and history of nonadherence to treatment regimens. Donors may be rejected for the same reasons or any condition that is determined to have an impact on the remaining kidney. Examples include hypertension and diabetes mellitus since both are known causes of renal disease. It is imperative when donors are evaluated that serious consideration be given to the overall long-term health of the donor. Every precaution must be taken to ensure that the remaining kidney in the donor will remain healthy. If these conditions are met, the donor should remain healthy after donation and have a normal lifespan. Since one kidney can easily handle the body’s needs, no longterm adjustments will need to be made. The patient’s native kidneys are not usually removed. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest because it allows for easier access to the blood supply needed to perfuse the kidney.

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Inferior vena cava

Aorta

Diseased kidney Adrenal gland remains intact Renal artery and vein tied off

Adrenal gland Ureter

1. Transplanted donor kidney cradled in ilium 2. Renal artery sutured to iliac artery Renal vein sutured to iliac vein 3. Ureter sutured

The ureter of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient (Fig. 45-10). Once the blood supply has been reestablished to the transplanted kidney in the operating room, urine should begin to flow. The production of urine at this stage is an important indicator of the overall success of the procedure and ultimate long-term outcome.

Preoperative 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.

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 medications to prevent transplant rejection will be prescribed. 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 obtain because psychiatric conditions are often aggravated

Ilium Internal iliac artery Inguinal ligament

FIGURE 45-10. Renal transplantation: 1, The transplanted kidney is placed in the iliac fossa. 2, The renal artery of the donated kidney is sutured to the ileac artery, and the renal vein is sutured to the iliac vein. 3, The ureter of the donated kidney is sutured to the bladder or to the patient’s ureter.

by the corticosteroids needed for immunosuppression after transplantation. If a dialysis routine has been established, hemodialysis is often performed the day before the scheduled transplantation procedure to optimize the patient’s physical status.

Nursing Management The nursing aspects of preoperative care for the patient undergoing renal transplant are similar to those for patients undergoing other types of kidney or 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, IV 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.

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 favourable prognosis than the patient whose kidney does not.

Medical Management After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute),

CHAPTER 45

or after many years. The long-term survival of a transplanted kidney depends on how well it matches the recipient and how well the body’s immune response is controlled. Since the body’s immune system views the transplanted kidney as “foreign,” it continually works to reject it. To overcome or minimize the body’s defense mechanisms, immunosuppressive agents are administered. Optimally, medications modify the immune system enough to prevent rejection, but not enough to allow infections or malignancies to occur. Combinations of glucocorticoids and medications specifically developed to affect the action of lymphocytes are used to minimize the body’s reaction to the transplanted organ. Treatment with combinations of new agents has dramatically improved survival rates, and now 90% to 95% of transplanted kidneys still function after 1 year (American Nephrology Nurses Association, 2007b). Doses of immunosuppressive agents are often adjusted depending on the patient’s immunologic response to the transplant. However, the patient will be required to take some form of immunosuppressive therapy for the entire time that he or she has the transplanted kidney.

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). PREVENTING INFECTION. The results of blood chemistry tests 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. Clinical manifestations of infection include shaking chills, fever, rapid heartbeat (tachycardia), and respirations (tachypnea), as well as either an increase or a decrease in WBCs (leukocytosis or leukopenia). 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 tip in a sterile container to be taken to the laboratory for culture (Chart 45-14). The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with active infections. Attention to hand hygiene by all who come in contact with the patient is imperative. MONITORING URINARY FUNCTION. A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large

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CHART 45-14

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 vs. 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 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 (Danovitch, 2005).

quantities of dilute urine. A kidney from a cadaver donor may undergo ATN 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. IV fluids are administered on the basis of urine volume and serum electrolyte levels and as prescribed by the physician. Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well. It may also be required if fluid overload and hyperkalemia occur. After successful renal transplantation, the vascular access device may clot, possibly from improved coagulation with the return of renal function. The vascular access for hemodialysis is monitored to ensure patency and to evaluate for evidence of infection. ADDRESSING PSYCHOLOGICAL CONCERNS. The rejection of a transplanted kidney is of great concern to the patient, the family, and the health care team for many months. The fear of kidney rejection and the complications of immunosuppressive therapy (Cushing’s syndrome, diabetes, capillary fragility, osteoporosis, glaucoma, cataracts, acne, nephrotoxicity) place tremendous psychological stress on the patient. Anxiety and uncertainty about the

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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 adhering to the prescribed medication regimen. If indicated or requested, the nurse refers the patient for counselling. 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 effects of long-standing renal failure and its treatment. Therefore, careful assessment for the complications related to renal failure and those associated with a major surgery are important aspects of nursing care. Breathing exercises, early ambulation, and 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. 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 immunosuppressive therapy as prescribed. In addition, the patient and family are instructed to assess for and report signs and symptoms of transplant rejection, infection, or significant adverse effects of the immunosuppressive 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. The patient is instructed to inform other health care providers (e.g., 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 I&O, prevention of infection, resumption of activity, and avoidance of contact sports in which the transplanted kidney may be injured. Because of the risk for other potential complications, the patient is followed closely. Cardiovascular disease is the major cause of morbidity and mortality after transplantation, due in part to the increasing age of patients with transplants. An additional problem is possible malignancy; patients receiving longterm immunosuppressive therapy are at higher risk for cancers than the general population. So the patient is reminded of the importance of health promotion and health screening. The Kidney Foundation of Canada and its provincial branches provide information and support to patients with kidney disease and their families.

It can provide many helpful suggestions for patients and family members learning to cope with dialysis and transplantation.

RENAL TRAUMA 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 kidneys 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. 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. Injuries may be blunt (automobile and motorcycle crashes, falls, athletic injuries, assaults) or penetrating (gunshot wounds, stabbings). Blunt renal trauma accounts for 80% to 90% of all renal injuries; penetrating renal trauma accounts for the remaining 10% to 20%. 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. 45-11). The kidneys receive half of the blood 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. In some cases, there is an isolated renal artery thrombosis. 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.

Medical Management The goals of management in patients with renal trauma are to control hemorrhage, pain, and infection as well as to preserve and restore renal function. All urine is saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Hematocrit and hemoglobin

CHAPTER 45

Expanding hematoma may cause rupture, extravasation, exsanguination

Pedicle injury; may cause ischemic necrosis of kidney

Contusion Bleeding into collecting system, shock Laceration

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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.

Nursing Management

Blood in urine FIGURE 45-11. Types and pathophysiologic effects of renal injuries: contusions, lacerations, rupture, and pedicle injury.

levels are monitored closely; decreasing values indicate hemorrhage. 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 pen 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 a contusion of the kidney, healing may take place with conservative measures. If the patient has microscopic hematuria and a normal IV urogram, outpatient management is possible. If gross hematuria or a minor laceration is present, the patient is hospitalized and kept on bed rest until the 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 suggests hemorrhage and requires rapid surgical intervention. Depending on the patient’s condition and

The patient with renal trauma must 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, the patient who has undergone surgery is 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 gradually increasing activity, 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, BUN and serum creatinine analyses). If a nephrectomy was necessary, the patient is advised to wear medical identification.

Critical Thinking Exercises 1 You are a staff nurse in an outpatient dialysis facility. A 50-year-old woman with ESRD is scheduled to be seen in the clinic; it is anticipated that she will need dialysis in the near future. The patient lives alone and will require teaching about the dialysis options. Develop a teaching plan to explain the different types of dialysis, goals, and level of involvement on the part of the patient. 2 A 45-year-old married man visits the nephrology department to discuss options for dealing with his ESRD. His brother has begun the workup to donate one of his kidneys and the preliminary reports show that a match is possible. The patient states that he does not want his brother to go through the process of kidney donation if dialysis is possible. Identify the evidence for and the criteria used to evaluate the strength of the evidence for dialysis compared to kidney transplantation.

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3 You are caring for a 35-year-old woman who has been recently diagnosed with renal cancer. Identify possible treatment options. What nursing assessment and interventions should you make at this time? What explanations would you give the patient about renal cancer?

Kopp, J. B. (2013). Rethinking hypertensive kidney disease: Arterionephrosclerosis as a genetic, metabolic, & inflammatory disorder. Current Opinion in Nephrology & Hypertension, 22(3), 266–272. Mosenkis, A., Kirk, D., & Berns, J. S. (2006). When chronic kidney disease becomes advanced. Postgraduate Medicine, 110(1), 83–91.

4 A 55-year-old man who is blind has just had a catheter placed for PD. His wife, his primary caretaker, is deaf. Develop a teaching plan to explain peritoneal dialysis, goals, and level of involvement to the patient and family.

Ali, B., & Gray-Vickrey, P. (2011). Limiting the damage from acute kidney injury. Nursing, 41(3), 22–31. Barreto, R. (2007). Prevention of contrast induced nephropathy. The rational use of sodium bicarbonate. Nephrology Nursing Journal, 34(4), 417–421. Dennen, P., Douglas, I. S., & Anderson, R. (2010). Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Critical Care Medicine, 38(1), 261–275. Dirkes, S. (2011). Acute kidney injury. Not just acute renal failure anymore? Critical Care Nurse, 31(1), 37–50. Ejaz, A. A., & Mohandas, R. (2014). Are diuretics harmful in the management of acute kidney injury? Current Opinion in Nephrology & Hypertension, 23(3), 155–160. Isaac, S. (2012). Contrast-induced nephropathy: Nursing implications. Critical Care Nurse, 32(3), 41–48. Jorgensen, A. L. (2013). Contrast-induced nephropathy: Pathophysiology & preventive strategies. Critical Care Nurse, 33(1), 37–47. Warise, L. (2010). Update: Diuretic therapy in acute renal failure-a clinical case study. MEDSURG Nursing, 19 (3), 149–152. Yaklin, K. M. (2011). Acute kidney injury: An overview of pathophysiology & treatments. Nephrology Nursing Journal, 38(1), 13–30.

REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS Danovitch, G. M. (2005). Handbook of kidney transplantation. Philadelphia, PA: Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Holcombe, D. M., & Kern Feely, N. (2013). Renal failure. In P. G. Morton, & D. K. Fontaine (Eds). Critical care nursing a holistic approach (10th ed., pp. 663–690). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Mount, D.B., & Zandi-Nejad, K. (2012). Disorders of potassium balance. In M. W. Taal, G. M. Chertow, P. A. Marsden, K. Skorecki, A. S. Yu, & B. M. Brenner (Eds.), Brenner & Rector’s the kidney (9th ed., pp. 640–688). Philadelphia, PA: Elsevier. Muzzy, A. C., & Snyder, K. A. (2013). Patient management: Renal system. In P. G. Morton, & D. K. Fontaine (Eds.), Critical care nursing a holistic approach (10th ed., pp. 637–662). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Mentes, J. C. (2013). The complexities of hydration issues in the elderly. Nutrition Today, 48(4S), S10–S12. Perico, N., Remuzzi, G., Benigni, A. (2011). Aging and the kidney. Current Opinion in Nephrology & Hypertension, 20, 312–317. Chronic Kidney Disease Canadian Institute for Health Information (CIHI). (2013). Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2003 to 2012. Ottawa: Author. Retrieved from https:// secure.cihi.ca/free_products/2014_CORR_Annual_Report_EN.pdf Canadian Organ Replacement Register/Canadian Institute for Health Information. (2014). CORR Annual Report:Treatment of End-Stage Organ Failure in Canada 2003–2012, 1–143. Retrieved from https:// secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2481 Castner, D. (2010). Understanding the stages of chronic kidney disease, Nursing, 40(5), 25–31. Elliot, M. J., Ronksley, P. E., Clase, C. M., et al. (2010). Management of patients with acute hyperkalemia, Canadian Medical Association Journal, 182(15), 1631–1635. Gosmanov, A. R., Wall, B. M., & Gosmanova, E. O. (2014). Diagnosis & treatment of diabetic kidney disease. The American Journal of the Medical Sciences, 0(0), 1–8. Kidney Disease Improving Global Outcomes (KDIGO). (2012). Clinical practice guideline for the evaluation & management of chronic kidney disease. Kidney International Supplement, 2013, 3(1), 1–150. Retrieved from www.kidney-international.org

Acute Renal Failure

Renal Carcinoma American Cancer Society. (2009). Cancer facts and figures: 2009. Available at: www.cancer.org Aschenbrenner, D. S. (2007). Drug watch. American Journal of Nursing, 107 (11), 25–26. Canadian Cancer Society. (2014). Signs and symptoms of kidney cancer. Retrieved from http://www.cancer.ca/en/cancer-information/ cancer-type/kidney/signs-and-symptoms/?region=on Canadian Cancer Society’s Steering Committee. (2013). Canadian Cancer Statistics 2013. Toronto: Canadian Cancer Society. Cohen, H. T., & McGovern, F. J. (2005). Renal-cell carcinoma. New England Journal of Medicine, 353(23), 2477–2490. Wood, L. S. (2010). New therapeutic strategies for renal cell carcinoma, Urologic Nursing, 30(1), 40–53. Chronic Renal Failure Bhan, I. (2014). Phosphate management in chronic kidney disease. Current Opinion in Nephrology & Hypertension, 23(2), 174–179. Bidani, A. K., Poliochnowski, A. J., Loutzenhiser, R., et al. (2013). Renal microvascular dysfunction, hypertension, & CKD progression. Current Opinion in Nephrology & Hypertension, 22(1), 1–9. Broscious, S. K., Castagnola, J. (2006). Chronic kidney disease: Acute manifestations and role of critical care nurses. Critical Care Nurse, 26(4), 17–20, & 22–27. Dutka, P. (2012). Erythropoiesis-stimulating agents for the management of anemia of chronic kidney disease: Past advancements and current innovations. Nephrology Nursing Journal, 39 (6), 447–457. Kane, P. M., Vinen, K., & Murtagh, F. E. (2013). Palliative care for advance renal disease: A summary of the evidence and future direction, Palliative Medicine, 27 (9), 817–821. Lane, B. R., Demirjian, S., Derweesh, I. H., et al. (2014). Is all chronic kidney disease created equal? Current Opinion in Urology, 24(20), 127–134. Schreiber, M. (2013a). Fluids and electrolytes: The highs and lows of potassium. Nursing 2013 Critical Care, 8(4), 8–13. Schreiber, M. (2013b). Understanding hyponatremia. Nursing 2013 Critical Care, 8(2), 8–10. Vasundhara, M., Kozman, H., Liu, K., et al. (2014). Cardiac troponins: Bench to bedside interpretation in cardiac disease. The American Journal of Medical Sciences, 347 (4), 331–337. Zuber, K., Liles, A. M., & Davies, J. (2013). Medication dosing in patients with chronic kidney disease. Journal of American Academy of Physician Assistants, 26(10), 19–25. Renal Replacement Therapies Castner, D. (2011). Management of patients on hemodialysis before, during, and after hospitalization:Challenges and suggestions for improvement. Nephrology Nursing Journal, 38(4), 319–330.

CHAPTER 45 Horigan, A., Rocchiccioli, J., & Trimm, D. (2012). Dialysis and fatigue: Implications for Nurses-a case study analysis. Medsurg Nursing, 21(3), 158–175. *Ka yee Chow, S., & Wong, F. K. (2010). Health-related quality of life in patients undergoing peritoneal dialysis: Effects of a nurse-led case management programme. Journal of Advanced Nursing, 66(8), 1780–1792. Martin, R. K., & Jurschak, J. (2007). Nursing management of continuous renal replacement therapy. Seminars in Dialysis, 9 (2), 192–199. Peters, A. (2014). Safety issues in home dialysis. Nephrology Nursing Journal, 41(1), 89–92. Richard, C. J. (2011). Preservation of vascular access for hemodialysis in acute care settings, Critical Care Nursing, 34(1), 76–83. Roeder, V. R., Atkins, H. N., Ryan, M., et al. (2013). Putting the C back into continuous renal replacement therapy. Nephrology Nursing Journal, 40(6), 509–516. Welch, J. L., & Perkins, S. M. (2006). Patterns of interdialytic weight gain during the first year of hemodialysis. Nephrology Nursing Journal, 33(5), 493–498. Kidney Transplantation American Nephrology Nurses Association (2007b). Chronic kidney disease. What every nurse should know. Module 6: The post transplant patient. Pitman, NJ. Author

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Gill, J. S. (2011). Managing patients with a failed kidney transplant: How can we do better? Current Opinion in Nephrology & Hypertension, 20(6), 616–621. Kim, S. P., & Thompson, R. H. (2013). Kidney function after partial nephrectomy: Current thinking. Current Opinion in Urology, 23(2), 105–111. Morgan, A., Scott, A., & Darbyshire, P. (2010). Waiting for kidney transplant: Patient’s experiences of hemodialysis therapy. Journal of Advanced Nursing, 67 (3), 501–509. Nierste, D. (2013). Issues in organ procurement, allocation, & transplantation. Journal of Christian Nursing, 30(2), 80–87. Russell, C. L. (2013). Optimal care for kidney transplant recipients. OR Nurse, 7 (1), 36–40.

RESOURCES Canadian Cancer Society www.cancer.ca Canadian Society of Nephrology www.csnscn.ca/ Canadian Society of Transplantation www.cst-transplant.ca Canadian Urological Association http://www.uroinfo.ca/ Polycystic Kidney Disease Foundation of Canada www.endpkd.ca/ Kidney Foundation of Canada http://www.kidney.ca/ Kidney Cancer Research Network of Canada www.ncbi.nlm.nih.gov/ entrez/query.fcgi?db=OMIM

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46 Management of Patients With Urinary Disorders Adapted by Kathryn Martin

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify factors contributing to upper and lower urinary tract infections. 2. Use the nursing process as a framework for care of the patient with a urinary tract infection. 3. Differentiate between the various adult dysfunctional voiding patterns. 4. Develop a patient education plan for a patient who has mixed (stress and urge) urinary incontinence. 5. Identify potential causes of an obstruction of the urinary tract and management of the patient with this condition. 6. Develop a teaching plan for the patient undergoing treatment for renal calculi (kidney stones). 7. Formulate preoperative and postoperative nursing diagnoses for the patient undergoing surgery for urinary diversion.

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The urinary system is responsible for providing the route for drainage of urine formed by the kidneys. The field of urologic nursing requires an understanding of the anatomy, physiology, diagnostic testing, nursing care, and rehabilitation of patients with multiple processes that interfere with the urinary system. Nurses care for patients with urologic disorders in all settings. This chapter focuses on the nursing management of patients with common urinary dysfunctions, including infections, dysfunctional voiding patterns, urolithiasis, genitourinary trauma, cancer of the urinary tract, and urinary diversions.

INFECTIONS OF THE URINARY TRACT Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally

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classified as infections involving the upper or lower urinary tract (Chart 46-1). Lower UTIs include bacterial cystitis (inflammation of the urinary bladder), bacterial prostatitis (inflammation of the prostate gland), and bacterial urethritis (inflammation of the urethra). There can be acute or chronic nonbacterial causes of inflammation in any of these areas that can be misdiagnosed as bacterial infections. Upper UTIs are much less common and include acute or chronic pyelonephritis (inflammation of the renal pelvis), interstitial nephritis (inflammation of the kidney), and renal abscesses. Upper and lower UTIs are further classified as uncomplicated or complicated, depending on other patient-related conditions (e.g., whether the UTI is recurrent and the duration of the infection). Most uncomplicated UTIs are community acquired. Complicated UTIs usually occur in people with urologic abnormalities or recent catheterization and are often hospital acquired. A UTI is the second most common reason patients seek out health care (Hannon, Pooler, & Porth, 2010). Women are more likely to develop a UTI than men; over 500,000 Canadian women visit the doctor each

Glossary bacteriuria: more than 105 colonies of bacteria per millilitre of urine continent urinary diversion (Kock or Charleston pouch): transplantation of the ureters to a segment of bowel with construction of an effective continence mechanism or valve Charleston pouch: uses the ileum and ascending colon as the pouch, with the appendix and colon junction serving as the one-way valve mechanism cystectomy: removal of the urinary bladder cystitis: inflammation of the urinary bladder dysuria: painful or difficult urination frequency: voiding more often than every 3 hours functional incontinence: physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding iatrogenic incontinence: the involuntary loss of urine due to extrinsic medical factors, predominantly medications ileal conduit: transplantation of the ureters to an isolated section of the terminal ileum, with one end of the ureters brought to the abdominal wall interstitial cystitis: inflammation of the bladder wall that eventually causes disintegration of the lining and loss of bladder elasticity interstitial nephritis: inflammation of the kidney Kock pouch: U-shaped pouch constructed of ileum, with a nipple-like one-way valve micturition: voiding or urination mixed incontinence: a combination of stress and urge incontinence neurogenic bladder: bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity, resulting in urinary urgency and urge incontinence nocturia: awakening at night to urinate

overflow incontinence: involuntary urine loss associated with overdistention of the bladder due to mechanical or anatomic bladder outlet obstruction prostatitis: inflammation of the prostate gland pyelonephritis: inflammation of the renal pelvis pyuria: white blood cells in the urine reflex incontinence: involuntary loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations; usually associated with micturition (voiding) residual urine: urine that remains in the bladder after voiding stress incontinence: involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure suprapubic catheter: a urinary catheter that is inserted through a suprapubic incision into the bladder urge incontinence: involuntary loss of urine associated with urinary urgency due to hypersensory disorders of the bladder, motor instability, or both urinary incontinence: involuntary or uncontrolled loss of urine from the bladder sufficient to cause a social or hygienic problem urethritis: inflammation of the urethra ureterosigmoidostomy: transplantation of the ureters into the sigmoid colon, allowing urine to flow through the colon and out the rectum ureterovesical or vesicoureteral reflux: backward flow of urine from the bladder into one or both ureters urethrovesical reflux: backward flow of urine from the urethra into the bladder urosepsis: sepsis resulting from infected urine, most often a urinary tract infection wound care specialist: a nurse specially educated in appropriate skin, wound, ostomy, and continence care; often referred to as an enterostomal therapist or a wound-ostomy-continence nurse (WOCN)

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CHART 46-2

CHART 46-1

Risk Factors for Urinary Tract Infection

Classifying Urinary Tract Infections Urinary tract infections (UTIs) are classified by location: the lower urinary tract (which includes the bladder and structures below the bladder) or the upper urinary tract (which includes the kidneys and ureters). They can also be classified as uncomplicated or complicated UTIs.

• Inability or failure to empty the bladder completely • Obstructed urinary flow

Lower UTIs Cystitis, prostatitis, urethritis

Upper UTIs Acute pyelonephritis, chronic pyelonephritis, renal abscess, interstitial nephritis, perirenal abscess

• •

Uncomplicated Lower or Upper UTIs

• •

Community-acquired infection; common in young women and not usually recurrent

Complicated Lower or Upper UTIs Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent

year because of a UTI (Kidney Foundation of Canada, 2007). Population-based research in Canada reflects an annual incidence of community onset UTIs of 17.5 per 1,000. Women, as well as the very old and the very young, are at increased risk. The most common organisms identified were Escherichia coli, Klebsiella pneumoniae, and Enterococcus sp. (Laupland, Ross, Pitout, et al., 2007). The urinary tract is also the most common site of nosocomial infection. In most of these hospital-acquired UTIs, instrumentation of the urinary tract or catheterization is the precipitating cause.

Lower Urinary Tract Infections Several mechanisms maintain the sterility of the bladder: the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and antiadherent effects mediated by the mucosal cells of the bladder. Abnormalities or dysfunctions of these mechanisms are contributing factors to lower UTIs (Chart 46-2).

Pathophysiology For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation (Moore, Day, & Albers, 2002). Most UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.

Bacterial Invasion of the Urinary Tract By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder can

Congenital abnormalities Urethral strictures Contracture of the bladder neck Bladder tumours Calculi (stones) in the ureters or kidneys Compression of the ureters Neurologic abnormalities Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in the urinary tract) Pregnancy Neurologic disorders Gout Altered states caused by incomplete emptying of the bladder and urinary stasis

clear itself of even large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and tryptophan metabolites). The normal bacterial flora of the vagina and urethral area also interfere with adherence of E. coli (the most common microorganism causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria.

Reflux An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder (Fig. 46-1). With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection in postmenopausal women. Reflux is most often noted, however, in young children. Treatment is based on its severity. Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into one or both ureters (Fig. 46-1). Normally, the ureterovesical junction prevents urine from travelling back into the ureter. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter

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Management of Patients With Urinary Disorders

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Routes of Infection

A

B

C

D

There are three well-recognized routes by which bacteria enter the urinary tract: up the urethra (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension). The most common route of infection is transurethral, in which bacteria (often from fecal contamination) colonize the periurethral area and subsequently enter the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uropathogenic bacteria (Hannon, Pooler, & Porth, 2010). Sexual intercourse or massage of the urethra forces the bacteria up into the bladder. This accounts for the increased incidence of UTIs in sexually active women. Bacteria may also enter the urinary tract by means of the blood (hematogenous spread) from a distant site of infection or through direct extension by way of a fistula from the intestinal tract.

Clinical Manifestations FIGURE 46-1. Mechanisms of urethrovesical and ureterovesical reflux

may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A: When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine.

during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and eventually destroy them (Hannon, Pooler, & Porth, 2010).

Uropathogenic Bacteria Bacteriuria is generally defined as more than 105 colonies of bacteria per millilitre of urine. Since urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch midstream urine is the measure that distinguishes true bacteriuria from contamination. In men, contamination of the collected urine sample occurs less frequently; hence, bacteriuria can be defined as 104 colonies/mL urine. Community-acquired UTIs are among the most common bacterial infections in women (Hannon, Pooler, & Porth, 2010). The organisms most frequently responsible for UTIs are those normally found in the lower gastrointestinal (GI) tract. In a large-scale study of the types and prevalence of organisms of patients with UTIs in both the community and hospital setting, E. coli was responsible for 54.7% of UTIs. Isolation of E. coli is decreasing in comparison to previous observations, especially in males and in patients with indwelling bladder catheters, who instead had higher rates of Pseudomonas and Enterococcus organisms than females and noncatheterized patients (Hannon, Pooler, & Porth, 2010).

A variety of signs and symptoms are associated with UTI. About half of all patients with bacteriuria have no symptoms. Signs and symptoms of uncomplicated lower UTI (cystitis) include frequent pain and burning on urination, frequency, urgency, nocturia, incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present (Stephen, Skillen, Day, et al., 2010). In older individuals, these symptoms are less common (see Gerontologic Considerations). Signs and symptoms of upper UTI (pyelonephritis) include fever, chills, flank or low back pain, nausea and vomiting, headache, malaise, and painful urination. Physical examination for tenderness begins by palpating with the fingertips over the area of the costovertebral angles, which are the angles formed on each side of the body by the bottom rib of the rib cage and the vertebral column (see Fig. 44-6 in Chapter 44). This will be enough pressure to detect tenderness or pain in some patients. If no pain is elicited, the examiner places the ball of one hand over each costovertebral angle in turn and strikes that hand with the ulnar side of the other fist, hard enough to jar the patient. In patients with complicated UTIs, such as those with indwelling catheters, manifestations can range from asymptomatic bacteriuria to a gram-negative sepsis with shock. Complicated UTIs are often due to a broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients with catheter-associated UTIs are asymptomatic; however, any patient who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis.

Gerontologic Considerations The incidence of bacteriuria in the older adult differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common cause of acute bacterial sepsis in patients older than 65 years of age, in whom gram-negative sepsis carries a mortality rate exceeding 50%. Urologists see many asymptomatic older patients

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with bacteriuria, and these individuals represent 20% of women over the age of 65 years. In the nursing home environment, up to 50% of women have asymptomatic bacteriuria (Goldrick, 2005). In the older adult population at large, structural abnormalities secondary to decreased bladder tone and neurogenic bladder (dysfunctional bladder) secondary to stroke or autonomic neuropathy of diabetes may prevent complete emptying of the bladder and increase the risk for UTI (Morton, Fontaine, Hudak, et al., 2005). When indwelling catheters are used, the risk for UTI increases dramatically. Older adult women often have incomplete emptying of the bladder and urinary stasis. In the absence of estrogen, following menopause, women are susceptible to colonization and increased adherence of bacteria to the vagina and urethra. Oral or topical estrogen has been used to restore the glycogen content of vaginal epithelial cells and an acidic pH for some of these women with recurrent cystitis. The antibacterial activity of prostatic secretions that protects men from bacterial colonization of the urethra and bladder decreases with aging. Although UTIs are rare in men, the prevalence of infection in men older than 50 years of age approaches that of women in the same age group. The dramatic rise in UTI in men as they age is due largely to prostatic hyperplasia or carcinoma, strictures of the urethra, and neuropathic bladder. The use of catheterization or cystoscopy in evaluation or treatment may contribute further to the higher incidence of UTI. The incidence of bacteriuria rises in men with confusion, dementia, or bowel or bladder incontinence. The most common cause of recurrent UTI in the older male patient is chronic bacterial prostatitis. Resection of the prostate gland may help to reduce its incidence (see Chapter 50). In older patients in institutions, such as those in longterm care facilities, infecting pathogens are often resistant to many antibiotics. Factors that may contribute to UTI include high incidence of chronic illness; frequent use of antimicrobial agents; infected pressure ulcers; immobility and incomplete emptying of the bladder; and use of a bedpan rather than a commode or toilet (Chart 46-3). Diligent hand hygiene, careful perineal care, and frequent toileting may decrease the incidence of UTIs. The organisms responsible for UTIs in the older adult in longterm care facilities may differ from those found in patients residing in the community; this is thought to be due in

CHART 46-3

Gerontologic Considerations Factors That Contribute to Urinary Tract Infection in Older Adults • • • • • • •

High incidence of chronic illness Frequent use of antimicrobial agents Presence of infected pressure ulcers Immunocompromise Cognitive impairment Immobility and incomplete emptying of bladder Use of a bedpan rather than a commode or toilet

part to the frequent use of antibiotic agents by patients in these facilities. E. coli is the most common organism seen in older patients in the community or hospital. Patients with indwelling catheters, however, are more likely to be infected with Proteus, Klebsiella, Pseudomonas, or Staphylococcus sp. Patients who have been previously treated with antibiotics may be infected with Enterococcus sp. Frequent reinfections are common in older adults. The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these patients usually exhibit even more profound cognitive changes with the onset of a UTI. Controversy continues about the need for treatment of asymptomatic bacteriuria in older patients in long-term care facilities, because resulting antibiotic-resistant organisms and sepsis may be greater threats to patients. Most experts now recommend withholding antibiotics unless symptoms develop. However, treatment regimens are generally the same as those for younger adults, although age-related changes in the intestinal absorption of medications and decreased renal function and hepatic flow may necessitate alterations in the antimicrobial regimen. Renal function must be monitored, and medication dosages should be altered accordingly.

!

NURSING ALERT

Older adult patients often lack the typical symptoms of UTI and sepsis. Although frequency, urgency, and dysuria may occur, nonspecific symptoms, such as altered sensorium, lethargy, anorexia, new incontinence, hyperventilation, and low-grade fever, may be the only clues.

Assessment and Diagnostic Findings Results of various tests, such as colony counts, cellular studies, and urine cultures, help to confirm the diagnosis of UTI. Pregnant women are generally screened for asymptomatic bacteriuria because the bladder may not empty as well as it usually does. In an uncomplicated UTI, the strain of bacteria will determine the antibiotic of choice.

Colony Counts UTI is diagnosed by bacteria in the urine. A colony count of at least 105 colony-forming units (CFU) per millilitre of urine on a clean-catch midstream or catheterized specimen is a major criterion for infection (Hannon, Pooler, & Porth, 2010). However, UTI and subsequent sepsis have occurred with lower bacterial colony counts. About one third of women with symptoms of acute infections have negative midstream urine culture results and may go untreated if 105 CFU/mL is used as the criterion for infection. The presence of any bacteria in specimens obtained by suprapubic needle aspiration of the urinary bladder or catheterization is considered indicative of infection.

CHAPTER 46

The following groups of patients should have urine cultures obtained when bacteriuria is present: • All men (because of the likelihood of structural or functional abnormalities) • All children • Women with a history of compromised immune function or renal problems • Patients with diabetes mellitus • Patients who have undergone recent instrumentation (including catheterization) of the urinary tract • Patients who were recently hospitalized or who live in long-term care facilities • Patients with prolonged or persistent symptoms • Patients with three or more UTIs in the past year • Pregnant women • Women following menopause • Women who are sexually active or have new sexual partners

Cellular Studies Microscopic hematuria (greater than 4 red blood cells [RBCs] per high-power field) is present in about half of patients with acute infection. Pyuria (greater than 4 white blood cells [WBCs] per high-power field) occurs in all patients with UTI; however, it is not specific for bacterial infection. Pyuria can also be seen with kidney stones, interstitial nephritis, and renal tuberculosis.

Urine Cultures Urine cultures remain the gold standard in documenting a UTI and can identify the specific organism present. Due to the high probability that the organism in young women with their first UTI is E. coli, cultures are often omitted.

Testing Methods Multistrip dipstick testing for WBCs, known as the leukocyte esterase test, and nitrite testing (nitrate reduction test) are common. If the leukocyte esterase test is positive, it is assumed that the patient has pyuria (WBCs in the urine) and should be treated. The nitrate reduction test is considered positive if bacteria that reduce normal urinary nitrates to nitrites are present. Tests for sexually transmitted infections (STIs) may be performed because acute urethritis caused by sexually transmitted organisms (i.e., Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex) or acute vaginitis infections (caused by Trichomonas or Candida sp.) may be responsible for symptoms similar to those of UTI. Therefore, evaluation for STIs may be performed (see Chapter 71). Diagnostic studies such as computed tomography (CT) and ultrasonography are useful diagnostic tools. A CT scan may detect pyelonephritis or abscesses, and ultrasonography is extremely sensitive for detecting obstruction, abscesses, tumours, and cysts. Transrectal ultrasonography (to assess the prostate and bladder) is the procedure of choice for men with recurrent or complicated UTIs. A cystourethroscopy may be indicated to visualize the ureters or to detect strictures, calculi, or tumours (Karpoff & Labus, 2008).

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Management of Patients With Urinary Disorders

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Medical Management Management of UTIs typically involves pharmacologic therapy and patient education. The nurse is a key figure in teaching the patient about medication regimens and infection prevention measures.

Acute Pharmacologic Therapy The ideal treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. (Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents that affect vaginal flora. Yeast vaginitis often causes more symptoms and is more difficult and costly to treat than the original UTI.) In addition, the antibacterial agent should be affordable and should produce few adverse effects and low resistance. Since the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3 to 4 days) medication regimens, or 7- to 10-day therapeutic courses. The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs because most are cured after 3 days of treatment. In a complicated UTI (i.e., pyelonephritis), the general treatment of choice is usually a cephalosporin or an ampicillin/aminoglycoside combination. Patients in institutional settings may require 7 to 10 days of medication for the treatment to be effective. Other commonly used medications include trimethoprim/sulfamethoxazole (TMPSMZ, Bactrim, Septra) and nitrofurantoin (Macrodantin, Furantoin). Occasionally, medications such as ampicillin or amoxicillin are used, but E. coli organisms have developed resistance to these agents. Because of the problem of resistance, the fluoroquinolone ciprofloxacin (Cipro) is often used as a first-line agent (Mehnert-Kay, 2005). Nitrofurantoin should not be used in patients with renal insufficiency because it is ineffective at glomerular filtration rates (GFRs) of less than 50 mL/minute and may cause peripheral neuropathy. A urinary analgesic, may be prescribed to relieve the discomfort associated with the infection. Regardless of the regimen prescribed, the patient is instructed to take all the doses prescribed, even if relief of symptoms occurs promptly. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Hospitalization and intravenous (IV) antibiotics are occasionally needed.

Long-Term Pharmacologic Therapy Although brief pharmacologic treatment of UTI for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTI. Infections that recur within 2 weeks after therapy (referred to as a relapse) do so because organisms of the original offending strain remain in the vagina. Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial treatment was inadequate or administered for

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too short a time. Recurrent infections in men are usually due to persistence of the same organism; further evaluation and treatment are indicated. Reinfection of the female patient with new bacteria is the reason for more than 90% of recurrent UTIs in women. If the diagnostic evaluation reveals no structural abnormalities in the urinary tract, the woman with recurrent UTIs may be instructed to begin treatment on her own whenever symptoms occur and to contact the health care provider only when symptoms persist, fever occurs, or the number of treatment episodes exceeds four in a 6-month period. The patient may be taught to use dip-slide culture devices to detect bacteria. If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. If there is no recurrence, medication is taken every other night for 6 to 7 months. Other options include a dose of an antimicrobial agent after sexual intercourse, a dose at bedtime, or a dose every other night or three times per week. Longterm use of antimicrobial agents decreases the risk of reinfection and may be indicated in patients with recurrent infections. If recurrence is caused by persistent bacteria from preceding infections, the cause (i.e., kidney stone, abscess), if known, must be treated. After treatment and sterilization of the urine, low-dose preventive therapy (trimethoprim with or without sulfamethoxazole) each night at bedtime is often prescribed. Studies suggest that the regular use of Cranberry juice or blueberry juice reduces bacterial adherence to the epithelial lining of the urinary tract thus acting as a prevention rather than treatment of UTI’s (Hannon, Pooler, & Porth, 2010). !!"##

Nursing Process

The Patient With Lower Urinary Tract Infection Nursing care of the patient with lower UTI focuses on treating the underlying infection and preventing its recurrence.

Assessment A history of signs and symptoms related to UTI is obtained from the patient with a suspected UTI. The presence of pain, frequency, urgency, and hesitancy and changes in urine are assessed, documented, and reported. The patient’s usual pattern of voiding is assessed to detect factors that may predispose him or her to UTI. Infrequent emptying of the bladder, the association of symptoms of UTI with sexual intercourse, contraceptive practices, and personal hygiene are assessed. The patient’s knowledge about prescribed antimicrobial medications and preventive health care measures is also assessed. In addition,

the urine is assessed for volume, colour, concentration, cloudiness, and odour, all of which are altered by bacteria in the urinary tract.

Diagnosis Nursing Diagnoses Based on assessment data, the nursing diagnoses may include the following: • Acute pain related to inflammation and infection of the urethra, bladder, and other urinary tract structures • Deficient knowledge related to factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy

Collaborative Problems/ Potential Complications Based on assessment data, the following complications may develop: • Sepsis • Renal failure, which may occur as the long-term result of either an extensive infective or inflammatory process.

Planning and Goals Major goals for the patient may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications.

Nursing Interventions Relieving Pain The pain associated with UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Aspirin and applying heat to the perineum help to relieve pain and spasm. The patient is encouraged to drink liberal amounts of fluids (water is the best choice) in order to promote renal blood flow and to flush the bacteria from the urinary tract. Urinary tract irritants (e.g., coffee, tea, citrus, spices, colas, alcohol) are avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely, as this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection.

Monitoring and Managing Potential Complications Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as renal failure, sepsis (urosepsis), strictures, and obstructions. The goal of

CHAPTER 46

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treatment is to prevent infection from progressing and causing permanent renal damage and renal failure. Thus, the patient must be taught to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTI. The patient is instructed to notify the physician if fatigue, nausea, vomiting, or pruritus occurs. Periodic monitoring of renal function (creatinine clearance, blood urea nitrogen [BUN], and serum creatinine levels) and evaluation for strictures, obstructions, or stones may be indicated for patients with recurrent UTIs. Patients with UTI, especially catheter-associated infection, are at increased risk for gram-negative sepsis. Indwelling catheters should be avoided, if possible, and removed at the earliest opportunity. If an indwelling catheter is necessary, however, specific nursing interventions are initiated to prevent infection and urosepsis:

Management of Patients With Urinary Disorders

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to the physician. At the same time, appropriate antibiotic therapy and increased fluid intake are prescribed (IV antibiotic therapy and fluids may be required). Aggressive early treatment is the key to reducing the mortality rate associated with gram-negative sepsis, especially in older patients.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. In helping patients learn about and prevent or manage a recurrent UTI, the nurse needs to implement teaching that meets individual patient needs. Health-related behaviours that help to prevent recurrent UTIs include practicing careful personal hygiene, increasing fluid intake to promote voiding and dilution of urine, urinating regularly and more frequently, and adhering to the therapeutic regime. For a detailed discussion of patient teaching interventions, refer to Chart 46-4.

Evaluation

• Using strict aseptic technique during insertion of the smallest catheter possible • Securing the catheter with tape to prevent movement • Frequently inspecting urine colour, odour, and consistency • Performing meticulous daily perineal care with soap and water • Maintaining a closed system • Following the manufacturer’s instructions when using the catheter port to obtain urine specimens

Expected Patient Outcomes Expected patient outcomes may include the following: 1. Experiences relief of pain a. Reports absence of pain, urgency, dysuria, nocturia, or hesitancy on voiding b. Takes analgesic and antibiotic agents as prescribed 2. Explains UTIs and their treatment a. Demonstrates knowledge of preventive measures and prescribed treatments b. Drinks eight to ten glasses of fluids daily c. Voids every 2 to 3 hours d. Voids urine that is clear and odourless

Careful assessment of vital signs and level of consciousness may alert the nurse to kidney involvement or impending sepsis. Blood cultures that are positive for infection and elevated WBC counts are reported

CHART 46-4

Patient Education: Preventing Recurrent Urinary Tract Infections Hygiene • Shower rather than bathe in tub because bacteria in the bathwater may enter the urethra. • After each bowel movement, clean the perineum and urethral meatus from front to back. This will help to reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening. Fluid Intake

• Drink liberal amounts of fluids daily to flush out bacteria. • Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.

Voiding Habits • Void every 2 to 3 hours during the day, and completely empty the bladder. This prevents overdistention of the bladder and compromised blood supply to the bladder wall. Both predispose the patient to urinary tract infection. Pre-

cautions expressly for women include voiding immediately after sexual intercourse. Therapy

• Take medication exactly as prescribed. • If bacteria continue to appear in the urine, long-term anti• • • • •

microbial therapy may be required to prevent colonization of the periurethral area and recurrence of infection. Special timing of administration may be required. For recurrent infection, consider acidification of the urine through ascorbic acid (vitamin C), 1,000 mg daily, or cranberry juice. If prescribed, test urine for presence of bacteria following manufacturer and health care provider’s instructions. Notify the primary health care provider if fever occurs or if signs and symptoms persist. Consult the primary health care provider regularly for follow-up.

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3. Experiences no complications a. Reports no symptoms of infection (fever, dysuria, frequency) or renal failure (nausea, vomiting, fatigue, pruritus) b. Has normal BUN and serum creatinine levels; negative urine and blood cultures c. Exhibits normal vital signs and temperature; no signs or symptoms of sepsis (urosepsis) d. Maintains adequate urine output of more than 30 mL/hour

Upper Urinary Tract Infection: Acute Pyelonephritis Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the bloodstream. It is not uncommon for bacteria that are causing a bladder infection to ascend into the kidney, causing pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection (see Fig. 46-1), because static urine provides a good medium for bacterial growth. Bladder tumours, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses. Pyelonephritis may be acute or chronic. Acute pyelonephritis is an infection of the renal parenchyma and renal pelvis. It is usually manifested by enlarged kidneys with interstitial infiltrations of inflammatory cells. Abscesses may be noted on the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. When pyelonephritis becomes chronic, there is scarring and deformation of the renal calyces and pelvis. The most common cause of chronic pyelonephritis is reflux involving either a single kidney or both, with the eventual development of chronic renal insufficiency (Hannon, Pooler, & Porth, 2010).

Acute Pyelonephritis Clinical Manifestations The patient with acute pyelonephritis is acutely ill with chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle (see Fig. 44-6 in Chapter 44). In addition, symptoms of lower urinary tract involvement, such as dysuria and frequency, are common.

Assessment and Diagnostic Findings An ultrasound study or a CT scan may be performed to locate any obstruction in the urinary tract. Relief of

obstruction is essential to save the kidney from destruction. An IVP is rarely indicated during acute pyelonephritis because findings are normal in up to 75% of patients. Radionuclide imaging with gallium citrate and Indium-111 labelled WBCs may be useful to identify sites of infection that may not be visualized on CT scan or ultrasound. Urine culture and sensitivity tests are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed.

Medical Management Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting dehydration, nausea or vomiting, or symptoms of sepsis. In addition, they must be responsible and reliable to ensure that all medications are taken as prescribed. Other patients, including all pregnant women, may be hospitalized for at least 2 or 3 days of parenteral therapy. Oral agents may be substituted once the patient is afebrile and showing clinical improvement.

Pharmacologic Therapy Antibiotic therapy is longer for pyelonephritis (7–14 days) than cystis (1 dose -7 days) because renal parenchymal infection is more difficult to eradicate than mucosal bladder infections. Increased resistance to E. coli, the primary causative bacteria in pyelonephritis, has changed the treatment options and monitoring required for this infection. An oral third-generation cephalosporin drug (i.e., cefixime) is now the drug of choice for the treatment of uncomplicated pyelonephritis (Blondel-Hill & Fryters, 2012). Other agents such as TMP-SMZ, ciprofloxacin, and amoxicillin-clavulanate may be used, however; pre-treatment urine cultures should be collected to detect any drug resistance (BaudrySimner, Singh, Karlowsky, et al., 2012; Blondel-Hill & Fryters, 2012). Intravenous third-generation cephalosporin agents (i.e., ceftriaxone) or gentamicin are used, as first line and second line therapies respectively, in pregnant patients or those with severe disease. Oral antibiotic agents, tailored to urine culture and sensitivity results, may be prescribed once the patient is afebrile and showing clinical improvement. A possible issue in acute pyelonephritis treatment is a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if evidence of a relapse is seen. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. Similarly, monthly urine cultures following pyelonephritis are recommended in pregnant females for the duration of their pregnancy (Blondel-Hill & Fryters, 2012).

Upper Urinary Tract Infection: Chronic Pyelonephritis Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.

CHAPTER 46

Clinical Manifestations The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney resulting in renal failure (see Chapter 45).

Assessment and Diagnostic Findings The extent of the disease is assessed by an IV urogram and measurements of creatinine clearance, blood urea nitrogenand creatinine levels. Bacteria, if detected in the urine, are eradicated, if possible.

Complications Complications of chronic pyelonephritis include endstage renal disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of kidney stones (from chronic infection with urea-splitting organisms).

Medical Management Long-term use of prophylactic antimicrobial therapy may help to limit recurrence of infections and renal scarring (Wein, Kavoussi, Novick, et al., 2007). Impaired renal function alters the excretion of antimicrobial agents and neces-

TABLE 46-1

Neurogenic Disorders Cerebellar ataxia Cerebrovascular accident Dementia Diabetes mellitus

Multiple sclerosis Parkinson’s disease Spinal Cord Dysfunction Acute injury Degenerative disease Nonneurogenic Disorders “Bashful bladder”

Post general surgery Post prostatectomy

Stress incontinence

Management of Patients With Urinary Disorders

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sitates careful monitoring of renal function, especially if the medications are potentially toxic to the kidneys.

Nursing Management The patient may require hospitalization or may be treated as an outpatient. When the patient is hospitalized, fluid intake and output are carefully measured and recorded. Unless contraindicated, fluids are encouraged (3 to 4 L/day) to dilute the urine, decrease burning on urination, and prevent dehydration. The patient’s temperature is assessed every 4 hours and antipyretic and antibiotic agents are administered as prescribed. Often, the patient is more comfortable on bed rest during the acute phase of the illness. Patient teaching focuses on prevention of UTIs by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking antimicrobial medications exactly as prescribed is stressed to the patient, as is the need for keeping follow-up appointments.

ADULT VOIDING DYSFUNCTION Both neurogenic and non-neurogenic disorders can cause adult voiding dysfunction (Table 46-1). The micturition (voiding or urination) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying (see Chapter 44). If voiding dysfunction goes undetected and untreated, the upper urinary system may be compromised.

Conditions Causing Adult Voiding Dysfunction

Condition

Overactive bladder

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Voiding Dysfunction

Treatment

Incontinence or dyssynergia Retention or incontinence Incontinence Incontinence and/or incomplete bladder emptying

Timed voiding; anticholinergics Anticholinergics; bladder retraining Prompted voiding; anticholinergics Timed voiding; electromyography (EMG)/biofeedback; pelvic floor nerve stimulation; anticholinergics/antispasmodics; well-controlled blood glucose levels Timed voiding; EMG/biofeedback to learn pelvic muscle exercises and urge inhibition; pelvic floor nerve stimulation; antispasmodics Anticholinergics/antispasmodics

Incontinence or incomplete bladder emptying Incontinence Urinary retention Incontinence and/or incomplete bladder emptying

Indwelling catheter EMG/biofeedback; pelvic floor nerve stimulation; anticholinergics

Inability to initiate voiding in public bathrooms Urgency, frequency, and/or urge incontinence Acute urine retention Incontinence

Relaxation therapy; EMG/biofeedback

Incontinence with cough, laugh, sneeze, and/or position change

EMG/biofeedback; pelvic floor nerve stimulation; bladder drill (see Chart 46-7); anticholinergics Catheterization Mild: Biofeedback; bladder drill (see Chart 46-7); pelvic floor nerve stimulation Moderate/Severe: Surgery—artificial sphincter Mild: Biofeedback: bladder drill (see Chart 46-7); periurethral bulking with collagen Moderate/Severe: Surgery

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Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis.

Urinary Incontinence It is estimated that as many as 3.3 million Canadians have urinary incontinence in some form (Canadian Continence Foundation, 2014). Despite widespread media coverage, urinary incontinence remains underdiagnosed and underreported. Patients may be too embarrassed to seek help, causing them to ignore or conceal symptoms. Many patients resort to using absorbent pads or other devices without having their condition properly diagnosed and treated. Health care providers must be alert to subtle cues of urinary incontinence and stay informed about current management strategies (Newman, 2003). The costs of care for patients with urinary incontinence include cost of absorbent products, medications, and surgical or nonsurgical treatment modalities as well as the psychosocial costs of urinary incontinence. These include embarrassment, loss of self-esteem, and social isolation. Urinary incontinence affects people of all ages but is particularly common among the older adult; it can decrease their ability to maintain an independent lifestyle. This increases dependence on caregivers and may lead to institutionalization. More than half of all residents of long-term care have urinary incontinence. Although urinary incontinence is not a normal consequence of aging, age-related changes in the urinary tract predispose the older person to incontinence. Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it is also common in young nulliparous women, especially during vigourous high-impact activity. Age, gender, and number of vaginal deliveries are established risk factors (Chart 46-5); they explain, in part, the increased incidence

CHART 46-5

Risk Factors for Urinary Incontinence • • • • • • • • • • • • • •

Pregnancy: vaginal delivery, episiotomy Menopause Genitourinary surgery Pelvic muscle weakness Incompetent urethra due to trauma or sphincter relaxation Immobility High-impact exercise Diabetes mellitus Stroke Age-related changes in the urinary tract Morbid obesity Cognitive disturbances: dementia, Parkinson’s disease Medications: diuretics, sedatives, hypnotics, opioids Caregiver or toilet unavailable

in women. Urinary incontinence is a symptom of many possible disorders.

Types of Incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position (Miller, 2011). It predominantly affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer primarily as a result of intrinsic sphincter deficiency that can coexist with new or recurring detrusor over activity (Hunter, Moore, & Glazener, 2007). Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time (Miller, 2011). An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void (see chapter 64). Reduced urethral function or overactivity/low bladder compliance is the involuntary loss of urine that occurs when intravesical pressure exceeds maximal urtethral pressure. This occurs because of bladder distension in the absence of detrusor activity (Hannon, Pooler, C & Porth, 2010). Such over distention results from the bladder’s inability to empty normally, despite frequent urine loss. Both neurologic abnormalities (e.g., spinal cord lesions) and factors that obstruct the outflow of urine (e.g., tumours, strictures, and prostatic hyperplasia) can cause overflow incontinence (Muller, 2005). Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment (e.g., Alzheimer’s dementia), make it difficult for the patient to identify the need to void or physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding. Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alphaadrenergic agents to decrease blood pressure. In some people with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intraabdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves. Mixed urinary incontinence which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing (Miller, 2011).

CHAPTER 46

Only with appropriate recognition of the problem, assessment, and referral for diagnostic evaluation and treatment can the outcome of incontinence be determined. All people with incontinence should be considered for evaluation and treatment.

Gerontologic Considerations If nurses and other health care providers accept incontinence as an inevitable part of illness or aging or consider it irreversible and untreatable, it cannot be treated successfully. Collaborative, interdisciplinary efforts are essential in assessing and effectively treating urinary incontinence (Specht, 2005). Many older people experience transient episodes of incontinence that tend to be abrupt in onset. When this occurs, the nurse should question the patient, as well as the family if possible, about the onset of symptoms and any signs or symptoms of a change in other organ systems. Acute UTI, infection elsewhere in the body, constipation, decreased fluid intake, or a change in a chronic disease pattern, such as elevated blood glucose levels in patients with diabetes or decreased estrogen levels in menopausal women, can provoke the onset of urinary incontinence. If the cause is identified and modified or eliminated early at the onset of incontinence, the incontinence itself may be eliminated. Although the bladder of the older person is more vulnerable to altered detrusor activity, age alone is not a risk factor for urinary incontinence (Vinsnes, Harkless, & Nyronning, 2007). Decreased bladder muscle tone is a normal age-related change found in the older adult. This leads to decreased bladder capacity, increased residual urine, and an increase in urgency (Miller, 2011). Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. All medications need to be assessed for potential interactions.

Assessment and Diagnostic Findings Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of medication use. The patient’s voiding history, a diary of fluid intake and output, and bedside tests (e.g., residual urine, stress manoeuvres) may be used to help determine the type of urinary incontinence involved. Extensive urodynamic tests may be performed (see Chapter 44). Urinalysis and urine culture are performed to identify infection. Urinary incontinence may be transient or reversible if the underlying cause is successfully treated and the voiding pattern reverts to normal (Chart 46-6).

Medical Management Management depends on the type of urinary incontinence and its causes. Management of urinary incontinence may be behavioural, pharmacologic, or surgical.

Behavioural Therapy Behavioural therapies are the first choice to decrease or eliminate urinary incontinence (Chart 46-7). In using

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Management of Patients With Urinary Disorders

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CHART 46-6

Causes of Transient Incontinence: DIAPPERS Delirium Infection of urinary tract Atrophic vaginitis, urethritis Pharmacologic agents (anticholinergics, sedatives, alcohol, analgesics, diuretics, muscle relaxants, adrenergic agents) Psychological factors (depression, regression) Excessive urine production (increased intake, diabetes insipidus, diabetic ketoacidosis) Restricted activity Stool impaction

these techniques, health care professionals help patients avoid potential adverse effects of pharmacologic or surgical interventions. Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioural intervention for addressing symptoms of stress, urge, and mixed incontinence. Other behavioural treatments include use of a voiding diary, biofeedback, verbal instruction (prompted voiding), and physical therapy (Miller, 2011). Pessaries can be used as an additional conservative treatment for women with stress urinary incontinence or obstruction related to pelvic organ prolapse.

Pharmacologic Therapy Pharmacologic therapy works best when used as an adjunct to behavioural interventions. Bladder-specific anticholinergic agents (e.g., oxybutynin [Ditropan], tolterodine [Detrol], trospium [Trosec]) inhibit bladder contraction and are considered first-line medications for urge incontinence in Canada (Canadian Continence Foundation, 2014). Several tricyclic antidepressant medications (e.g., amitriptyline) can also decrease bladder contractions but have high anticholinergic side effects, so they should be avoided in older adults. Hormone therapy (e.g., estrogen) taken orally, transdermally, or topically was once the treatment of choice for urinary incontinence in postmenopausal women. Estrogen is believed to decrease obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. The use of oral estrogen is now avoided as it is associated with worsening incontinence (Robinson & Cardozo, 2011). Topical intravaginal estrogen, however, is associated with one to two fewer voids per day and decreased urinary frequency (Cody, Jacobs, Richardson, et al., 2012). Few studies have investigated the use of Duloxetine for the treatment of stress urinary incontinence. Initial results show some clinical effectiveness in reducing the number of incontinent episodes; however, drug tolerability and thus drug adherence is low (Davila, 2011; Li, Chunxiao, Tang, 2013). Although previously only used for the treatment neurogenic urge incontinence (multiple sclerosis, spinal cord injury), Canadian researchers have found a clinical reduction in urinary urge incontinence by injecting botulinum

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CHART 46-7

Behavioural Interventions for Urinary Incontinence Behavioural strategies are largely carried out, coordinated, and monitored by the nurse. These interventions may or may not be augmented by the use of medications.

Fluid Management One of the most common approaches is fluid management because adequate daily fluid intake of approximately 1,500 to 1,600 mL, taken as small increments between breakfast and the evening meal, helps to reduce urinary urgency related to concentrated urine production, decreases the risk of urinary tract infection, and maintains bowel functioning. (Constipation, resulting from inadequate daily fluid intake, can increase urinary urgency and/or urine retention.) The best fluid is water. Fluids containing caffeine, carbonation, alcohol, or artificial sweetener should be avoided because they irritate the bladder wall, thus resulting in urinary urgency. Some patients who have coexisting medical diagnoses, such as heart failure or end-stage renal disease, need to discuss their daily fluid limit with their primary health care provider.

Standardized Voiding Frequency After establishing a patient’s natural voiding and urinary incontinence tendencies, voiding on a schedule can be very effective in those with and without cognitive impairment, although patients with cognitive impairment may require assistance with this technique from nursing personnel or family members. The object is to purposely empty the bladder before the bladder reaches the critical volume that would cause an urge or stress incontinence episode. This approach involves the following: • Timed voiding involves establishing a set voiding frequency (such as every 2 hours if incontinent episodes tend to occur 2 or more hours after voiding). The individual chooses to “void by the clock” at the given interval while awake, rather than wait until a voiding urge occurs. • Prompted voiding is timed voiding that is carried out by staff or family members when the individual has cognitive difficulties that make it difficult to remember to void at set intervals. The caregiver checks the patient to assess if he or she has remained dry and, if so, assists the patient to use the bathroom while providing positive reinforcement for remaining dry. • Habit retraining is timed voiding at an interval that is more frequent than the individual would usually choose. This technique helps to restore the sensation of the need to void in individuals who are experiencing diminished sensation of bladder filling due to various medical conditions such as a mild cerebrovascular accident (CVA). • Bladder retraining, also known as bladder drill, incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding, or leaking urine, in an attempt to remain dry for a set time. When the first timing interval is easily reached on a consistent basis without urinary urgency or incontinence, a new voiding interval, usually 10 to 15 minutes beyond the last, is established. Again,

Toxin A injections into the detrusor muscle (Jabs & Carleton, 2013).

Surgical Management Surgical correction may be indicated in patients who have not achieved continence using behavioural and

the individual practices urge inhibition exercises to delay voiding or avoid incontinence until the next preset interval arrives. When an acceptable voiding interval is reached, the patient continues that timed voiding sequence throughout the day.

Pelvic Muscle Exercise Also known as Kegel exercises, pelvic muscle exercise (PME) aims to strengthen the voluntary muscles that assist in bladder and bowel continence in both men and women. Research shows that written and/or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted PME uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. The biofeedback method also allows assessment of the strength of this muscle area. PME involves gently tightening the same muscles used to stop flatus or the stream of urine for 5- to 10-second increments, followed by 10-second resting phases. To be effective, these exercises need to be performed two or three times a day for at least 6 weeks. Depending on the strength of the pelvic musculature when initially evaluated, anywhere from 10 to 30 repetitions of PME are prescribed at each session. Elderly patients may need to exercise for an even longer time to strengthen the pelvic floor muscles. Pelvic muscle exercises are helpful for women with stress, urge, or mixed incontinence and for men who have undergone prostate surgery.

Vaginal Cone Retention Exercises Vaginal cone retention exercises are an adjunct to the Kegel exercises. Vaginal cones of varying weight are inserted intravaginally twice a day. The patient tries to retain the cone for 15 minutes by contracting the pelvic muscles.

Transvaginal or Transrectal Electrical Stimulation Commonly used to treat urinary incontinence, electrical stimulation is known to elicit a passive contraction of the pelvic floor musculature, thus re-educating these muscles to provide enhanced levels of continence. This modality is often used with biofeedback-assisted pelvic muscle exercise training and voiding schedules. At high frequencies, it is effective for stress incontinence. At low frequencies, electrical stimulation can also relieve symptoms of urinary urgency, frequency, and urge incontinence. Intermediate ranges are used for mixed incontinence.

Neuromodulation Neuromodulation via transvaginal or transrectal nerve stimulation of the pelvic floor inhibits detrusor overactivity and hypersensory bladder signals and strengthens weak sphincter muscles.

pharmacologic therapy. Surgical options vary according to the underlying anatomy and the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra. Women with stress incontinence may undergo an anterior vaginal repair, retropubic suspension, or needle

CHAPTER 46

suspension to reposition the urethra. Procedures to compress the urethra and increase resistance to urine flow include sling procedures and placement of periurethral bulking agents such as artificial collagen. Recent introduction of minimally invasive procedures for placement of a mesh midurethral sling has been demonstrated as effective treatment of stress incontinence in women who have failed conservative therapy such as pelvic floor muscle therapy and behaviour modification. Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen are placed within the walls of the urethra to enhance the closing pressure of the urethra. This procedure takes only 10 to 20 minutes and may be performed under local anesthesia or moderate sedation. A cystoscope is inserted into the urethra. An instrument is inserted through the cystoscope to deliver a small amount of collagen into the urethral wall at locations selected by the urologist. The patient is usually discharged home after voiding. There are no restrictions following the procedure, although occasionally more than one collagen bulking session may be necessary if the initial procedure has not halted the stress urinary incontinence. Collagen placement anywhere in the body is considered semipermanent because its durability averages between 12 and 24 months, until the body absorbs the material. Periurethral bulking with collagen offers an alternative to surgery, as in a frail, elderly person. It is also an option for people who are seeking help with stress urinary incontinence who prefer to avoid surgery and who do not have access to behavioural therapies. An artificial urinary sphincter can be used to close the urethra and promote continence. Two types of artificial sphincters are a periurethral cuff and a cuff inflation pump. Men with overflow and stress incontinence may undergo a transurethral or laser resection to relieve symptoms of prostatic enlargement. An artificial sphincter can be used after prostatic surgery for sphincter incompetence (Fig. 46-2). After surgery, periurethral bulking agents can be injected into the periurethral area to increase compression of the urethra. Ureter Pressureregulating reservoir Inflatable cuff Prostate

Urethra

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Management of Patients With Urinary Disorders

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CHART 46-8

Patient Education: Strategies for Promoting Urinary Continence • Increase your awareness of the amount and timing of all fluid intake.

• Avoid taking diuretics after 4 PM. • Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet).

• Take steps to avoid constipation: Drink adequate fluids,

eat a well-balanced diet high in fibre, exercise regularly, and take stool softeners if recommended. • Void regularly, five to eight times a day (about every 2 to 3 hours): First thing in the morning Before each meal Before retiring to bed Once during night if necessary • Perform all pelvic floor muscle exercises as prescribed, every day. • Stop smoking (smokers usually cough frequently, which increases incontinence).

Nursing Management Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. The nursing interventions are determined in part by the type of treatment that is undertaken. For behavioural therapy to be effective, the nurse must provide support and encouragement because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence. Patient teaching is important and should be provided verbally and in writing (Chart 46-8). The patient should be taught to develop and use a log or diary to record timing of pelvic floor muscle exercises, frequency of voiding, any changes in bladder function, and any episodes of incontinence (Miller, 2011). If pharmacologic treatment is used, its purpose is explained to the patient and family. It is important to educate patients who have mixed incontinence (both stress and urge incontinence) that anticholinergic and antispasmodic agents can help to decrease urinary urgency and frequency and urge incontinence but that they do not decrease the urinary incontinence related to stress incontinence. If surgical correction is undertaken, the procedure and its desired outcomes are described to the patient and family. Follow-up contact with the patient enables the nurse to answer the patient’s questions and to provide reinforcement and encouragement.

Control pump

Urinary Retention

Scrotum

Urinary retention is the inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. In a

FIGURE 46-2. Male artificial urinary sphincter. An inflatable cuff is

inserted surgically around the urethra or neck of the bladder. To empty the bladder, the cuff is deflated by squeezing the control pump located in the scrotum.

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healthy adult younger than 60 years, complete bladder emptying should occur with each voiding. In adults older than 60 years, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying.

urodynamic studies, described in Chapter 43, may be performed to identify the type of bladder dysfunction and to aid in determining appropriate treatment. The patient may complete a voiding diary to provide a written record of the amount of urine voided and the frequency of voiding. Postvoid residual urine may be assessed either using straight catheterization or an ultrasound bladder scanner and is considered diagnostic of urinary retention if there is more than 100 mL of residual urine.

Pathophysiology

Urine retention can lead to chronic infection. Infections that are unresolved predispose the patient to renal calculi (urolithiasis or nephrolithiasis), pyelonephritis, and sepsis. The kidney may also eventually deteriorate if large volumes of urine are retained, causing hydronephrosis. In addition, urine leakage can lead to perineal skin breakdown, especially if regular hygiene measures are neglected.

Urinary retention may result from diabetes; prostatic enlargement; urethral pathology (infection, tumour, calculus); trauma (pelvic injuries); pregnancy; or neurologic disorders such as stroke, spinal cord injury, multiple sclerosis, or Parkinson’s disease. Some medications cause urinary retention, either by inhibiting bladder contractility or by increasing bladder outlet resistance. Medications that cause retention by inhibiting bladder contractility include anticholinergic agents (atropine sulfate, dicyclomine hydrochloride [Antispas, Bentyl]); antispasmodic agents (oxybutynin chloride [Ditropan], belladonna, and opioid suppositories); and tricyclic antidepressant medications (imipramine [Tofranil], doxepin [Sinequan]). Medications that cause urine retention by increasing bladder outlet resistance include alpha-adrenergic agents (ephedrine sulfate, pseudoephedrine), beta-adrenergic blockers (propranolol), and estrogens.

Assessment and Diagnostic Findings The assessment of a patient for urinary retention is multifaceted because the signs and symptoms may be easily overlooked. The following questions serve as a guide in assessment: • What was the time of the last voiding, and how much urine was voided? • Is the patient voiding small amounts of urine frequently? • Is the patient dribbling urine? • Does the patient complain of pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly.) • Is the pelvic area rounded and swollen (could indicate urine retention and a distended bladder)? • Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)? • Are other indicators of urinary retention present, such as restlessness and agitation? • Does a postvoid bladder ultrasound test reveal residual urine? The patient may verbalize an awareness of bladder fullness and a sensation of incomplete bladder emptying. Signs and symptoms of UTI (hematuria, urgency, frequency, nocturia, and dysuria) may be present. A series of

Complications

Nursing Management Management strategies are instituted to prevent overdistention of the bladder and to treat infection or correct obstruction. However, many problems can be prevented with careful assessment and appropriate nursing interventions. The nurse explains why normal voiding is not occurring and monitors urine output closely. The nurse also provides reassurance about the temporary nature of retention and successful management strategies.

Promoting Urinary Elimination Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and a position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. The male patient may stand beside the bed while using the urinal; most men find this position more comfortable and natural. Additional measures include applying warmth to relax the sphincters (i.e., sitz baths, warm compresses to the perineum, showers), giving the patient hot tea, and offering encouragement and reassurance. Simple trigger techniques, such as turning on the water faucet while the patient is trying to void, may also be used. Other examples of trigger techniques are stroking the abdomen or inner thighs, tapping above the pubic area, and dipping the patient’s hands in warm water. A combination of techniques may be necessary to initiate voiding. After surgery or childbirth, prescribed analgesics should be administered because pain in the perineal area can make voiding difficult. When the patient cannot void, catheterization is used to prevent overdistention of the bladder (see later Neurogenic Bladder and Catheterization sections). In the case of prostatic obstruction, attempts at catheterization (by the urologist) may not be successful, requiring insertion of a suprapubic catheter (catheter inserted through a small abdominal incision into the bladder). After urinary drainage is restored, bladder retraining is initiated for the patient who cannot void spontaneously.

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Promoting Home and Community-Based Care

Medical Management

In addition to the strategies listed for promoting urinary continence found in Chart 46-8, modifications to the home environment can provide simple and effective ways to assist in treating urinary incontinence and retention. For example, the patient may need to remove obstacles, such as throw rugs or other objects, to provide easy, safe access to the bathroom. Other modifications that the nurse may recommend include installing support bars in the bathroom; placing a bedside commode, bedpan, or urinal within easy reach; leaving lights on in the bedroom and bathroom; and wearing clothing that is easy to remove quickly.

The problems resulting from neurogenic bladder disorders vary considerably from patient to patient and are a major challenge to the health care team. There are several longterm objectives appropriate for all types of neurogenic bladders:

Neurogenic Bladder Neurogenic bladder is a dysfunction that results from a lesion of the nervous system and leads to urinary incontinence. It may be caused by spinal cord injury, spinal tumour, herniated vertebral disk, multiple sclerosis, congenital disorders (spina bifida or myelomeningocele), infection, or diabetes mellitus (see Chapters 42, 64, and 65).

Pathophysiology The two types of neurogenic bladder are spastic (or reflex) bladder and flaccid bladder. Spastic bladder is the more common type and is caused by any spinal cord lesion above the voiding reflex arc (upper motor neuron lesion). The result is a loss of conscious sensation and cerebral motor control. A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity. Flaccid bladder is caused by a lower motor neuron lesion, commonly resulting from trauma. This form of neurogenic bladder is also increasingly being recognized in patients with diabetes mellitus. The bladder continues to fill and becomes greatly distended, and overflow incontinence occurs. The bladder muscle does not contract forcefully at any time. Because sensory loss may accompany a flaccid bladder, the patient feels no discomfort.

Assessment and Diagnostic Findings Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residual urine volume; urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies are also performed.

Complications The most common complication of neurogenic bladder is infection resulting from urinary stasis and catheterization. Long-term complications include urolithiasis (stones in the urinary tract), vesicoureteral reflux, and hydronephrosis, all of which can lead to destruction of the kidney.

• • • •

Preventing overdistention of the bladder Emptying the bladder regularly and completely Maintaining urine sterility with no stone formation Maintaining adequate bladder capacity with no reflux

Specific interventions include continuous, intermittent, or self-catheterization (discussed later in this chapter); use of an external condom-type catheter; a diet low in calcium (to prevent calculi), and encouragement of mobility and ambulation. A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce stasis, decrease the concentration of calcium in the urine, and minimize the precipitation of urinary crystals and subsequent stone formation. A bladder retraining program may be effective in treating a spastic bladder or urine retention. Use of a timed, or habit, voiding schedule may be established. To further enhance emptying of a flaccid bladder, the patient may be taught to “double void.” After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder.

Pharmacologic Therapy Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase the contraction of the detrusor muscle in acute retention not related to obstruction. These medications are not effective in chronic urinary retention.

Surgical Management In some cases, surgery may be carried out to correct bladder neck contractures or vesicoureteral reflux or to perform some type of urinary diversion procedure.

Catheterization In patients with a urologic disorder or with marginal kidney function, care must be taken to ensure that urinary drainage is adequate and that kidney function is preserved. When urine cannot be eliminated naturally and must be drained artificially, catheters may be inserted directly into the bladder, the ureter, or the renal pelvis. Catheters vary in size, shape, length, material, and configuration. The type of catheter used depends on its purpose. Catheterization is performed to achieve the following: • Relieve urinary tract obstruction • Assist with postoperative drainage in urologic and other surgeries • Provide a means to monitor accurate urine output in critically ill patients • Promote urinary drainage in patients with neurogenic bladder dysfunction or urine retention • Prevent urinary leakage in patients with stage III to IV pressure ulcers (see Chapter 12)

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A patient should be catheterized only if necessary, as catheterization commonly leads to UTI. Catheters impede most of the natural defenses of the lower urinary tract by obstructing the periurethral ducts, irritating the bladder mucosa, and providing an artificial route for organisms to enter the bladder. Organisms may be introduced from the urethra into the bladder during catheterization, or they may migrate along the epithelial surface of the urethra or external surface of the catheter. Many of the organisms can form a bacterial biofilm impenetrable to antibiotics. In addition, urinary catheters have been associated with other complications, such as bladder spasms, urethral strictures, and pressure necrosis.

Removable trocar cannula Abdominal wall

Bladder

Suprapubic catheter

Indwelling Catheters When an indwelling catheter cannot be avoided, a closed drainage system is essential. This drainage system is designed to prevent any disconnections, thereby reducing the risk of contamination. Triple-lumen catheters are commonly used after transurethral prostate surgery (see Chapter 50). This system has a triple-lumen indwelling urethral catheter attached to a closed sterile drainage system. With the triple-lumen catheter, urinary drainage occurs through one channel. The retention balloon of the catheter is inflated with water or air through the second channel, and the bladder is continuously irrigated with sterile irrigating solution through the third channel. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. By keeping the drainage bag lower than the patient’s bladder and not allowing urine to flow back into the bladder, this risk is minimized.

Suprapubic Catheters Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture (Fig. 46-3). The catheter or suprapubic drainage tube is then threaded into the bladder and secured with sutures or tape, and the area around the catheter is covered with a sterile dressing. The catheter is connected to a sterile closed drainage system, and the tubing is secured to prevent tension on the catheter. This may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable (because of injuries, strictures, prostatic obstruction), after gynecologic or other abdominal surgery when bladder dysfunction is likely to occur, and occasionally after pelvic fractures. Suprapubic bladder drainage may be maintained continuously for several weeks. When the patient’s ability to void is to be tested, the catheter is clamped for 4 hours, during which time the patient attempts to void. After the patient voids, the catheter is unclamped, and the residual urine is measured. If the amount of residual urine is less than 100 mL on two separate occasions (morning and evening), the catheter is usually removed. However, if the patient complains of pain or discomfort, the suprapubic catheter is usually left in place until the patient can void successfully.

FIGURE 46-3. Suprapubic bladder drainage. A trocar cannula is used to puncture the abdominal and bladder walls. The catheter is threaded through the trocar cannula, which is then removed, leaving the catheter in place. The catheter is secured by tape or sutures to prevent unintentional removal.

Suprapubic drainage offers certain advantages. Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. The suprapubic catheter is removed when it is no longer required, and a sterile dressing is placed over the site. The patient requires liberal amounts of fluid to prevent encrustation around the catheter. Other potential problems include the formation of bladder stones, acute and chronic infections, and problems collecting urine. A wound care specialist/enterostomal therapist, also referred to as a wound-ostomy-continence nurse, may be consulted to assist the patient and family in selecting the most suitable urine collection system and to teach them about its use and care.

Nursing Management During Catheterization Assessing the Patient and the System For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The colour, odour, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. The nurse observes the catheter to make sure that it is properly anchored, to prevent pressure on the urethra at the penoscrotal junction in male patients, and to prevent

CHAPTER 46

tension and traction on the bladder in both male and female patients. Patients at high risk for UTI from catheterization need to be identified and monitored carefully. These include women; older adults; and patients who are debilitated, malnourished, chronically ill, immunosuppressed, or have diabetes. They are observed for signs and symptoms of UTI: cloudy malodourous urine, hematuria, fever, chills, anorexia, and malaise. The area around the urethral orifice is observed for drainage and excoriation. Urine cultures provide the most accurate means of assessing a patient for infection.

Gerontologic Considerations The older patient with an indwelling catheter may not exhibit the typical signs and symptoms of infection. Therefore, any subtle change in physical condition or mental status must be considered a possible indication of infection and promptly investigated because sepsis may occur before the infection is diagnosed. Figure 46-4 summarizes the sequence of events leading to infection and leakage of urine that often follow long-term use of an indwelling catheter in an older patient.

Preventing Infection Certain principles of care are essential to prevent infection in patients with a closed urinary drainage system (Chart 46-9). The catheter is a foreign body in the urethra and produces a reaction in the urethral mucosa with some urethral discharge. Vigourous cleansing of the meatus while the catheter is in place is discouraged because the cleansing action can move the catheter back and forth, increasing the risk of infection. To remove obvious encrustations from the external catheter surface, the area can be washed gently with soap during the daily bath. The catheter is anchored as securely as possible to prevent it from moving in the urethra. Encrustations arising from urinary salts may serve as a nucleus for stone formation; however, using silicone catheters results in significantly less crust formation. A liberal fluid intake, within the limits of the patient’s cardiac and renal reserve, and an increased urine output must be ensured to flush the catheter and to dilute urinary substances that might form encrustations. Urine cultures are obtained as prescribed or indicated when monitoring the patient for infection; many catheters have an aspiration (puncture) port from which a specimen can be obtained. Bacteriuria is considered inevitable in patients with indwelling catheters; therefore, controversy remains about the usefulness of taking cultures and treating asymptomatic bacteriuria, because overtreatment may lead to resistant strains of bacteria. Continual observation for fever, chills, and other signs and symptoms of systemic infection is necessary; these symptoms are generally treated aggressively.

Minimizing Trauma Trauma to the urethra can be minimized by the following: • Using an appropriate-sized catheter • Lubricating the catheter adequately with a water-soluble lubricant during insertion

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Physiology/Pathophysiology CAUSES Catheterization

Bacterial ascension

Manipulations of catheter Change of catheter Irrigation Unintentional removal

Bacterial colonization Permanent bacteriuria

Bacterial invasion

PATHOPHYSIOLOGY

Damaged mucosa

Bladder infection

Damaged and inflamed mucosa

Detrusor irritation

Detrusor spasms

Inflammatory cells Red blood cells Fibrin Other glutinous products

MANIFESTATIONS

Leakage

Adherence to the catheter

CLINICAL SIGNS Encrustation Obstruction Distention Leakage

URINALYSIS Leukocytes Erythrocytes Urothelial cells

FIGURE 46-4. Pathophysiology and manifestations of bladder infection in long-term catheterized older patients.

• Inserting the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon of the catheter is inflated Manipulation of the catheter is the most common cause of trauma to the bladder mucosa in the catheterized patient. Infection then inevitably occurs when urine invades the damaged mucosa. The catheter is secured properly to prevent it from moving, causing traction on the urethra, or being unintentionally removed, and care is taken to ensure that the catheter position permits leg movement. In male patients, the drainage tube (not the catheter) is taped laterally to the thigh to prevent pressure on the urethra at the penoscrotal junction, which can eventually lead to formation of a urethrocutaneous fistula. In female patients, the drainage tubing attached to the catheter is taped to the thigh to prevent tension and traction on the bladder. Special care should be taken to ensure that any patient who is confused does not remove the catheter with the retention balloon still inflated, as this could cause bleeding and considerable injury to the urethra.

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CHART 46-9

Preventing Infection in the Catheterized Patient • Use scrupulous aseptic technique during insertion of the

• Never irrigate the catheter routinely. If the patient is prone

•

•

•

•

• • •

catheter. Use a preassembled, sterile, closed urinary drainage system. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon of the catheter is inflated. To prevent contamination of the closed system, never disconnect the tubing. The drainage bag must never touch the floor. The bag and collecting tubing are changed if contamination occurs, if urine flow becomes obstructed, or if tubing junctions start to leak at the connections. If the collection bag must be raised above the level of the patient’s bladder, clamp the drainage tube. This prevents backflow of contaminated urine into the patient’s bladder from the bag. Ensure a free flow of urine to prevent infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing loops. To reduce the risk of bacterial proliferation, empty the collection bag at least every 8 hours through the drainage spout—more frequently if there is a large volume of urine. Avoid contamination of the drainage spout. A receptacle in which to empty the bag is provided for each patient.

Retraining the Bladder When an indwelling urinary catheter is in place, the detrusor muscle does not actively contract the bladder wall to stimulate emptying, because urine is continuously draining from the bladder. As a result, the detrusor may not immediately respond to bladder filling when the catheter is removed, resulting in either urine retention or urinary incontinence. This condition, known as postcatheterization detrusor instability, can be managed with bladder retraining (Chart 46-10). Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner. If 100 mL or more of urine remains in the bladder, straight catheterization may be performed for complete bladder emptying. After a few days, as the nerve endings in the bladder wall become aware of bladder filling and emptying, bladder function usually returns to normal. If the person has had an indwelling catheter in place for an extended period, bladder retraining will take longer; in some cases, function may never return to normal, and long-term intermittent catheterization may become necessary.

Assisting With Intermittent Self-Catheterization Intermittent self-catheterization provides periodic drainage of urine from the bladder. By promoting drainage and eliminating excessive residual urine, intermittent catheterization protects the kidneys, reduces the incidence of UTIs, and improves continence. It is the treatment of choice in patients with spinal cord injury and other neurologic disorders, such as multiple sclerosis, when the ability to empty the bladder is impaired. Self-catheterization promotes independence,

• • • • •

• •

to obstruction from clots or large amounts of sediment, use a three-way system with continuous irrigation. Never disconnect the tubing to obtain urine samples, to irrigate the catheter, or to ambulate or transport the patient. Never leave the catheter in place longer than is necessary. Avoid routine catheter changes. The catheter is changed only to correct problems such as leakage, blockage, or encrustations. Avoid unnecessary handling or manipulation of the catheter by the patient or staff. Carry out hand hygiene before and after handling the catheter, tubing, or drainage bag. Wash the perineal area with soap and water at least twice a day; avoid a to-and-fro motion of the catheter. Dry the area well, but avoid applying powder because it may irritate the perineum. Monitor the patient’s voiding when the catheter is removed. The patient must void within 8 hours; if unable to void, the patient may require catheterization with a straight catheter. Obtain a urine specimen for culture at the first sign of infection.

results in few complications, and enhances self-esteem and quality of life. When teaching the patient how to perform selfcatheterization, the nurse must use aseptic technique to minimize the risk of cross-contamination. However, the patient may use a “clean” (nonsterile) technique at home, where the risk of cross-contamination is reduced. Either antibacterial liquid soap or povidone-iodine (Betadine) solution is recommended for cleaning urinary catheters at

CHART 46-10

Bladder Retraining after Indwelling Catheterization • Instruct the patient to drink a measured amount of fluid • • • • • •

from 8 AM to 10 PM to avoid bladder overdistention. Offer no fluids (except sips) after 10 PM. At specific times, ask the patient to void by applying pressure over the bladder, tapping the abdomen, or stretching the anal sphincter with a finger to trigger the bladder. Immediately after the voiding attempt, catheterize the patient to determine the amount of residual urine. Measure the volumes of urine voided and obtained by catheterization. Palpate the bladder at repeated intervals to assess for distention. Instruct the patient who has no voiding sensation to be alert for any signs that indicate a full bladder, such as perspiration, cold hands or feet, or feelings of anxiety. Lengthen the intervals between catheterizations as the volume of residual urine decreases. Catheterization is usually discontinued when the volume of residual urine is less than 100 mL.

CHAPTER 46

home. The catheter is thoroughly rinsed with tap water after soaking in the cleaning solution. It must dry before reuse. It should be kept in its own container, such as a plastic food-storage bag. In teaching the patient, the nurse emphasizes the importance of frequent catheterization and emptying the bladder at the prescribed time. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. If the patient is awakened at night with an urge to void, catheterization may be performed after an attempt is made to void normally. The female patient assumes a Fowler’s position and uses a mirror to help locate the urinary meatus. She inserts the lubricated catheter 7.5 cm (3 in) into the urethra, in a downward and backward direction. The male patient assumes a Fowler’s or sitting position, lubricates the catheter, retracts the foreskin of the penis with one hand while grasping the penis and holding it at a right angle to the body. (This manoeuvre straightens the urethra and makes it easier to insert the catheter.) He inserts the catheter 15 to 25 cm until urine begins to flow. After removal, the catheter is cleaned, rinsed, and wrapped in a paper towel or placed in a plastic bag or case. Patients who follow this routine should consult a primary health care provider at regular intervals to assess urinary function and detect complications. If the patient cannot perform intermittent self-catheterization, a family member may be taught to carry out the procedure at regular intervals during the day. An alternative to self-catheterization that requires an extensive surgical procedure is creation of the Mitrofanoff umbilical appendicovesicostomy, which provides easy access to the bladder. In this procedure, the bladder neck is closed and the appendix is used to create access to the bladder from the skin surface through a submucosal tunnel created with the appendix. One end of the appendix is brought to the skin surface and used as a stoma, and the other end is tunnelled into the bladder. The appendix serves as an artificial urinary sphincter when an alternative is necessary to empty the bladder. A surgically prepared continent urine reservoir with a sphincter mechanism is required in cases of bladder cancer and severe interstitial cystitis (inflammation of the bladder wall). Various types of urological stomas may be used when a radical cystectomy (surgical removal of the bladder) is necessary.

UROLITHIASIS AND NEPHROLITHIASIS Urolithiasis and nephrolithiasis refer to stones (calculi) in the urinary tract and kidney, respectively. Urinary stones account for more than 320,000 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.

Pathophysiology Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. Referred to as

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Right kidney Renal stones

Left kidney Ureters

Bladder

FIGURE 46-5. Examples of potential sites of calculi formation (urolithiasis) in the urinary tract.

supersaturation, this is dependent on the amount of the substance, ionic strength, and pH of the urine. Stones may be found anywhere from the kidney to the bladder and may 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 46-5. Stone formation is not clearly understood, and there are a number of theories about their causes. One theory is that there is a deficiency of substances that normally prevent crystallization in the urine, such as citrate, magnesium, nephrocalcin, and uropontin (Porth & Matfin, 2009). Another theory relates to fluid volume status of the patient (stones tend to occur more often in dehydrated patients). Certain factors favour the formation of stones, including infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism. In addition, increased calcium concentrations in the 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 (e.g., 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

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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 urease-splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma sp. Predisposing factors for struvite 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) (Porth & Matfin, 2009). Several conditions as well as certain metabolic risk factors predispose patients to stone formation. These include anatomic derangements such as polycystic kidney disease, horseshoe kidneys, chronic strictures, and medullary sponge disease. Urinary stone formation can occur in patients with inflammatory bowel disease and in those with an ileostomy or bowel resection because these patients absorb more oxalate. Medications known to cause stones in some patients include antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin (Karch, 2014). However, in many patients, no cause may be found.

Assessment and Diagnostic Findings

Clinical Manifestations

The goals of management are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and 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. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating renal stone pain because they provide specific pain relief. They also inhibit the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone. Generally, once the stone has passed, the pain is relieved. 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.

Signs and symptoms of stones in the urinary system depend on the presence of obstruction, infection, and edema. When 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 UTI with chills, fever, and dysuria) can be a contributing factor with struvite stones (Porth & Matfin, 2009). 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 radiates 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, wave-like 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 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 urosepsis threatening the patient’s life.

The diagnosis is confirmed by x-rays of the kidneys, ureters, and bladder (KUB) or by ultrasonography, IV 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 (Porth & Matfin, 2009).

Medical Management

Nutritional Therapy Nutritional therapy plays an important role in preventing renal stones (Dudek, 2006) (Chart 46-11). Fluid intake is the mainstay of most medical therapy for renal stones. Unless fluids are contraindicated, patients with renal stones should drink eight to ten 8-ounce glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L/day is advisable. CALCIUM STONES. Historically, patients with calciumbased renal stones were advised to restrict calcium in their diet. However, recent evidence 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. Liberal fluid intake is encouraged 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. Medications such as

CHAPTER 46

CHART 46-11

Patient Education: Preventing Kidney Stones • Avoid protein intake; usually, protein is restricted to • •

• • • • •

60 g/day to decrease urinary excretion of calcium and uric acid. A sodium intake of 3 to 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. Avoid intake of oxalate-containing foods (e.g., spinach, strawberries, rhubarb, tea, peanuts, wheat bran). 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 leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. Contact your primary health care provider at the first sign of a urinary tract infection.

ammonium chloride may be used, and 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 (Porth & Matfin, 2009). 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. CYSTINE STONES. A low-protein diet is prescribed, the urine is alkalinized, and fluid intake is increased. OXALATE STONES. A dilute urine is maintained, and the intake of oxalate is limited. Many foods contain oxalate; however, only certain foods increase the urinary excretion of oxalate. These include spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran.

Interventional Procedures If the stone does not pass spontaneously or if complications occur, common interventions include endoscopic or other procedures—for example, ureteroscopy, extracorporeal shock wave lithotripsy (ESWL), or endourologic (percutaneous) stone removal. Ureteroscopy (Fig. 46-6A) 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.

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ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney (Fig. 46-6B). 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 that are excreted in the urine. Discomfort from the multiple shocks may occur, although the shock waves usually do not cause damage to other tissue. 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, its cost is offset by a decrease in the length of hospital stay and avoidance of a surgical procedure. Endourologic methods of stone removal (Fig. 46-6C) 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. A nephroscope is introduced through a percutaneous route into the renal parenchyma. Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. If the stone is too large to initially be removed, an ultrasound probe inserted through a nephrostomy tube is used to pulverize the stone. Small stone fragments and stone dust are then removed from the collecting system. 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 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, which is stone dissolution using infusions of chemical solutions (e.g., alkylating agents, acidifying agents) for the purpose of dissolving the stone, is an alternative treatment sometimes used in patients who are at risk of 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 chemical solution is allowed to flow continuously onto the stone. The 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.

Surgical Management Surgical removal was the major mode of therapy before the advent of lithotripsy. However, today, surgery is performed

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Optical lens

Light source

Urethral opening

Bladder

Cytoscope 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

Kidney stone fragments Alligator forceps

C FIGURE 46-6. Methods of treating renal stones. A: During a cystoscopy, which is used for removing small

stones located in the ureter 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 46

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 cystolitholapaxy. Nursing management following kidney surgery is discussed in Chapter 45. !!"##

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. The patient’s knowledge about renal stones and measures to prevent their occurrence or recurrence is also assessed.

Diagnosis Nursing Diagnoses Based on 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 urosepsis (from UTI and pyelonephritis) • Obstruction of the urinary tract by a stone or edema with subsequent acute renal failure

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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 Severe and acute pain is often the presenting symptom of a patient with renal and urinary calculi and requires immediate attention. Opioid analgesic agents (IV or intramuscular) may be prescribed and administered to provide rapid relief along with an IV NSAID. The patient is encouraged and assisted to assume a position of comfort. If activity brings pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and an increase in severity is reported promptly to the physician so that relief can be provided and additional treatment initiated.

Monitoring and Managing Potential Complications 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, IV fluids are prescribed. The total urine output and patterns of voiding are monitored. Ambulation is encouraged as a means of moving the stone through the urinary tract. 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. Because renal stones increase the risk of infection, sepsis, and obstruction of the urinary tract, the patient is instructed to report decreased urine volume and bloody or cloudy urine. Patients with calculi require frequent nursing observation to detect the spontaneous passage of a stone. The patient is instructed to immediately report any sudden increases in pain intensity because of the possibility of a stone fragment obstructing a ureter. 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.

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 recommendations to prevent their recurrence (see Chart 46-11). The patient is encouraged to follow a regimen to avoid further stone formation, including maintaining a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink

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enough fluid to excrete greater than 2,000 mL (preferably 3,000 to 4,000 mL) of urine every 24 hours. Urine cultures may be performed every 1 to 2 months the first year and periodically thereafter. Recurrent UTI is treated vigourously due to the fact that 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 nurse instructs the patient 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 ESWL has been performed, the nurse must provide instructions for home care and necessary followup. 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, decreasing urine output, and pain. It is also important to inform 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 the stent is removed. The patient is instructed to check his or her temperature daily and notify the physician if the temperature is greater than 38°C or the pain is unrelieved by the prescribed medication. 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. In addition, the nurse has the opportunity to assess the patient’s understanding of factors that increase the risk of 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. Due to the high risk of 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 the following:

1. Reports relief of pain 2. States increased knowledge of health-seeking behaviours 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 (fever, chills, flank pain, hematuria) to be reported to health care provider 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 infection or urosepsis 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 ureters, bladder, or urethra. Approximately 10% of all injuries seen in the emergency department involve the genitourinary system (Wein et al., 2007). (Renal trauma is discussed in Chapter 45.)

Specific Injuries 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. 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 can develop. IV 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 an anastomosis) 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, 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.

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Urethral Trauma 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.

Medical Management The goals of management in patients with genitourinary trauma are to control hemorrhage, pain, and infection and to maintain urinary drainage. Genitourinary trauma is frequently associated with renal trauma (see Chapter 45). Hematocrit and hemoglobin levels are monitored closely; decreasing values indicate hemorrhage within the genitourinary system. The patient is also monitored for oliguria, signs of hemorrhagic shock, and signs and symptoms of acute peritonitis (Wein et al., 2007).

Surgical Management In urethral trauma, unstable patients who need monitoring of urine output may need a suprapubic catheter inserted. 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 favoured 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 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. The patient with a ruptured bladder may have gross bleeding for several days after repair. 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.

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well, 6,900 cases of bladder cancer and 4,600 cases of kidney cancer are projected. (Renal cancer is discussed in Chapter 45, and prostate cancer is discussed in Chapter 50.) Malignant tumours of the urinary tract include transitional cell carcinomas (90%), squamous cell carcinomas (5% to 8%), adenocarcinomas (1% to 2%), sarcomas (less than 1%) and other types of cancers.

Cancer of the Bladder Cancer of the urinary bladder affects more men than women at approximately a 4:1 ratio. In Canada, the probability of developing bladder cancer for men is 3.6% but only 1.2% in women (Canadian Cancer Society’s Steering Committee, 2009). Bladder cancer has a high worldwide incidence. Bladder cancer, combined with prostatic cancer, is among the most common urologic malignancies. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder (Chart 46-12). The risk of developing bladder cancer increases with age. It usually occurs in people over the age of 65 years. Men develop bladder cancer more often than women. Bladder cancer is more common in white people. It was estimated that in 2013: • 7,900 Canadians will be diagnosed with bladder cancer. • 2,100 Canadians will die from bladder cancer. • 5,900 men will be diagnosed with bladder cancer and 1,500 will die from it. • 2,000 women will be diagnosed with bladder cancer and 630 will die from it. Tobacco smoking, particularly cigarette smoking, accounts for more than 50% of bladder cancers in men and approximately 40% of bladder cancers in women. Exsmokers’ risk of developing bladder cancer is double that of people who have never smoked. Carcinogens that are found in tobacco smoke are also found in the urine of smokers. In the urine, these chemicals damage the cells that line the inside of the bladder (urothelial cells), which could lead to cancer. The carcinogens from tobacco smoke found in urine include: • aromatic amines—alpha naphthylamine and beta naphthylamine CHART 46-12

Risk Factors for Bladder Cancer • Cigarette smoking: risk proportional to number of packs smoked daily and number of years of smoking

• Exposure to environmental carcinogens: dyes, rubber, leather, ink, or paint

URINARY TRACT CANCERS

• Recurrent or chronic bacterial infection of the urinary

Urinary tract cancers include those of the urinary bladder; kidney and renal pelvis; ureters; and other urinary structures, such as the prostate. The Canadian Cancer Society’s Steering Committee (2009) project that prostate cancer will continue as the leading type of cancer in Canadian men, with an estimated 25,500 newly diagnosed cases. As

• • • • •

tract Bladder stones High urinary pH High cholesterol intake Pelvic radiation therapy Cancers arising from the prostate, colon, and rectum in males

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• some cyclic N-nitrosomines • arsenic The risk of bladder cancer is associated with the number of cigarettes smoked per day, the number of years a person has smoked and the age at which a person started smoking (Canadian Cancer Society, 2013c).

Clinical Manifestations Bladder tumours 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. However, any alteration in voiding or change in the urine 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, CT, ultrasonography, and bimanual examination with the patient anaesthetized. Biopsies of the tumour 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 and staging, especially for patients at high risk for recurrence of primary bladder tumours. Although the mainstay diagnostic tools such as cytology and CT have a high detection rate, they are costly. Newer diagnostic tools such as bladder tumour antigens, nuclear matrix proteins, adhesion molecules, cytoskeletal proteins, and growth factors are being studied to support the early detection and diagnosis of bladder cancer. Regular cystoscopy continues to be the standard test for finding bladder cancer (Canadian Cancer Society, 2013a).

Medical Management Treatment of bladder cancer depends on the grade of the tumour (the degree of cellular differentiation), the stage of tumour growth (the degree of local invasion and the presence or absence of metastasis), and the multicentricity (having many centres) of the tumour. 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 tumours). These procedures, described in more detail in Chapter 50, eradicate the tumours through surgical incision or electrical current with the use of instruments inserted through the urethra. After this bladder-sparing surgery, intravesical administration of bacille Calmette-Guérin (BCG) is the treatment of choice. BCG is an attenuated live strain of Mycobacterium bovis, the causative agent for tuberculosis. The exact action of BCG is unknown, but it is thought to produce a local

inflammatory as well as a systemic immunologic response (Sharma, Old, & Allison, 2007). 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 tumours 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 tumours. A simple cystectomy 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. This is described later in this chapter. Although radical cystectomy remains the standard of care for invasive bladder cancer, researchers are exploring trimodality therapy—transurethral resection of the bladder tumour, radiation, and chemotherapy—in an effort to spare patients the need for cystectomy. This approach to transitional cell bladder cancer mandates lifelong surveillance with periodic cystoscopy. Although most patients respond completely and their bladders remain free from invasive relapse, one fourth develop a relapse of noninvasive disease. This may be managed with transurethral resection of the bladder tumour and intravesical therapies but carries an additional risk that a late cystectomy may be required (Wein et al., 2007).

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. IV chemotherapy may be accompanied by radiation therapy. 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 of recurrence, when cancer in situ is present, or when tumour resection has been incomplete. Topical chemotherapy delivers a high concentration of medication (thiotepa, doxorubicin, mitomycin, ethoglucid, and BCG) to the tumour to promote tumour destruction. 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 (Wein et al., 2007). BCG is now considered the most effective intravesical agent for recurrent bladder cancer, especially superficial transitional cell carcinoma, because it is an immunotherapeutic agent that enhances the body’s immune response to cancer. BCG has a 43% advantage in preventing tumour 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

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to intravesical chemotherapy, BCG has also been shown to decrease the risk of tumour 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 for tumours that do not respond. In high-risk cancers, maintenance BCG administered in a 3-week course at 6, 12, 18, and 24 months may limit recurrence and prevent progression (Sharma et al., 2007). However, the adverse effects associated with this prolonged therapy may limit its widespread applicability. The patient is allowed to eat and drink before the instillation procedure. 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 tumour may be performed preoperatively to reduce microextension of the neoplasm and viability of tumour 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 inoperable tumours. 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 tumour 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 has received renewed interest with regulatory approval of several photosensitizing drugs and light applicators as potential palliative and curative treatments (Huang, 2005).

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 tumour necessitates cystectomy. Urinary diversion has also been used in managing pelvic malignancy, birth defects, strictures, trauma to the ureters and urethra, neurogenic bladder, chronic infection causing severe ureteral and renal damage, and intractable interstitial cystitis. It may also be used as a last resort in managing incontinence. Controversy exists regarding 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

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patient’s learning ability and willingness to participate in postoperative care are all taken into consideration when determining the appropriate surgical procedure. 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. There are two types of urinary diversion. In a cutaneous urinary diversion, urine drains through an opening created in the abdominal wall and skin (Fig. 46-7). In a continent urinary diversion, a portion of the intestine is used to create a new reservoir for urine (Fig. 46-8).

Cutaneous Urinary Diversions Ileal Conduit The ileal conduit (ileal loop) is the oldest and most common of the urinary diversion procedures in use 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 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 (Diepenbrock, 2007). 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 inspected and the patency of the stent and the urine output to be monitored. The ileal bag drains urine (not feces) continuously. The appliance (bag) usually remains in place as long as it is watertight; it is changed when necessary to prevent leakage of urine.

Complications 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 gangrene of the stoma. Delayed complications include ureteral obstruction, contraction or narrowing of the stoma (stenosis), renal deterioration due to chronic reflux, pyelonephritis, and renal calculi.

Nursing Management In the immediate postoperative period, urine volumes are monitored hourly. Throughout the patient’s hospitalization,

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Ileal segment

A 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).

B Cutaneous ureterostomy.

C Vesicostomy. The surgeon sutures the bladder to the abdominal wall and creates an opening (stoma) through the abdominal and bladder walls for urinary drainage.

D Nephrostomy.

The surgeon brings the detached ureter through the abdominal wall and attaches it to an opening in the skin.

The surgeon inserts a catheter into the renal pelvis via an incision in the flank or by percutaneous catheter placement into the kidney.

the nurse monitors closely for complications, reports signs and symptoms of them promptly, and intervenes quickly to prevent their progression. A urine output below 30 mL/hour may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis. After the physician’s order is obtained, a catheter may be inserted through the urinary conduit 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 carefully irrigate with 5 to 10 mL of sterile normal saline solution, being careful not to exert tension that could dislodge the stent. 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 a wound care specialist/enterostomal therapist. The stoma is inspected frequently for colour and viability. A healthy stoma is beefy red. A change from this normal colour to a dark purplish colour suggests that the vascular

FIGURE 46-7. Types of cutaneous diversions

include the conventional ileal conduit (A), cutaneous ureterostomy (B), vesicostomy (C), and nephrostomy (D).

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 (a) signs of irritation and bleeding of the stoma mucosa, (b) encrustation and skin irritation around the stoma (from alkaline urine coming in contact with exposed skin), and (c) wound infections.

Testing Urine and Caring for the Ostomy Moisture in bed linens or clothing or the odour 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 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.

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Stoma Indiana pouch

Kock pouch

Stoma

A Indiana pouch.

B Continent ileal urinary diversions (Kock pouch).

The surgeon introduces the ureters into a segment of ileum and cecum. Urine is drained periodically by inserting a catheter into the stoma.

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 Rectum

Juncture of pouch and urethra

FIGURE 46-8. Types of continent urinary

diversions include the Indiana pouch (A), the Kock pouch (B, C), also called a continent ileal diversion, and a ureterosigmoidostomy (D).

C

D Ureterosigmoidostomy.

In male patients, the Kock 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.

The surgeon introduces the ureters into the sigmoid colon, thereby allowing urine to flow through the colon and out of the rectum.

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 anxiety in many patients. 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.

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. A wound care specialist/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 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

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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 46-14. Controlling Odour. The patient is instructed to avoid foods that give the urine a strong odour (e.g., asparagus, cheese, eggs). Today, most appliances contain odour 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 odours. Ascorbic acid by mouth helps to acidify the urine and suppress urine odour. Patients should be cautioned not to put aspirin tablets in the pouch to control odour, as they may ulcerate the stoma. Also, the patient is reminded that odour will develop if the pouch is worn longer than recommended 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 more urine will cause the pouch to separate from the skin. 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 deodourizing solution for 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 air-drying. CONTINUING CARE. Follow-up care is essential to determine how the patient has adapted to the body image changes as well as 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 (e.g., 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 size of the stoma is measured 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 larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage. The nurse teaches the patient and family about resources (see the Resources and Web Sites section). Local chapters of

the Canadian Cancer Society can provide resources for the patient who has undergone ostomy surgery for cancer. The home care nurse assesses the patient for potential long-term complications such as ureteral obstruction, stenosis, hernias, or deterioration of renal function and reinforces previous teaching about these complications.

Cutaneous Ureterostomy Cutaneous ureterostomy (Fig. 46-7), 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 (i.e., advanced pelvic cancer) because it requires less extensive surgery than other urinary diversion procedures. It is also an appropriate procedure 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.

Continent Urinary Diversions Continent Ileal Urinary Reservoir (Indiana Pouch) The most common continent urinary diversion is the Indiana pouch, created for the patient whose bladder is removed or no longer functions. The Indiana pouch uses a segment of the ileum and cecum to form the reservoir for urine (Fig. 46-8A). The ureters are tunnelled 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 collects in the pouch until a catheter is inserted and the urine is drained (Diepenbrock, 2007). 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, and Penrose drain as well as a urethral catheter). All drainage tubes must be carefully monitored for patency and amount and type of drainage. In the immediate postoperative period, the cecostomy tube is irrigated two or three times daily to remove mucus and prevent blockage. Other variations of continent urinary reservoirs include the Kock pouch (U-shaped pouch constructed of ileum, with a nipple-like one-way valve; see Fig. 46-8B 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.

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CHART 46-13

Patient Education: Using Urinary Diversion Collection Appliances Applying a Reusable Pouch System 1. Gather all necessary supplies. 2. Prepare the new appliance according to the manufacturer’s directions. • Apply a double-faced adhesive disk that has been properly sized to fit the reusable pouch faceplate. Remove paper backing and set the pouch aside, or apply a thin layer of contact cement to one side of the reusable pouch faceplate. Set the pouch aside. 3. Remove the soiled pouch gently. Lay it aside to clean later. 4. Clean the peristomal skin (skin around the stoma) with a 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) over the stoma to absorb urine and keep the skin dry throughout the appliance change. 6. Inspect the peristomal skin for irritation. 7. A skin protector wipe or barrier ring may be applied before centering the faceplate opening directly over the stoma. 8. Position the appliance over the 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 the soiled pouch, and prepare it for reuse.

6. Inspect the peristomal skin (skin around the stoma) for irritation. 7. Use a wick (rolled gauze pad or tampon) over the stoma to absorb urine and keep the skin dry during the appliance change. 8. Centre the opening of the skin barrier over the stoma and, apply it with firm, gentle pressure to attain a watertight seal. 9. If using a two-piece system, snap the pouch onto the flanged wafer that adheres to the skin. 10. Close the drainage tap or spout at the bottom of the pouch. 11. A pouch cover can be used or cornstarch applied under the pouch to prevent perspiration and skin irritation. 12. Apply hypoallergenic tape around the skin barrier in a picture-frame manner. 13. Dispose off the soiled appliance.

Applying a Disposable Pouch System 1. Gather all necessary supplies. 2. Measure the stoma, and prepare an opening in the skin barrier about 3 millimetres (1/8-inch) larger than the stoma and the same shape as the stoma. 3. Remove the paper backing from the skin barrier, and set it aside. 4. Gently remove the old appliance, and set it aside. 5. Clean the peristomal skin with warm water, and dry it thoroughly.

Ureterosigmoidostomy Ureterosigmoidostomy, another form of continent urinary diversion, is an implantation of the ureters into the sigmoid colon (see Fig. 46-8D). 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. 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. However, patients have the advantage of urinary control without having to wear an external appliance.

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.

Nursing Management

Monitoring Fluid and Electrolytes

In addition to the usual preoperative regimen, the patient may be placed on a liquid diet for several days preoperatively

In ureterosigmoidostomy, larger areas of the bowel mucosa are exposed to urine and electrolyte reabsorption. As a

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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 IV fluids. Acidosis may be prevented by placing the patient on a lowchloride 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 dysuria.

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 gasforming foods (flatus can cause stress incontinence and offensive odours). 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.

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, warranting lifelong medical follow-up.

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Nursing Process

The Patient Undergoing Urinary Diversion Surgery Preoperative Assessment The following are key preoperative nursing assessment concerns: • Cardiopulmonary function assessments are performed because patients undergoing cystectomy are often older people who may be at greater risk for cardiac and respiratory complications. • 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

Preoperative Planning and Goals

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. However, the Camey procedure applies only to men because the entire urethra is removed when a cystectomy is performed in women.

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 anxiety related to changes in body image. Patients may face problems adapting to an external appliance, a stoma, a surgical incision, and altered toileting habits. Men must also adapt to sexual impotency; a penile implant is considered if the patient is a candidate for the procedure. Women also have anxiety related to altered appearance, body image, and selfesteem. A supportive approach, both physical and psychosocial, is needed and includes assessing the

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patient’s self-concept and manner of coping with stress and loss; helping the patient 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.

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. In addition, 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 tumour, 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 Participation of a wound care specialist/enterostomal therapist is invaluable for informed preoperative teaching and postoperative care planning. 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, and lying down to locate the stoma away from bony prominences, skin creases, and 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 is or may be allergic to latex (see Chapter 18).

Preoperative Evaluation To measure the effectiveness of care, the nurse evaluates the patient’s preoperative anxiety level and nutritional status as well as pre-existing knowledge and expectations of surgery.

Expected Patient Outcomes Expected patient outcomes may include the following: 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

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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, equipment, 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 colour 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 need for pain control is assessed regularly, as with all postoperative patients.

Postoperative Diagnosis Nursing Diagnoses Based on 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 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 • Stoma ischemia and necrosis due to compromised blood supply to stoma • Stoma retraction and separation of mucocutaneous border due to tension or trauma

Postoperative Planning and Goals The major goals for the patient may include maintaining skin integrity, relieving pain, increasing self-esteem,

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developing appropriate coping mechanisms to accept and deal with altered urinary function and sexuality, increasing knowledge about management of urinary function, and preventing potential complications.

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 monitored, 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, IV fluids and electrolytes are administered. The patient is assisted to ambulate as soon as possible to prevent complications of immobility.

Maintaining Skin Integrity Strategies to promote skin integrity begin with reducing and controlling those factors that increase the patient’s risk of 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 results in maintenance of skin integrity and patient comfort. Additionally, maintenance of skin integrity around the stoma enables the patient and family to adjust more easily to the alterations in urinary function and helps them 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 perform deep-breathing exercises. Patient-controlled analgesia (PCA) 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 self-esteem 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 toilet-

ing habits. The nurse can also help to 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 this loss. Encouraging the patient 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 counselling 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 respiratory complications (e.g., atelectasis, pneumonia), fluid and electrolyte imbalances, breakdown of any anastomosis, 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 output 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. STOMA ISCHEMIA AND NECROSIS. The stoma is monitored because ischemia and necrosis of the stoma can result from tension on the mesentery blood

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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 colour changes to purple, brown, or black. These changes are reported immediately to the physician. The physician or wound care specialist/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. STOMA 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 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 nurse and wound care specialist/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. Follow-up telephone calls from the nurse to the patient and family after discharge may provide added support as well as 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 46-13. The patient is encouraged to participate in decisions regarding the type of collecting appliance and the time

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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: • 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, stenosis of the stoma, deterioration in renal function, or incontinence. 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 of Canada and any local ostomy support groups to provide ongoing support, assistance, and education.

Postoperative Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Maintains skin integrity a. Maintains intact skin and demonstrates skill in managing drainage system and appliance b. States actions to take if skin excoriation occurs 2. Reports relief of pain 3. Exhibits improved body image 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

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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 counsellor 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, nurse, 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 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 appropriate in size without edema f. Has intact and healed border of the stoma

Critical Thinking Exercises 1

As the supervisor in a long-term care facility, you are approached by the daughter of one of the residents. She requests that her mother, who can ambulate with assistance, have an indwelling urinary catheter inserted “for convenience sake.” What is the evidence base that supports your response? Identify the criteria used to evaluate the strength of the evidence.

2

As one of the nurses in a busy urology practice, you are performing telephone triage. A 62-year-old man who was seen 2 days ago for increasing urinary frequency, including several awakenings at night, phones to report increasing abdominal pain. He states that he has not voided for more than 12 hours, although he has made several unsuccessful attempts. Explain the instructions you would provide. What medical and nursing interventions would you anticipate?

3 A 50-year-old woman comes for her annual pelvic checkup with complaints of occasional urinary urgency, sometimes with “near incontinences” just as she reaches the toilet. She denies the intake of any potentially bladderirritating substances, such as beverages containing caffeine or synthetic sweeteners. She also mentions that she is having difficulty with decreased lubrication during intercourse, and her menses are irregular. On physical examination, thinning of the vaginal mucosa is noted. Identify the evidence for and the criteria used to evaluate the strength of the evidence for and against the use of estrogen in maintaining continence. 4 A 55-year-old man returns to your unit following a Camey procedure after cystectomy for bladder cancer. What immediate nursing assessment and interventions should you take at this time? Describe the nursing diagnoses and plan of care in the postoperative period. How will you modify the plan if the patient is a 75-year-old?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Blondel-Hill, E., & Fryters, S. (2012). Bugs and Drugs - an antimicrobial/ infectious disease reference. Alberta Health Services; Edmonton, Alberta. Canadian Cancer Society’s Steering Committee (2009). Canadian Cancer Statistics 2009. Toronto, ON: Canadian Cancer Society. Diepenbrock, N. H. (2007). Quick reference to critical care (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Dudek, S. G. (2006). Nutrition essentials for nursing practice (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Karch, A. (2014). 2014 Lippincott’s nursing drug guide. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins. Karpoff, S., & Labus, D. (Eds.). (2008). Portable diagnostic tests. Philadelphia, PA: Lippincott Williams & Wilkins. Miller, C. A. (2011). Nursing for wellness in older adults. Philadelphia, PA: Lippincott Williams & Wilkins. Morton, P. G., Fontaine, D. K., Hudak, C. M., et al. (2005). Critical care nursing: A holistic approach (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Porth, C. M., & Matfin, G. (2009). Pathophysiology (8th ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins. Schnell, Z., Leeuwen, A., & Kranpitz, T. (2006). Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications (2nd ed.). Philadelphia, PA: F. A. Davis. Stanley, M., Blair, K. A., & Beare, P. G. (2005). Gerontological nursing: Promoting successful aging with older adults (3rd ed.). Philadelphia, PA: FA Davis. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Wein, A., Kavoussi, L. R., Novick, A. C., et al. (Eds.). (2007). CampbellWalsh urology (9th ed.). Philadelphia, PA: WB Saunders Elsevier.

JOURNALS AND ELECTRONIC DOCUMENTS General Burrows-Hudson, S. (2005). Chronic kidney disease: An overview: Early and aggressive treatment is vital. American Journal of Nursing, 105(2), 40–50. Hanson, K. (2003a). Laboratory studies in the evaluation of urological disease: Part I. Urologic Nursing, 23(6), 400–404. Hanson, K. (2003b). Laboratory studies in the evaluation of urological disease: Part II. Urologic Nursing, 23(6), 405–414. Toughill, E. (2005). Indwelling catheters: Common mechanical and pathogenic problems. American Journal of Nursing, 105(5), 35–37. Infections of the Urinary Tract Baudry-Simner, P. J., Singh, A., Karlowsky, J. A., et al. (2012). Mechanisms of reduced susceptibility to ciprofloxacin in Escherichia coli isolates from Canadian hospitals. Canadian Journal of Infectious Disease and Medical Microbiology. 23(3), e60–e64. Goldrick, B. (2005). Infection in the older adult. Long term care poses particular risk. American Journal of Nursing, 105(6), 31–34. Jackson, S. L., Boyko, E. J., Scholes, D., et al. (2004). Predictors of urinary tract infection after menopause: A prospective study. American Journal of Medicine, 117(12), 903–911. Kidney Foundation of Canada. (2007). Urinary tract infections. Retrieved from http://www.kidney.ca/files/Kidney/a29723_UrinTract_Eng.pdf Laupland, K. B., Ross, T., Pitout, J. D. D., et al. (2007). Community-onset urinary tract infections: A population-based assessment. Infection, 35(3), 150–153. McMurdo, M. E., Bissett, L. Y., Price, R. J., et al. (2005). Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? Age and Ageing, 34(3), 256–261.

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Mehnert-Kay, S. A. (2005). Diagnosis and management of uncomplicated urinary tract infections. American Family Physician, 72(3), 451–456. Midthum, S. (2004) Criteria for urinary tract infection in the elderly: Variables that affect nursing assessment. Urologic Nursing, 24(3), 157–169. Moore, K., Day, R. A., & Albers, M. (2002). Pathogenesis of urinary tract infections: A review. Journal of Clinical Nursing, 11, 568–574. Public Health Agency of Canada. (2012). The Canadian nosocomial infection surveillance program. Retrieved from http://www.phac-aspc.gc.ca/ nois-sinp/survprog-eng.php Public Health Agency of Canada. (2013). The chief public health officer’s report on the state of public health in Canada, 2013 infectious disease – the never-ending threat. Retrieved from http://www.phac-aspc.gc.ca/ cphorsphc-respcacsp/2013/index-eng.php#toc

Sampselle, C. (2003). Teaching women to use a voiding diary. American Journal of Nursing, 103(11), 62–64. Specht, J. (2005). Nine myths of incontinence in older adults. American Journal of Nursing, 105(6), 58–70. *Vinsnes, A. G., Harkless, G. E., & Nyronning, S. (2007). Unit-based intervention to improve urinary incontinence in frail elderly. Journal of Nursing Research and Clinical Studies, 27(3), 53–56. Wilde, M. H. (2004). Urinary catheter management for the older adult patient. Clinical Geriatrics, 12(4), 26–32.

Adult Voiding Dysfunction

Urinary Tract Cancers

Canadian Continence Foundation. (2014). Incontinence: A Canadian perspective. Retrieved from http://www.continence-fdn.ca/pdf/Research_ paper_August2007.pdf Cody, J. D., Jacobs M. L., Richardson K., et al. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database of Systematic Reviews, 10, CD001405. DOI: 10.1002/14651858.CD001405. pub3 Davila, W. G. (2011). Nonsurgical outpatient therapies for the management of female stress urinary incontinence: Long-term effectiveness and durability: A review article. Advances in Urology, 2011, 176498, doi:10.1155/2011/176498 Diokno, A. C., Sampselle, C. M., Herzog, A. R., et. al. (2004). Prevention of urinary incontinence by behavioral modification program: A randomized, controlled trial among older women in the community. Journal of Urology, 171(3), 1165–1171. Fick, D. M., Cooper, J., Waller, J., et al. (2003). Updating criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine, 163(22), 2716–2724. Gokula, R. (2004). Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. American Journal of Infection Control, 4(32), 196–199. Hunter, K. F., Moore, K. N., & Glazener, C. M. A. (2007). Conservative management for postprostatectomy urinary incontinence. Cochrane Database of Systematic Reviews, (2), CD001843, DOI: 10.1002/14651858. CD001843.pub3 Jabs, C., & Carleton, E. (2013). Efficacy of botulinum toxin A intradetrusor injections for non-neurogenic urinary urge incontinence: A randomized double-blind controlled trial. Journal of Obstetrical Gynecology of Canada, 35(1), 53–60. *Klay, M., & Marfyak, K. (2005). Use of a continence nurse specialist in an extended care facility. Urologic Nursing, 25(2), 101–108. Lekan-Rutledge, D. (2004). Urinary incontinence strategies for frail elderly women. Urologic Nursing, 24(4), 281–301. Lekan-Rutledge, D., Doughty, D., Moore, K., et al. (2003). Promoting social continence: Products and devices in the management of urinary incontinence. Urologic Nursing, 23(6), 416–458. Li, J., Yang, L., Chunxiao, P. (2013). The role of duloxetine in stress urinary incontinence: A systematic review and meta-analysis. International Urology and Nephrology, 45(3), 679–686. Mennick, F. (2005). Urinary incontinence worsens with menopausal hormone therapy. American Journal of Nursing, 105(7), 22. *Muller, N. (2005). What Americans understand and how they are affected by bladder control problems: Highlights of recent nationwide consumer research. Urologic Nursing, 25(2), 109–115. Newman, D. (2003). Stress urinary incontinence in women. American Journal of Nursing, 103(8), 46–56. Newman, D. (2004). Incontinence products and devices for the elderly. Urologic Nursing, 24(4), 317–333. Palmer, M. (2004). Physiologic and psychologic age-related changes that affect urologic clients. Urologic Nursing, 24(4), 247–252. Robinson, D., & Cardozo, L. (2011). Estrogens and the lower urinary tract. Neurourology and Urodynamics, 30, 754–757.

Canadian Cancer Society. (2013a). Research and development in bladder cancer. Retrieved from http://www.cancer.ca/en/cancer-information/ cancer-type/bladder/research-and-development/ Canadian Cancer Society. (2013b). Risk factors for bladder cancer. Retrieved from http://www.cancer.ca/en/cancer-information/cancertype/bladder/risks/ Canadian Cancer Society. (2013c). Causes of bladder cancer. Retrieved from http://www.cancer.ca/Canada-wide/About%20cancer/Types%20 of%20cancer/Causes%20of%20bladder%20cancer.aspx?sc_lang=en Huang, Z. (2005). A review of progress in clinical photodynamic therapy. Technology in Cancer Research and Treatment, 4(3), 283–293. Sanger, C., Busche, A., Bentien, G., et al. (2004). Immunodominant PstS1 antigen of mycobacterium tuberculosis is a potent biological response modifier for the treatment of bladder cancer. BioMedCentral Cancer, 86(4), 1471–2407. Retrieved July 14, 2008, from http://www. biomedcentral.com/1471-2407/4/86 Sharma, P., Old, L. J., & Allison, J. P. (2007). Immunotherapeutic strategies for high-risk bladder cancer. Seminars in Oncology, 34(2), 165–172.

Urolithiasis and Nephrolithiasis *Schnelle, J. (2003). Translating clinical research into practice: A randomized controlled trial of exercise and incontinence care with nursing home patients. Journal of American Geriatric Society, 50(9), 1476–1483.

Genitourinary Trauma Armenakas, N. A., Pareek, G., & Fracchia, J. A. (2004). Iatrogenic bladder perforations: Long-term follow-up of 65 patients. Journal of the American College of Surgeons, 198(1), 78–82. Ziran, B., Chamberlin, E., Shuler, F. D., et al. (2005). Delays and difficulty in the diagnosis of lower urologic injuries in the context of pelvic fractures. Journal of Trauma-Injury and Critical Care, 58(3), 533–537. Urinary Diversions Quallich, S. A., & Ohl, D. (2003a). Artificial urinary sphincter. Part I: Overview. Urologic Nursing, 23(4), 259–268. Quallich, S. A., & Ohl, D. (2003b). Artificial urinary sphincter. Part II: Patient teaching and perioperative care. Urologic Nursing, 23(4), 269–273. Quallich, S. A., & Ohl, D. (2003c). Artificial urinary sphincter case study. Urologic Nursing, 23(4), 274–275.

RESOURCES Association de la C.I. du Québec: http://www.cystiteinterstitielle.org/. Canadian Association of Enterostomal Therapy: http://www.caet.ca. Canadian Association of Nephrology Nurses and Technologists: http:// www.cannt.ca. Canadian Association of Transplantation: http://www.transplant.ca. Canadian Cancer Society and National Cancer Institute of Canada: http://www.cancer.ca. Canadian Continence Foundation: http://www.continence-fdn.ca. Interstitial Cystitis Association, http://www.ichelp.com. Kidney Foundation of Canada: http://www.kidney.ca United Ostomy Association of Canada: http://www.ostomycanada.ca Urology Nurses of Canada: http://www.unc.org/ Wound, Ostomy and Continence Nurses Society; http://www.wocn.org.

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Case Study Applying Concepts From NANDA, NIC, and NOC A Patient With a Difficult Health Care Choice Involving Losses Mrs. Cole is a 49-year-old woman who has been undergoing cancer staging after positive breast biopsy results. The surgeon has informed her that she has stage IIB infiltrating ductal carcinoma. The surgeon has discussed with her two different surgical approaches—breast conserving or modified radical mastectomy (MRM). If she chooses MRM, Mrs. Cole must decide whether she will undergo breast reconstruction or use a breast prosthesis. The nurse notes that Mrs. Cole is trembling and near tears. Mrs. Cole tells the nurse that she is uncertain about how her husband will respond if she chooses MRM. She is also concerned that she will not feel feminine after MRM but states she is very frightened about anything less since a friend died of metastatic breast cancer. Visit to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems.

Reproductive Function

A patient with a difficult health care choice involving losses receives the nursing diagnoses Decisional Conflict

requires

requires nursing interventions Active Listening and

outcomes should show improvement in may enhance

may enhance

Decision-Making Support and and

Grieving

requires

Decision Making

and may enhance

Grief Resolution

Anticipatory Guidance and may enhance

and

Grief Work Facilitation Psychosocial Adjustment: Life Change

and may enhance Emotional Support

and

and and Situational Low Self-Esteem

requires

Self-Esteem Enhancement

supports increased

Self-Esteem

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes Return to functional baseline status, stabilization of, or improvement in:

Decisional Conflict—Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to personal life values

Active Listening—Attending closely to and attaching significance to a patient’s verbal and nonverbal messages

Decision Making—Ability to make judgments and choose between two or more alternatives

Anticipatory Grieving—Intellectual and emotional responses and behaviours by which individuals, families, and communities work through the process of modifying self-concept based on the perception of potential loss

Decision-Making Support— Providing information and support for a patient who is making a decision regarding health care

Grief Resolution—Adjustment to actual or impending loss

Anticipatory Guidance—Preparation of a patient for an anticipated developmental and/or situational crisis

Psychosocial Adjustment: Life Change—Adaptive psychosocial response of an individual to a significant life change

Grief Work Facilitation—Assistance with the resolution of a significant loss Emotional Support—Provision of reassurance, acceptance, and encouragement during times of stress From Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2012). Nursing interventions classification (NIC) (6th ed.). St. Louis: Mosby; Johnson, M., Moorhead, S., Bulechek, G. M., et al. (2011). NOC and NIC linkages to NANDA-1 and clinical conditions: Supporting critical reasoning and quality care (NANDA, NOC, and NIC linkages) (3rd ed.). St. Louis, MO: Mosby; Moorhead, S., Johnson, M., Mass, M. L., et al. (2012). Nursing outcomes classification (NOC) (5th ed.). St. Louis: Mosby; NANDA International. (2011). Nursing diagnoses: Definitions & classification 2012–2014 (9th ed.) Hoboken, NJ: Wiley-Blackwell.

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47 Assessment and Management of Female Physiologic Processes Adapted by Jean Chow

Learning Objectives 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 methods of identifying and treating women who are survivors of abuse. 4. 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. 5. Identify types of menstrual disorders and related nursing implications. 6. Describe nursing care for patients with premenstrual syndrome. 7. Develop a teaching plan for women who are approaching or have completed menopause. 8. Describe methods of contraception and implications for health care and education. 9. Describe the nursing management of the patient having an abortion. 10. Describe the causes and management of infertility. 11. Use the nursing process to plan for the care of the patient with an ectopic pregnancy. 12. Discuss the healthy older woman and health teaching related to aging.

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Women are becoming more knowledgeable about their health. Nurses who work with them need to understand normal female anatomy and physiology and the physical, developmental, psychological, and sociocultural influences on women’s health, health practices, and use of health care resources. Health assessment, maintenance, and promotion across the lifespan must consider women’s growth and development, sexuality, contraception, preconception care, conception, prenatal care, effects of pregnancy on health, perimenopause, menopause, and aging. It is also necessary to consider how medications and diseases affect women. In addition, women’s sexuality is complex and often affected by many factors, and related issues need careful evaluation and treatment. 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 improves quality and access for women and their families.

ROLE OF NURSES IN WOMEN’S HEALTH As their presence in the labour market continues to increase, women face challenges in their roles, lifestyles,

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and family patterns. Furthermore, they encounter environmental hazards and stress, prompting greater attention on health and health-promoting practices. As a result, many women are taking a greater interest in and responsibility for their own health and health care, although not all women have the time, finances, or other resources to do so. In recent years, many women have delayed pregnancy and childbearing until well after they have established careers, in part because of the wide variety of contraceptive methods that are available. Advances in the treatment of infertility have enabled many women previously unable to have children to become pregnant and have allowed couples well into their 40s to have children. Women who have many roles and multiple responsibilities (e.g., workers, wives, mothers, parental caretakers) often “multitask”; they have little time for themselves and often put the needs of others before their own health needs. Nurses must be sensitive to these needs and knowledgeable about preventive health care for women. Nurses are in an ideal position to encourage women to determine their own health goals and behaviour, teach about health promotion and illness prevention, offer intervention strategies, and provide support, counselling, and ongoing monitoring.

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 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: condition in which endometrial tissue implants in other areas of the pelvis; may produce dysmenorrhea or infertility endometrium: lining of 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: perineal opening to the vagina 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 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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Reproductive Function

Areas of special interest in health promotion include the following: • Normal physical changes and optimal personal hygiene • Strategies for detecting and preventing disease, especially sexually transmitted diseases (STDs), also referred to as sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) • Issues related to sexuality and sexual function, such as contraception; preconception, prenatal, and postnatal care; sexual satisfaction; and menopause • Diet, exercise, and health-promoting practices that maintain and enhance health, including having a normal weight for height • Appropriate stress management to reduce the detrimental effects of stress on health and well-being • Treatment for substance abuse and smoking Nurses need to model a healthy lifestyle for their patients. It is important that nurses promote positive practices and behaviour related to the reproductive and sexual health of all patients. Necessary strategies include the following: • Recommending regular examinations to promote health, detect health problems at an early 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 (crucial in providing nursing and health care, especially when patients are discussing personal issues). Nurses must convey understanding and sensitivity and be alert to cues about unspoken patient concerns • 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

ASSESSMENT OF THE FEMALE REPRODUCTIVE SYSTEM Anatomic and Physiologic Overview

Mons pubis Prepuce Clitoris Labia majora Urinary meatus Labia minora Vaginal V introitus Hymen Perineum Anus FIGURE 47-1. External female genitalia.

sensitive organ composed of erectile tissue. Between the labia minora, below and posterior to the clitoris, is the urinary meatus, the external opening of the female urethra, which is about 3 cm (less than 1.5 in) long. Below this orifice is a larger opening, the vaginal orifice or introitus (Fig. 47-1). 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. 47-2).

Vagina The vagina, a canal lined with mucous membrane, is 7.5 to 10 cm (3 to 4 in) 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).

Anatomy of the Female Reproductive System

Fallopian tube Fundus of uterus

The female reproductive system consists of external and internal pelvic 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

Isthmus Interstitial Ampulla portion

Ovary Ovarian ligament Round Uterus: ligament Corpus Isthmus Vagina

Infundibulum

Cervix Internal os Cervical canal External os

FIGURE 47-2. Internal female reproductive structures.

Fimbria Broad ligament

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Uterus

Menstrual Cycle

The uterus, a pear-shaped, muscular organ, is about 7.5 cm (3 in) long and 5 cm (2 in) wide at its upper part. Its walls are about 1.25 cm (0.5 in) thick. The size of the uterus varies, depending on parity (number of viable births) and uterine abnormalities (e.g., fibroids, which are a type of tumour 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 (Hannon, Pooler, & Porth, 2010).

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 (Hannon et al., 2010). 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 and adrenal glands, but only in small amounts. These hormones are involved in the early development of the follicle and also affect the female libido (Hannon et al., 2010). Two gonadotropic hormones are released by the pituitary gland: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH is primarily responsible for stimulating the ovaries to secrete estrogen. 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. 47-3, Table 47-1). This cycle is typically 28 days in length, but there are many normal variations (from 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. In the luteal phase, which begins after ovulation, progesterone is secreted by 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, menstrual flow, consisting of old blood, mucus, and endometrial tissue, is discharged

Ovaries The ovaries lie behind the broad ligaments and behind and below the fallopian tubes. They are oval bodies about 3 cm (1.2 in) 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 At puberty (usually between 12 and 14 years of age, but earlier for some; 10 or 11 years of age is not uncommon), the ova begin to mature and menstrual cycles begin. In the follicular phase, an ovum enlarges as a type of cyst called a graafian follicle until it reaches the surface 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 is penetrated by 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.

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Reproductive Function

●

smaller. No more ova mature; therefore, no ovarian hormones are produced. (An earlier menopause may occur if the ovaries are surgically removed or are destroyed by radiation or chemotherapy or because of an unknown etiology.) Multifaceted changes also occur throughout the woman’s body. These changes are neuroendocrinologic, biochemical, and metabolic and are related to normal maturation or aging (Table 47-2).

Mature corpus luteum

ASSESSMENT

Early corpus luteum

A nurse who is obtaining information from a 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. Relevant topics include fitness, nutrition, cardiovascular risks, health screening, sexuality, menopause, abuse, health risk behaviour, emotional well-being, and immunizations. Recommendations for health screening are summarized in Chart 47-1.

Ovulation

Mature follicle

Health History

Growing follicle

In addition to the general health history, the nurse asks about past illnesses and experiences specific to a woman’s health. Data should be collected about the following:

Primary follicle Corpus albicans

Endometrial changes during menstrual cycle 25 26 27 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Menstruation

Day

Ovulation Menstrual cycle

Times approximate

FIGURE 47-3. One menstrual cycle and the corresponding changes in the endometrium.

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 (Hannon et al., 2010).

Menopausal Period The menopausal period marks the end of a woman’s reproductive capacity. It usually occurs between 45 and 52 years of age but may occur as early as 42 or as late as 55; the median age is 51 years. Perimenopause precedes this and can begin as early as 35 years of age. Physical, emotional, and menstrual changes may occur, and this transition offers another opportunity for health promotion and disease prevention teaching and counselling. Menopause is not a pathologic phenomenon but a normal part of aging and maturation. Menstruation ceases, and because the ovaries are no longer active, the reproductive organs become

• Menstrual history (including menarche, length of cycles, duration and amount of flow, presence of cramps or pain, bleeding between periods or after intercourse, bleeding after menopause) • Pregnancies (number of pregnancies, outcomes of pregnancies) • Exposure to medications (diethylstilbestrol [DES], immunosuppressive agents, others) • Pain with menses (dysmenorrhea), pain with intercourse (dyspareunia), pelvic pain • Symptoms of vaginitis (i.e., odour or itching) • Problems with urinary function, including frequency, urgency, and incontinence • Bowel problems • Sexual history • STDs and methods of treatment • Current or previous sexual abuse or physical abuse • Past surgery or other procedures on reproductive tract structures (including female genital mutilation [FGM] or female circumcision) • Chronic illness or disability that may affect health status, reproductive health, need for health screening, or access to health care • Presence of or family history of a genetic disorder. Chart 47-2 presents information about genetic reproductive disorders. In collecting data related to reproductive health, the nurse can teach the patient about normal physiologic processes, such as menstruation and menopause, and assess possible abnormalities. Many problems experienced by young or middle-age women can be corrected easily. However, if they are not treated, they may result in anxiety and health problems. Issues related to sexuality and sexual function are typically more often brought to the attention

CHAPTER 47

TABLE 47-1

1

2

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Hormonal Changes During the Menstrual Cycle

(Times approximate) Phase Menstrual Days

●

3

Follicular

4

5

6

7

8

9

10

11

12

13

Ovulation 14

15

16

17

18

Luteal 19

20

Premenstrual 21

22

23

24

25

26

27

28

1

2

Ovary Degenerating corpus luteum; beginning follicular development

Growth and maturation of follicle

Ovulation

Active corpus luteum

Degenerating corpus luteum

Estrogen Production Low

Increasing

High

Declining, then a secondary rise

Decreasing

Progesterone Production None

Low

Low

Increasing

Decreasing

FSH Production Increasing

High, then declining

Low

Low

Increasing

LH Production Low

Low, then increasing

High

High

Decreasing

Endometrium Degeneration and shedding of superficial layer. Coiled arteries dilate, then constrict again.

Reorganization and proliferation of superficial layer

Continued growth

Active secretion and glandular dilation; highly vascular; edematous

Vasoconstriction of coiled arteries; beginning degeneration

of the gynecologic or women’s health care provider than other health care providers; however, nurses caring for all women should consider these issues part of routine health assessment.

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 a woman’s sexuality and sexual practices and to promote sexual health. The sexual history may enable a patient to discuss sexual matters openly and to discuss sexual concerns with an informed health professional. This information can be obtained 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 TABLE 47-2

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 patient to label herself as single, married, widowed, or divorced may be considered by some women as inappropriate. 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, 1974). The assessment begins by introducing the topic and asking the woman for permission to discuss issues related to sexuality with her. The nurse can begin by explaining the purpose of obtaining a sexual history (e.g., “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 (e.g., “Are

Age-Related Changes in the Female Reproductive System

Cessation of ovarian function and decreased estrogen production

Relaxation of pelvic musculature

Physiologic Changes

Signs and Symptoms

Decreased ovulation Onset of menopause Vasomotor instability and hormonal fluctuations Decreased bone formation

Decreased/loss of ability to conceive; increased infertility 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 inflammation (atrophic vaginitis) with discharge, itching, and vulvar burning Dyspareunia, incontinence, feelings of perineal pressure

Decreased vaginal lubrication Thinning of urinary and genital tracts Increased pH of vagina Thinning of pubic hair and shrinking of labia Prolapse of uterus, cystocele, rectocele

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CHART 47-1

Summary of Health Screening and Counselling Issues for Women Ages 19–39 SEXUALITY AND REPRODUCTIVE ISSUES Annual pelvic examination Annual clinical breast examination Contraceptive options High-risk sexual behaviours HEALTH AND RISK BEHAVIOURS Hygiene Injury prevention Nutrition Exercise patterns Risk for domestic abuse Use of tobacco, drugs, and alcohol Life stresses Immunizations DIAGNOSTIC TESTING* Pap smear every 3 years after onset of sexual intercourse STD/STI screening as indicated

Ages 40–64 SEXUALITY AND REPRODUCTIVE ISSUES Annual pelvic examination Annual clinical breast examination Contraceptive options High-risk sexual behaviours Menopausal concerns HEALTH AND RISK BEHAVIOURS 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 every 2 to 3 years after three consecutive negative tests if no history of cervical abnormalities, HIV infection, or DES exposure 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 examination High-risk sexual behaviours HEALTH AND RISK BEHAVIOURS Hygiene Injury prevention Nutrition Exercise patterns Risk for domestic abuse Use of tobacco, drugs, and alcohol Life stresses Immunizations DIAGNOSTIC TESTING* Pap smear every 2 to 3 years after three consecutive negative tests if no history of cervical abnormalities, HIV infection, or DES exposure 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.

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. A patient can be asked about her thoughts on what is causing the current problem. Information about sexual function can be introduced during the health history. As the discussion progresses, the nurse may offer specific suggestions for interventions. A professional who specializes in sex therapy may provide more intensive therapy if necessary. By initiating an assessment about sexual concerns, the nurse communicates to the patient that issues about changes or problems in sexual functioning are valid health issues, which provides a safe environment for discussing these sensitive topics. Young women may be apprehensive about having irregular periods, may be concerned about STDs, or may need contraception. They may want information about 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 discomfort with intercourse. Women of any age may have concerns about relationships, sexual satisfaction, orgasm, or masturbation. Risk of STDs can be assessed by asking about the number of sexual 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 (e.g., “Do you have any questions or concerns about your sexual health?”). Women can be advised that intercourse should never be painful; pain should be investigated by a care provider. They should also be encouraged to talk openly about their sexual feelings with their partner.

Female Genital Mutilation or Cutting Female genital mutilation (FGM), or cutting, refers to the partial or total removal of the external female genitalia or

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GENETICS IN NURSING PRACTICE

Chart 47-2. 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 (e.g., Ashkenazi Jewish populations and hereditary breast/ovarian cancer mutations). • Inquire about relatives with other cancers, including earlyonset ovarian, uterine, renal, prostate cancers. Patient 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 genetics testing (DNA chromosomal, metabolic) has been carried out on affected family member(s).

other injury to female organs. Over 125 million girls and women worldwide have been subjected to this practice (WHO, 2013). Some cultures accept FGM as a rite of passage to womanhood and believe that this practice promotes hygiene, protects virginity and family honour, prevents promiscuity, improves female attractiveness and male sexual pleasure, and enhances fertility. FGM is considered an acceptable practice in many cultures, mostly in Africa and the Middle East. However, FGM is illegal in the Canada and many organizations (e.g., World Health Organization, Amnesty International) consider it a health and human rights issue and are working to end it. Many women entering the Canadian health care system underwent FGM before coming to Canada (Perron & Senikas, 2013), and others have undergone FGM since their arrival in this country. Some of these women think that the practice is acceptable and do not consider themselves mutilated, whereas others believe it to be harmful and feel that they have been traumatized. FGM is usually performed when a girl is between 4 and 14 years of age, but it may be performed on infants or adult women. Short-term complications of FGM include severe pain, urinary retention, genital ulceration, injury to adjacent tissues, and death (Perron & Senikas, 2013). Long-term complications include infection, keloid, repro-

• If indicated, refer for further genetics counselling and

• • • •

evaluation so that family members can discuss inheritance, risk to other family members, availability of genetics 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—a directory of support groups for patients and families with genetic conditions, www.geneticalliance. org Canadian Cancer Society—offers general information about cancer and support resources for families, www. cancer.ca Gene Clinics—a listing of common genetic disorders with up-to-date clinical summaries, genetic counselling and testing information, www.geneclinics.org National Organization of Rare Disorders—a directory of support groups and information for patients and families with rare genetic disorders, www.rarediseases.org National Cancer Institute—current information about cancer research, treatment, resources for health care providers, individuals and families, www.nci.nih.gov OMIM: Online Mendelian Inheritance in Man—a complete listing of inherited genetic conditions, www.ncbi.nlm.nih. gov/omim/stats/html

ductive tract infection, STIs, increased risk of HIV, birth complications, and psychological consequences such as fear of sexual intercourse and posttraumatic stress disorder. Because FGM can affect sexual function, menstrual hygiene, and bladder function, the possibility of FGM must be considered in the sexual history, particularly in women from cultures and countries where the practice is common. Nurses who care for patients who have undergone FGM need to be sensitive, empathetic, knowledgeable, culturally competent, and nonjudgmental (Burke, 2011). Respect for others’ health beliefs, practices, and behaviour, and recognition of the complexity of issues involved is crucial. The nurse should use the woman’s terminology. “Cutting” is a more acceptable term than mutilation. Speculums are not used in some developing countries; the function of this instrument should be explained and an appropriate-sized speculum used to examine women who have experienced FGM.

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. Abuse

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CHART 47-3

Managing Reported Domestic Abuse 1. Reassure the woman that she is not alone. Rationale: Women often believe that they are alone in experiencing abuse at the hands of their partners. 2. Express your belief that no one should be hurt, that abuse is the fault of the batterer and is against the law. Rationale: Doing so lets the woman know that no one deserves to be abused and that she has not caused the abuse. 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 about laws on reporting abuse, they need to check with their local or state domestic violence agency. Rationale: Women are often afraid that their information will be reported to the police or protective services and their children may be taken away. 4. Document the woman’s statement of abuse and take photographs of any visible injuries if written formal consent has

involves fear of one partner by another and control by threats, intimidation, and physical abuse. Abuse is related to the need to maintain control of a partner and is rooted in sex role inequality. In 2011, 173,600 women experienced violent crime. The most common violent offences included common assault (49%), uttering threats (13%), serious assault (10%), sexual assault (10%), and criminal harassment (stalking) (7%). Men were responsible for 83% of the police-reported violence against women. Women experiencing violence are encountered daily in nursing practice. Battering involves repeated physical or sexual assault in a context of coercive control and, more broadly, emotional degradation, threats, and intimidation. 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 behaviour but not without extensive counselling and motivation. If a woman states that she is being hurt, sensitive care is required (Chart 47-3). 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 and can save lives by making women safer through education and support. Asking each woman about violence in her life in a safe environment (i.e., a private room with the door closed) is part of a comprehensive assessment and universal screening. Asking about abuse directly is effective in identifying the presence of abuse and should be included in the health history of

been obtained. (Emergency departments usually have a camera available if one is not on the nursing unit.) Rationale: Doing so provides documentation of injuries that may be needed for later legal or criminal proceedings. 5. Provide teaching. Rationale: The following options may be lifesaving for the woman and her children: • 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 the woman that violence gets worse, not better. • If the woman chooses to go to a shelter, let her make the call. • If the woman 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 the woman 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.)

all women (Chart 47-4). The third and fourth questions of the screening questionnaire are specifically directed at abuse in women with disabilities. 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 (e.g., 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 department visits, vague pelvic pain, somatic complaints, and depression. CHART 47-4

Screening for Abuse Abuse Assessment Screen-Disability (AAS-D) • Within the last year, have you been hit, slapped, kicked,

pushed, shoved, or otherwise physically hurt by someone?

• Within the last year, has anyone forced you to have sexual activities?

• Within the last year, has anyone prevented you from using a wheelchair, cane, respiratory, or other assistive devices?

• Within the last year, has anyone you depend on refused to help you with an important personal need, such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink?

Center for Research on Women with Disabilities. Abuse Assessment ScreenDisability. www.bcm.edu/crowd/?PMID=1325m

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However, there may be no obvious signs or symptoms. Women in abusive situations often report that they do not feel well, possibly because of the stress of fear and anticipation of impending abuse. The assessment for abuse by health professionals has lagged behind community awareness and response (Gibbons, 2011; Hooker, Ward, & Verrinder, 2012). In addition to asking about domestic abuse, nurses need to provide resources and referral, as well as to follow written protocols of their institution or agency to ensure comprehensive care (Hooker et al., 2012).

Incest and Childhood Sexual Abuse Many women have experienced incest or childhood sexual abuse, and 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 victims of abuse. 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 use health care services more frequently than people who were not victims. In women, chronic pelvic pain is often associated with physical violence, emotional neglect, and sexual abuse in childhood (Abercrombie & Learman, 2012). Women who have experienced rape or sexual abuse may be very anxious about pelvic examinations, labour, pelvic or breast irradiation, or any treatment or examination that involves handson 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 A woman is sexually assaulted about every 17 minutes in Canada (Rape Victims Support Network, 2012). Men, women, and children may be victims. Many rapes occur on dates. 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. The postexposure prophylaxis recommended by the Public Health Agency of Canada (PHAC) consists of Cefixime or Ciprofloxacin, metronidazole (Flagyl), and azithromycin (Zithromax) or Doxycycline (PHAC, 2012). Hepatitis B immune globulin (HBIG) should be given up to 14 days post exposure with Hepatitis B vaccine given at 0, 1 month, and 6 months post exposure with an accelerated schedule if appropriate (PHAC, 2012). Recommendations for HIV postexposure prophylaxis (PEP) testing varies across the country. Decisions for treatment should be made according to provincial/territorial/regional protocols or in conjunction with a HIV specialist. HIV PEP is recommended when the assailant is known to be HIV infected and significant exposure (e.g., anal, oral or vaginal) has occurred. PEP is also available on a case-by-case basis when other high-risk exposures occur (e.g., injection drug abuser). Emergency contraception is explained and provided if requested and

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appropriate. Emotional counselling 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 and helpful for survivors to discuss the experience and to obtain professional counselling. Screening for abuse, rape, and violence should be part of routine assessment because women often do not report or seek treatment for assault. Often, the assailant is a partner, husband, or date. Nurses may encounter women with infections or pregnancies related to sexual assault who require support, understanding, and comprehensive care.

Health Issues of Women With Disabilities Approximately 15% of women in Canada have disabilities and the number of women with disabilities increases with age (Statistics Canada, 2013) and encounter physical, architectural, and attitudinal barriers that may limit their full participation in society. Approximately 45% of women 75 years or older are disabled. Women with disabilities may experience stereotyping and increased risk of abuse. They have reported that others, including health care providers, often equate them with their disability. 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 who focus on the causes of disability rather than on health issues that are of concern to all women. To address these issues, the health history must include questions about barriers to health care encountered by women with disabilities and the effect of their disability on their health status and health care. Other issues to be addressed are identified in Chart 47-5. If a patient has hearing loss, vision loss, or another disability that affects communication, it may be necessary to obtain the assistance of an interpreter or to establish another method of communication. Nurses assessing women with disabilities may require additional time and the assistance of others to be certain that accurate information is obtained in a sensitive and unhurried manner (Smeltzer, Avery, & Haynor, 2012). Women with disabilities may have had previous negative experiences with health care providers (Smeltzer et al., 2012), and it is important that nurses provide them with knowledgeable and sensitive care. See Chapter 12 for further discussion of health care of patients with disabilities.

Gerontologic Considerations Care of older women with gynecologic concerns requires knowledge and understanding. Many older women are functioning at various levels across the health spectrum; some function at a high level in their jobs or families, whereas others may be very ill. Nurses need to be prepared to care for older women who may be bright, energetic, and ambitious or who are coping with multiple family crises, including their own health issues as well as for those who are experiencing a life-altering or life-threatening health problem. Older women are at risk for several conditions, including diabetes, dyslipidemia, hypertension, and thyroid

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CHART 47-5

Assessing a Woman With a Disability Health History

Physical Assessment

Address questions directly to the woman herself rather than to people accompanying her. Ask about: • 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; abuse by neglect, withholding or withdrawing assistive devices or personal or health care) • Presence of secondary disabilities (i.e., those resulting from the patient’s primary disability: pressure ulcers, spasticity, osteoporosis, etc.) • Health concerns related to aging with a disability

Provide instructions directly to the woman herself rather than to people 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 examination 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

disease, all of which have symptoms that may be dismissed as typical aging. Nurses can help prevent morbidity and mortality from these conditions by encouraging women to obtain regular health screenings. In addition, knowledge related to heart disease prevention, pharmacology, diet, signs of dementia or cognitive decline, fall prevention, osteoporosis prevention, gynecologic and breast cancers, and sexuality are important for providing high-level nursing care. Health disparities, cultural competency, and endof-life issues also need to be considered.

Physical Assessment Periodic examinations and routine cancer screening are important for all women. Annual breast and pelvic examinations are important for all women 18 years of age or older and for those who are sexually active, regardless of age. Patients deserve understanding and support because of the emotional and physical considerations associated with gynecologic examinations. Women may be 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; the nurse can alleviate many of these feelings with explanations and teaching (Chart 47-6). It may be helpful to emphasize that a pelvic examination should not usually be uncomfortable. 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 47-6

Patient Education: The Pelvic Examination A pelvic examination includes assessment of the appearance of the vulva, vagina, and cervix and the size and shape of the uterus and ovaries to ensure reproductive health and absence of illness. The following should make the examination proceed more smoothly: • You may have a feeling of fullness or pressure during the examination, but you should not feel pain. It is important to relax, because if you are very tense, you may feel discomfort. • 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. • You may watch the examination with a mirror if you choose. • The examination usually takes no longer than 5 minutes. • Draping will be used to minimize exposure and reduce embarrassment.

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 unable to lie safely on the examination table or unable to maintain the supine lithotomy position because of acute illness or disability, the Sims’ position (or alternate positions) 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. 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 years of age. 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 Chapter 19 for a latex screening form and Chapter 54 for more information on latex allergy.)

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 (e.g., venereal warts, pigmented lesions [melanoma]) are evaluated. In the nulliparous woman, the labia minora come together at the opening of the vagina. In a woman who has

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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 48 for a discussion of these structural changes. To identify such protrusions, the examiner asks the patient to “bear down.” 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 women who have not had vaginal intercourse, a hymen of variable thickness may be felt circumferentially within 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 have had intercourse, a rim of scar tissue representing the remnants of the hymenal ring may be palpated 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.

Speculum Examination 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 can be warmed with a heating pad or warm water to make insertion more comfortable for the patient. The speculum is not usually lubricated because commercial lubricants may interfere with cervical cytology (Papanicolaou [Pap] smear) findings. 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 speculum is then slowly opened and the setscrew of the thumb rest is tightened to hold the speculum open (Fig. 47-4). INSPECTING THE CERVIX. The cervix is inspected. In nulliparous women, the cervix usually is 2 to 3 cm wide and smooth. In women who have borne children, the cervix 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 beefy-red surface epithelium circumferentially around the os. Occasionally, the cervix of a woman whose mother took DES during pregnancy has a hooded appearance (a peaked aspect superiorly or a ridge of tissue surrounding it); this is evaluated by colposcopy when identified. 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;

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A

B

FIGURE 47-4. 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

they are rarely malignant and usually are removed easily in an office or clinic setting. A carcinoma may appear as a cauliflowerlike growth that bleeds easily when touched. Bluish colouration of the cervix is a sign of early pregnancy (Chadwick’s sign).

Obtaining Pap Smears and Other Samples A Pap smear is obtained by rotating a small spatula at the os, followed by a cervical brush rotated in the os. The material obtained is spread on a glass slide and sprayed/ fixed immediately, or inserted into liquid (thin “prep”). A small broomlike 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 TABLE 47-3

used to obtain the specimen, which is immediately placed in an appropriate medium for transfer to a laboratory. In a patient who has a high risk of infection, routine cultures for gonococcal and chlamydial organisms are recommended because of the high incidence of both diseases and the complications of pelvic infection, fallopian tube damage, and subsequent infertility. Vaginal discharge, which may be normal or may result from vaginitis, may be present. Table 47-3 summarizes the characteristics of vaginal discharge found in different conditions.

Inspecting the Vagina The vagina is inspected as the examiner withdraws the speculum. It is smooth in young girls and thickens after

Characteristics of Vaginal Discharge

Cause of Discharge

Symptoms

Odour

Consistency/Colour

Physiologic Candida species infection Bacterial vaginosis Trichomonas species infection Atrophic

None Itching, irritation Odour Irritation, odour Vulvar or vaginal dryness

None Yeast odour or none Fishy, often noticed after intercourse Malodourous Occasional mild malodour

Mucus/white Thin to thick, curdlike/white Thin/greyish or yellow Copious, often frothy/yellow-green Usually scant and mucoid/may be blood tinged

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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, usually from a standing position. 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. Movement of the abdominal wall causes the body of the uterus to descend, and the organ becomes freely movable between the hand used to examine the abdomen and the fingers of the hand used to examine the pelvis. 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 uterus, which tips posteriorly toward the sacrum, whereas others have a uterus that is neither anterior nor posterior and is described as 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

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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.

Gerontologic Considerations Yearly examinations are important; they identify problems of the reproductive tract in aging women early. Some older women do not have regular gynecologic examinations. For example, a woman who delivered her children at home may never have had a pelvic examination. Some women regard it as an embarrassing and unpleasant procedure. Nurses play an important role; they can encourage all women to have an annual gynecologic examination. Nurses can make the examination a time for education and reassurance rather than a time of embarrassment. Perineal pruritus is abnormal in older women and should be evaluated because it may indicate a disease process (diabetes or malignancy). Vulvar dystrophy, a thickened or whitish discoloration of tissue, may be visible, and biopsy is needed 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 should know that tissue repair and healing may require more time with aging. 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. The patient must be assessed for allergy prior to insertion of a latex pessary (see Chapter 47 for details about pessaries).

DIAGNOSTIC EVALUATION Cytologic Test for Cancer (Pap Smear) The Pap smear is used to detect cervical cancer. Cervical secretions are gently removed from the cervical os and may be transferred to a glass slide and fixed immediately by spraying with a fixative or immersed in solution (Fig. 47-5). If the Pap smear reveals atypical cells, the liquid method allows for human papillomavirus (HPV) testing (see Chapter 47 for further discussion of HPV, a commonly transmitted STD that can cause venereal warts or cervical cancer). HPV DNA testing is helpful in that it can detect high-risk types that may require careful monitoring. HPV infection is often temporary, especially in healthy young women. The proper technique for obtaining a cervical specimen for cytologic study is described in Chart 47-7. A Pap smear should be performed when a patient is not menstruating, because blood usually interferes with interpretation.

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A B

C FIGURE 47-5. Method of using an 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, Instead of the cells being smeared on a slide, the sampling device is rinsed or twirled in the small vial containing the transport medium and sent to the laboratory.

CHART 47-7

GUIDELINES for Obtaining an Optimal Pap Smear Equipment Needed

• Speculum • Gloves • Slide, spatula, and cytobrush or thin prep kit Implementation 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 (e.g., 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 Thin-prep 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 for a gynecological cancer, use a cotton applicator moistened with saline solution to obtain a sampling of cells from the vaginal cuff or posterior vagina. Women who have had a hysterectomy for benign conditions do not require frequent Pap smears. 8. Immediately spray the slide or, if a Thin-prep, swirl the brush and spatula in the solution.

1. Blood obscures a proper reading of cells. 2. By performing the Pap smear first, the chance of a bloody smear is avoided. 3. Ink may rub off or blur. Labelling with a pencil prevents improper identification. 4. Gloves provide protection and warm water prevents discomfort. Lubricants may obscure cells on Pap smear. 5. This technique obtains a sampling of the exocervix and squamocolumnar junction. 6. This technique obtains a sampling of the endocervical cells and may sample cells from the squamocolumnar junction if it is high in the canal. 7. 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. 8. Exposure to light or air causes distortion of cells.

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To avoid washing away cellular material, the patient should be instructed not to douche before having a Pap smear taken. Terminology used to describe findings includes the following categories: • Normal • Atypical squamous cells of undetermined significance (ASCUS), either HPV + or – • Low-grade squamous intraepithelial lesion (LSIL), which is equivalent to cervical intraepithelial neoplasia (CIN; grade 1) and to mild changes related to exposure to HPV • High-grade squamous intraepithelial lesion (HGSIL), which equates to moderate and severe dysplasia, carcinoma in situ (CIS), as well as CIN grade 2 and CIN grade 3

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(magnification from 10X to 25X) 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 tilelike pattern), and atypical vascular patterns. If biopsy specimens show premalignant cells or CIN, the patient usually requires cryotherapy, laser therapy, or a cone biopsy (excision of an inverted tissue cone from the cervix).

The terms in the last category are precursors to invasive carcinoma of the cervix that indicate the need for evaluation and treatment. The patient may incorrectly assume that an abnormal Pap smear signifies cancer. If the Pap smear (liquid immersion method) shows atypical cells and no high-risk HPV types, the next Pap smear is performed in 1 year. 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 with high-risk HPV types, colposcopy may be indicated. Pap smears that indicate LSIL should be repeated in 4 to 6 months and colposcopy performed if the LSIL has not resolved. Patients with Pap smears that indicate HGSIL and CIS require prompt colposcopy. If the Pap smear results are abnormal, prompt notification, evaluation, and treatment are crucial. Notification of patients is often the responsibility of nurses in a women’s health care practice or clinic. Pap smear follow-up is essential because it can prevent cervical cancer. Some women do not adhere to recommendations—particularly women who are young, who are of low socioeconomic status, who have difficulty coping with the diagnosis, or who have no social support. Fear, lack of understanding, and child care responsibilities have all been identified by women as reasons for poor follow-up. Women with a history of abuse, obese women, and women who have had a negative gynecologic experience may also find returning for follow-up difficult. Interventions are tailored to meet the needs of the particular patient. Intensive telephone counselling, tracking systems, brochures, videos, and financial incentives have all been used to encourage follow-up. The nurse provides clear explanations and emotional support along with a carefully designed setting-specific follow-up protocol designed to meet the needs of the patient. The Society of Obstetricians and Gynaecologists issued a set of guidelines for the evaluation and management of abnormal cervical cytology and histology in adolescent females (Bentley, 2012).

Cryotherapy and Laser Therapy

Colposcopy and Cervical Biopsy

Endometrial (Aspiration) Biopsy

If a Pap smear result requires evaluation, a colposcopy is performed. The colposcope is a portable microscope

Endometrial biopsy, a method of obtaining endometrial tissue, is performed as an outpatient procedure. This

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 response). A watery discharge is normal for a few weeks after the procedure as the cervix heals.

Cone Biopsy and Loop Electrosurgical Excision Procedure If 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 loop electrosurgical excision procedure (LEEP), 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. The gynecologist excises a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if disease is present. A patient who has received anesthesia for a surgical cone biopsy is advised to rest for 24 hours after the procedure and to leave any vaginal packing in place until it is removed (usually the next day). The patient is instructed to report any excessive bleeding. The nurse or physician provides guidelines regarding postoperative sexual activity, bathing, and other activities. Because open tissue may be potentially exposed to HIV and other pathogens, the patient is cautioned to avoid intercourse until healing is complete and verified at follow-up. LEEP has a low incidence of complications, but there is a slight increase in the risk of later cervical stenosis or premature deliveries.

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procedure is usually indicated in cases of midlife irregular bleeding, postmenopausal bleeding, and irregular bleeding while taking hormone therapy (HT) or tamoxifen. A tissue sample obtained through biopsy permits diagnosis of cellular changes in the endometrium. Women who undergo endometrial biopsy may experience slight discomfort. The examiner may apply a tenaculum (a clamplike instrument that stabilizes the uterus) after the pelvic examination and then inserts a thin, hollow, flexible suction tube (Pipelle or sampler) through the cervix into the uterus. 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, which refers to overgrowth of cells with abnormal features, is a risk factor for uterine cancer and is treated with progesterone and careful follow-up. Women who are overweight, who are older than 45 years of age, who have a history of nulliparity and infertility, or who have a family history of colon cancer seem to be at higher risk for hyperplasia. Endometrial cancer is discussed in Chapter 48.

bleeding, and as a therapeutic measure for incomplete abortion. Because D & C 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) or midazolam (Versed). The nurse explains the procedure, preparation, and expectations regarding postoperative discomfort and bleeding. 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.

Dilation and Curettage

Endoscopic Examinations

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

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-in) incision below the umbilicus to allow visualization of the pelvic structures (Fig. 47-6).

Forceps Operating laparoscope

Pneumoperitoneum

Uterine cannula

FIGURE 47-6. 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.

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Laparoscopy may be used for diagnostic purposes (e.g., in cases of pelvic pain when no cause can be found) or treatment. Laparoscopy facilitates many surgical procedures, such as tubal ligation, ovarian biopsy, myomectomy, hysterectomy, 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 carbon dioxide intraperitoneally into the cavity. Called insufflation, this technique separates the intestines from the pelvic organs. If a 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 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 ceases, 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, which has few complications, is useful for evaluating endometrial pathology. Hysteroscopy may be 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 (e.g., fibroid tumours) can be accomplished during this procedure, and sterilization may also be performed. 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 resector (cutting loop), roller ball (a barrel-shaped electrode), or laser beam in cases of severe bleeding not responsive to other therapies. Performed in an outpatient setting under general, regional, or local anesthesia, this rapid procedure is an alternative to hysterectomy for some patients. Following uterine distension with fluid infusion, the lining of the uterus is destroyed. Hemorrhage, perforation, and burns can occur.

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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. In addition, because the uterus, ovaries, and fallopian tubes are near the structures of the urinary tract, urologic diagnostic studies, such as x-ray study of the kidney, ureters, and bladder (KUB) 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 (HSG) 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. Prior to hysterosalpingography, laxatives and an enema may be administered to evacuate the intestinal tract so that gas shadows do not distort the x-ray findings. A mild sedative or an analgesic agent, such as ibuprofen (Advil, Motrin) 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 pad for several hours, because the radiopaque contrast agent may stain clothing.

Computed Tomography CT 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 for patients with a distended bowel. CT can also demonstrate a tumour 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 obstetric patients or in patients 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) by way of a transducer placed in contact with the abdomen (abdominal scan) or a vaginal probe (vaginal ultrasound). Mechanical energy is converted 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.

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The entire procedure takes usually less than 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; however, the vaginal probe can cause mild discomfort in some women.) Saline may be instilled into the uterus (saline infusion sonogram) to help delineate endometrial polyps or fibroids.

Magnetic Resonance Imaging Magnetic resonance imaging (MRI) produces patterns that are finer and more definitive than other imaging procedures, and it does not expose patients to radiation. However, MRI is more costly.

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NURSING ALERT

All metal devices, including medication skin patches with foil backing, must be removed before MRI is performed to avoid burns.

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 and appropriate 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 healthy diet have been found to decrease discomfort for some women. Heating pads or nonsteroidal anti-inflammatory drugs (NSAIDs) may be very effective for cramps. For women with excessive cramping or dysmenorrhea, referral to a women’s health care provider is appropriate; following evaluation, practitioners may prescribe oral contraceptives.

Cultural Considerations

MANAGEMENT OF FEMALE PHYSIOLOGIC PROCESSES Many health concerns of women are related to normal changes or abnormalities of the menstrual cycle and may 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 tsp) of blood are lost. A perineal pad or tampon is generally used to absorb menstrual discharge. Tampons are 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, and superabsorbent tampons should not be used because of their association with toxic shock syndrome. If a tampon is difficult to remove or shreds when removed, less absorbent tampons should be used. If the string breaks or retracts, the woman should squat in a comfortable position, insert one finger into the vagina, try to locate the tampon, and remove it. If she feels uncomfortable attempting this manoeuvre or cannot remove the tampon, she should consult a gynecologic health care provider promptly.

Culture refers to knowledge, beliefs, customs, and values acquired as members of a racial, ethnic, religious, or social group. Canada is becoming more culturally diverse. Various aspects of culture affect many health care encounters, and these encounters can be positive if nurses understand the various cultures of their patients. Cultural views and beliefs about menstruation differ. 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 believe 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 during menstruation. In such situations, nurses are 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 appropriate materials in the patient’s language, asking about traditional beliefs and dietary practices, and asking about fears regarding care. Patience, sensitivity, and a desire to learn about other cultures and groups will enhance the nursing care of all women (Chart 47-8).

Perimenopause Perimenopause is the period extending from the first signs of menopause—usually hot flashes, vaginal dryness, or 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

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CHART 47-8

Health Care for Women who are Lesbians 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, and are seen in all age groups, including 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 feel invisible and underuse health care. Whether heterosexual or homosexual, nurses need to consider lesbianism within the continuum of human sexual behaviour and need to use gender-neutral questions and terms that are nonjudgmental and accepting.

these must be considered when 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, and STDs • Unintended pregnancy (if contraception is not used correctly and consistently) • 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 are 35 years of age or older should not take oral contraceptives because of an increased risk of cardiovascular disease.) Contraception is discussed in detail later in this chapter. • Breast health. About 16% of cases of breast cancer occur in perimenopausal women, so breast self-examination, routine physical examinations, and mammograms are essential. Women in their 40s are often less concerned with menopause and more interested in their health, wellbeing, and appearance.

Menopause Menopause is the permanent physiologic cessation of menses associated with declining ovarian function; during

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 have lower health screening rates than other women. They are at high risk for cancer, heart disease, depression, and alcohol abuse. They may have a higher body mass index, may bear fewer or no children, and often have fewer health preventive screenings than heterosexual women. These factors may increase the risk of colon, endometrial, ovarian, and breast cancer, as well as cardiovascular disease and diabetes. Adolescent lesbians are at risk for smoking and suicide/ depression. Nurses need to understand the unique needs of this population and provide appropriate and sensitive care (Shafii & Burstein, 2009).

this time, reproductive function diminishes and ends. Postmenopause is the period beginning from about 1 year after menses cease. Menopause may be 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 or 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 increase 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 thought to be caused by hormonal changes and denote vasomotor instability. They 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. Other physical changes may include increased bone loss (discussed later in this chapter). 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 gradual shrinkage of the labia. Vaginal secretions decrease, and women may report dyspareunia (discomfort during intercourse). The vaginal pH increases during menopause, predisposing women to bacterial infections and atrophic vaginitis. Discharge, itching, and vulvar burning may result. Some women report fatigue, forgetfulness, weight gain, irritability, trouble sleeping, feeling “blue,” and feelings of panic. Menopausal complaints need to be evaluated

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carefully because they may indicate other disorders. Most women have few problems and are relieved to be free from menstrual periods.

managing menopausal symptoms and maintaining her health.

Psychological Considerations

Until recently, HT was prescribed to prevent hot flashes, reduce the risk of osteoporotic fractures, and decrease the risk of cardiovascular disease. The Menopause and Osteoporosis Update 2009 published by the SOGC describes the use of HT on a short-term basis of up to 5 years for moderate to severe menopausal symptoms. If HT is taken for longer than 5 years, consultation should be held with health care providers. Although HT decreases hot flashes and reduces the risk of osteoporotic fractures as well as colorectal cancer, studies have shown that it increases the risk of breast cancer, heart attack, stroke, and blood clots (SOGC, 2009). Because of these findings, many women have discontinued HT or are reluctant to begin HT. The current recommendation for treatment of hot flashes with HT is to use the lowest dose possible for the shortest time possible. Nurses need to be knowledgeable about HT-related issues to be able to respond to women’s questions about HT use. METHODS OF ADMINISTRATION. Both estrogen and progestin are prescribed for women who have not had a hysterectomy; progestin prevents proliferation of the

Women’s reactions and feelings related to loss of reproductive capacity may vary. Some women may experience role confusion, whereas others experience a sense of sexual and personal freedom. Women may be relieved that the childbearing phase of their lives is over. Each woman’s personal views about menopause and circumstances affect her response and must be considered on an individual basis. Nurses need to be sensitive to all possibilities and take their cues from the patient. Chart 47-9 describes how women with disabilities may view menopause.

Medical Management Women approaching menopause often have many concerns about their health. Some have concerns based on a family history of heart disease, osteoporosis, or cancer. Each woman needs to be as knowledgeable as possible about her health options and should be encouraged to discuss her concerns with her primary health care provider so that she can make an informed decision about

Hormone Therapy

NURSING RESEARCH PROFILE

Chart 47-9. Careproviders’ Responsibility for Women With Intellectual Disabilities in Menopause Willis, D. S., Wishart, J. G., & Muir, W. J. (2010). Carer knowledge and experiences with menopause in women with intellectual disabilities. Journal of Policy and Practice in Intellectual Disabilities, 7 (1), 42–48. Purpose Women with intellectual disabilities may experience menopause in ways that differ from women without disabilities. Little information about menopause in women with intellectual disabilities and the knowledge and experiences of their careproviders is available. The purpose of this study was to examine the careproviders of women with intellectual impairments about menopause—their knowledge and experiences of caring for women who are intellectually disabled. Design A total of 69 paid care providers including 7 males and 62 females caring for intellectually disabled women between 35–67 years of age were included in this qualitative, study. The care providers were interviewed individually about general knowledge about personal, health related concerns, and experiences of supporting women with intellectual disabilities during menstruation and menopause. Interviews were audiotaped for those who agreed and then transcribed verbatim. Notes were taken during the interview for those participants who did not want to be audiotaped. Data were analyzed using thematic analysis. Results Care provider knowledge of balanced diet and exercise, bone and cardiovascular health, and health screening was

generally lacking. Four main themes emerged from the study. The primary theme was universality. The care providers recognized that women would undergo menopause and that women with intellectual disabilities need to have explanation about menopause using appropriate and comprehensible words. Entanglement was another theme. Careproviders indicated that they had difficulties differentiating menopausal behaviours from the personality and behaviours of the women. Resilience was identified as a theme in which women who had intellectual disabilities in their lives would either accept what was happening in terms of menopause or have difficulties understanding the life change. The final theme, “ignorance is bliss,” reflected the careproviders’ reports that the women had minimal understanding of their bodies related to menstruation and menopause. Nursing Implications Women with intellectual disabilities have a limited understanding of menopause. Information on menopause that is tailored individually for the woman with an intellectual disability is needed. Care providers of women with intellectual disabilities require education and training about the care of menopausal women with intellectual disabilities. Nurses should discuss health-related issues with care providers of women with intellectual disabilities. Nurses should provide educational programs to the care providers of women with intellectual disabilities.

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uterine lining and hyperplasia. Women who no longer have a uterus because of hysterectomy can take estrogen without progestin (i.e., unopposed estrogen) because there is no longer a risk of estrogen-induced hyperplasia of the uterine lining. There is a decreased risk of stroke in women taking estrogen alone following hysterectomy and the risk of breast cancer is also decreased (LaCroix, Chlebowski, Manson, et al., 2011; Chlebowski & Anderson, 2012). Some women take both estrogen and progestin daily; others take estrogen for 25 consecutive days each month, with progestin taken in cycles (e.g., 10 to 14 days of the month). Women who take HT for 25 days often experience bleeding after completing the progestin. Other women take estrogen and progestin every day and usually experience no bleeding. They occasionally have irregular spotting, which should be evaluated by their health care provider. Progestin administration may be oral, transdermal, vaginal, or intrauterine. 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. Another type of patch provides estrogen and progestin treatment. Skin should be dry at the area of application, and cleansing the site with alcohol may improve adhesiveness. Vaginal treatment with an estrogen cream, suppository, or an estradiol ring (Estring) may be used for vaginal dryness or atrophic vaginitis. The estradiol ring is a small, flexible vaginal ring that slowly releases estrogen in small doses over 3 months. Vaginal estrogen preparations may improve vulvovaginal sensation; however, women who use them should be monitored for endometrial hyperplasia (Levine, 2011; Speroff & Fritz, 2010). RISKS AND BENEFITS. HT is contraindicated in women with a history of breast cancer, vascular thrombosis, impaired liver function, uterine cancer, and undiagnosed abnormal vaginal bleeding. Because the risk of thromboembolic phenomena is increased with HT, women who elect to take it should be taught the signs and symptoms of deep vein thrombosis and pulmonary embolism and instructed to report these signs and symptoms immediately. Women who take HT should be assessed for leg redness, tenderness, chest pain, and shortness of breath. Furthermore, they need to be informed about the importance of regular follow-up care, including a yearly physical examination and mammogram. An endometrial biopsy is indicated for any irregular bleeding. Because the risk of complications increases the longer HT is used, HT should be used for the shortest time possible (Contraceptive Technology Update, 2012). Estrogen reduces the risk of dementia or cognitive impairment if therapy is started in women younger than 60 or within 10 years of menopause (Shoupe, 2012). ALTERNATIVE THERAPY FOR HOT FLASHES. Because women often seek information about alternatives to HT use, nurses must be knowledgeable about other approaches women can use to promote their health in the perimenopausal and postmenopausal period. Problematic hot flashes have been treated with venlafaxine (Effexor), paroxetine (Paxil), gabapentin (Neurontin), and clonidine (Catapres). Similarly, vitamin B6 and vitamin E may be effective. Some women have expressed interest in other alternative treatments (e.g., natural estrogens and progestins, black cohosh,

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ginseng, dong quai, soy products, and several other herbal preparations); however, few data exist about their safety or effectiveness. Therefore, assessment of menopausal women should address their use of complementary and alternative therapies and supplements. Glucose levels also affect hot flashes; thus, nurses can encourage patients to maintain stable glucose levels (Dormire, 2009). MAINTAINING BONE HEALTH. Acceleration of bone loss resulting in osteoporosis and microarchitectural deterioration of bone tissue occurs at menopause and leads to increased bone fragility and risk of fracture. Other factors that increase a woman’s risk of 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. About one in three women will experience a fracture related to osteoporosis during her lifetime (Osteoporosis Canada, 2013a). Thus, women are advised to remain active and to begin or continue a regular exercise program of weight-bearing activity, such as walking, which helps maintain bone mass; to take a calcium supplement; to decrease or stop smoking; and to discuss with their health care provider the use of pharmacologic agents to reduce bone loss if indicated. Osteoporosis and its treatment are described in detail in Chapter 68. MAINTAINING CARDIOVASCULAR HEALTH. The Hearth and Stroke Foundation (2013) recommends a variety of strategies to lower the risk of heart disease in women. These include lifestyle changes and behaviour strategies. Diet, exercise, stress reduction, and a healthy lifestyle all contribute to older women’s cardiac health and are an essential part of health promotion. Regular physical exercise increases the heart rate and high-density lipoprotein levels. Weight-bearing exercise (e.g., walking, jogging) at least four times a week is recommended. Pharmacologic therapy (e.g., aspirin, betablockers, “statins,” angiostatin-converting enzyme inhibitors) may be indicated in women who have cardiovascular disease or are at high risk for it. Prevention and treatment of cardiovascular disease are discussed in detail in Chapter 27.

Behavioural Strategies As previously stated, regular physical exercise is beneficial. It may also reduce stress, enhance well-being, and improve self-image. In addition, weight-bearing exercise may prevent loss of muscle tissue and bone tissue. Women are also encouraged to participate in other health-promoting activities. These include regular health screening recommended for women at the time of menopause: gynecologic examinations, mammograms, colonoscopy, fecal occult blood testing, and bone mineral density testing if at risk for osteoporosis.

Nutritional Therapy Women are encouraged to decrease their fat and caloric intake and increase their intake of whole grains, fibre, fruit, and vegetables. Women of all ages tend to ingest less than the recommended amount of calcium; therefore, they should be encouraged to increase their intake of foods high in calcium (e.g., nonfat yogurt, green leafy vegetables, seafood, and calcium-fortified foods). Calcium and vitamin D supplementation may be helpful in reducing

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bone loss and preventing the morbidity associated with osteoporotic fractures (Osteoporosis Canada, 2013b).

Nursing Management Nurses can encourage women to view menopause as a natural change resulting in freedom from symptoms related to menses. No relationship exists between menopause and mental health problems; however, social circumstances (e.g., adolescent children, ill partners, and dependent or ill parents) that may coincide with menopause can be stressful.

Measures should be taken to promote general health. The nurse explains to the patient that cessation of menses is a normal occurrence that is rarely accompanied by nervous symptoms or illness. The current expected lifespan after menopause for the average woman is 30 to 35 years, which may encompass as many years as the childbearing phase of her life. 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

CHART 47-10

HOME CARE CHECKLIST •

The Woman Approaching Menopause

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• 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 at least 30 minutes three or four times a week to main-

✔

✔

• 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,

✔

✔

• Describe this phase of life as having the potential for intellectual growth, personal accomplish-

✔

✔

tain good health.

dependence of parents, possible loss of loved ones. ment, 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 pro-

✔

• Identify strategies and methods to prevent or manage the following problems:

✔

mote general health.

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. Undergo 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.

✔ ✔ ✔ ✔ ✔

✔ ✔

CHAPTER 47

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Assessment and Management of Female Physiologic Processes

her emotional reaction to menopause. Patient teaching and counselling regarding healthy lifestyles, health promotion, and health screening are of paramount importance (Chart 47-10).

Menstrual Disorders Menstrual disorders may include premenstrual syndrome (PMS); dysmenorrhea; amenorrhea; and excessive bleeding, irregular bleeding, or bleeding between cycles or unrelated to cycles. These disorders need to be discussed with a health care provider and managed individually. Menstrual-related disorders have been reported in as many as 19% of women who report feeling more anxious, sad, nervous, restless, hopeless, and worthless than those without complaints. Affected women are more likely to smoke cigarettes, drink alcohol to excess, and be overweight (Krueger, 2011). Dysmenorrhea may result from endometriosis or anatomic abnormalities or it can be a normal variation. Amenorrhea may be related to pregnancy, thyroid disorders, anatomic abnormalities, and eating disorders. Excessive bleeding may be caused by fibroids, clotting disorders, thyroid disorders, and miscarriage. Irregular bleeding may be secondary to hormonal changes in adolescence or perimenopause or may result from pregnancy, threatened abortion, or a variety of other factors.

Premenstrual Syndrome Premenstrual symptoms are common in ovulating women and can influence quality of life. Symptoms occur in the luteal phase and disappear with the onset of menses. PMS is a combination of bothersome symptoms, and premenstrual dysphoric disorder is a severe type of premenstrual disorder that significantly impairs normal activity (Chart 47-11). The cause of these conditions is unknown; they are diagnosed if symptoms occur during the 5 days prior to the onset of menses, disappear within 4 days of the

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onset of menses, and occur through several cycles. PMS tends to become less symptomatic with menopause.

Clinical Manifestations Major symptoms of PMS include physical symptoms such as headache, fatigue, low back pain, painful breasts, and a feeling of abdominal fullness. Behavioural and emotional symptoms may include general irritability, mood swings, fear of losing control, binge eating, and crying spells. Symptoms vary widely from one woman to another and from one cycle to the next in the same woman. Great variability is found in the degree of symptoms. Many women are affected to some degree, but some are severely affected. 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 injuries, and absenteeism.

Medical Management Because there is no single treatment or known cure for PMS, women should chart their symptoms so they can anticipate and therefore cope with them. Regular exercise may be helpful. Although women have been advised to avoid caffeine, high-fat foods, and refined sugars, little research demonstrates the efficacy of dietary changes. Alternative therapies that have been used include vitamins B and E, magnesium, and oil of evening primrose capsules. No studies have evaluated the effectiveness of these therapies. Pharmacologic remedies include selective serotonin reuptake inhibitors (e.g., fluoxetine [Prozac, Sarafem]), GnRH agonists, prostaglandin inhibitors (e.g., ibuprofen and naproxen [Anaprox, Aleve]), diuretics, antianxiety agents, and calcium supplements. Oral contraceptives containing drospirenone (a synthetic progestin) and extended regimens also may be effective (Lopez, Kaptein, & Helmerhorst, 2012).

CHART 47-11

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 (e.g., bloating, breast tenderness) • Headache

Affective Symptoms • • • • •

Depression Anger Irritability Anxiety Confusion

• Withdrawal • Symptoms begin in the 5 days preceding menses and relief occurs 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 risk of physical and psychological dependence is high

• Spironolactone, a diuretic, may be effective in treating fluid retention

• Initiation/maintenance of exercise program • Stress reduction techniques

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Nursing Management The nurse obtains a health history, noting the time when symptoms began and their nature and intensity. The nurse then determines whether symptoms occur before or shortly after the menstrual flow begins. In addition, the nurse can show the patient how 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, improved coping with day-to-day stressors, improved relationships with family and coworkers, and increased knowledge about PMS. Positive coping measures are promoted. This may involve encouraging the woman’s partner to offer support and assistance with child care. The patient can try to plan her working time to accommodate the days she is 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 provides instructions about the desired effects of the medications. Enrolling in a PMS group may help the patient learn to recognize and cope with this condition. If the patient has severe symptoms of PMS or premenstrual dysphoric disorder, the nurse assesses her for suicidal, uncontrollable, and violent behaviour. An immediate psychiatric evaluation is necessary for women with any suggestions of suicidal tendencies. In rare cases, uncontrollable behaviour may lead to violence toward family members. If abuse of children or other members of a patient’s family is suspected, it is important to implement and follow reporting protocols. Referral for immediate psychiatric or psychological care and counselling is required.

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 become older, dysmenorrhea often decreases and frequently completely resolves after childbirth. In secondary dysmenorrhea, pelvic pathology such as endometriosis, tumour, or pelvic inflammatory disease (PID) contributes to symptoms. Patients frequently have pain that occurs several days before menses, with ovulation, and occasionally with intercourse.

Assessment and Diagnostic Findings A pelvic examination is performed to rule out possible disorders, such as endometriosis, PID, adenomyosis, and

uterine fibroids. A laparoscopy may be 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 about 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, naproxen, and mefenamic acid (Ponstel). 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 aspirinlike medications, asthma, and pregnancy. Low-dose oral contraceptives provide relief in more than 90% of patients and may be prescribed for women with dysmenorrhea who are sexually active but do not desire pregnancy. Continuous low-level local heat may also be effective in relieving primary dysmenorrhea. 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 because this relieves 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 (e.g., endometriosis or PID).

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 young women older than 16 years of age have not begun to menstruate but otherwise show evidence of sexual maturation, or in which young women have not begun to menstruate and have not begun to show development of secondary sex characteristics by 14 years of age. Amenorrhea may be of considerable concern but often occurs as a result of minor variations in body build, heredity, environment, and physical, mental, and emotional development. The nurse encourages 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 rule out possible causes, such as metabolic or endocrine disorders 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, emotional upset, eating disorder, or excessive exercise. In adolescents, secondary amenorrhea

CHAPTER 47

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Assessment and Management of Female Physiologic Processes

can be caused by minor emotional upset related to being away from home, attending college, tension due to schoolwork, or interpersonal problems. However, the second most common cause 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, often result in lack of menses because the decrease in body fat and caloric intake affects hormonal function. Intense exercise can induce menstrual disturbances. Competitive female athletes often experience amenorrhea. If they do, they may be placed on HT 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. Women who are HIV positive are apt to miss menstrual periods and need to be evaluated for pregnancy, thyroid disorders, hyperprolactinemia, and menopause (if appropriate) (Cejtin, Kalinowski, Bacchetti, et al., 2006).

Abnormal Uterine Bleeding Dysfunctional uterine bleeding is abnormal bleeding that has no known organic cause. The bleeding is defined as irregular, painless bleeding of endometrial origin that may be excessive, prolonged, or without pattern. Dysfunctional uterine bleeding can occur at any age but is most common at opposite ends of the reproductive lifespan. 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; they often do not ovulate regularly as the pituitary–ovarian axis matures. Perimenopausal women also experience this condition because of irregular ovulation secondary to decreasing ovarian hormone production. Other causes may include fibroids, obesity, and hypothalamic dysfunction. Abnormal or unusual vaginal bleeding that is atypical in time or amount must be evaluated because it could possibly be a manifestation of a major disorder. A 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.

Menorrhagia Menorrhagia is prolonged or excessive bleeding at the time of the regular menstrual flow. In young women the cause is usually related to endocrine disturbance, whereas in later life it usually results from inflammatory disturbances, tumours of the uterus, or hormonal imbalance. Women with menorrhagia are urged to see a primary health care provider and to describe the amount of bleeding by pad count and saturation (i.e., absorbency of perineal pad or tampon and number saturated hourly).

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Persistent heavy bleeding can result in anemia. It can also be a sign of a bleeding disorder or a result of anticoagulant therapy. Hysterectomy can be challenging in these women; endometrial ablation has been found to be less risky (El-Nashar, Hopkins, Barnes, et al., 2010).

Metrorrhagia Metrorrhagia (vaginal bleeding between regular menstrual periods) is probably the most significant form of menstrual dysfunction because it may signal cancer, benign tumours of the uterus, or other gynecologic problems. This condition warrants prompt evaluation and treatment. Although bleeding between menstrual periods by women taking oral contraceptives is usually not serious, irregular bleeding by women taking HT should be evaluated. Menometrorrhagia is heavy vaginal bleeding between and during periods. It, too, requires evaluation.

Postmenopausal Bleeding Bleeding 1 year after menses cease at menopause must be investigated, and a malignant condition must be considered until proven otherwise. A vaginal ultrasound can be used 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 or a D & C.

Dyspareunia Dyspareunia (difficult or painful intercourse) can be superficial, deep, primary, or secondary and may occur at the beginning of, during, or after intercourse. Dyspareunia may be related to many factors, including injury during childbirth; lack of vaginal 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). Depending on the cause of dyspareunia, counselling, extra lubrication, or antidepressants may be prescribed. Women’s health issues related to sexuality may be affected by many factors. Thus, these issues need to be taken seriously, carefully assessed, and treated.

Contraception Each year, many pregnancies in Canada are unintended. Although unintended pregnancies occur in women of all ages, incomes, and racial and ethnic groups, the highest rates occur among adolescents and perimenopausal women. Adolescents are more likely to experience pregnancy complications and are more prone to have lowbirthweight babies. In addition, adolescent mothers are less likely to obtain a high school diploma and are more likely subsequently to live in poverty. Women may fail to use effective methods of contraception consistently or at all. Of the women who undergo

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abortions, many were not using contraception when they became pregnant, and others have never used any method of contraception. Decreasing unwanted pregnancies may reduce the number of abortions, abused children, stressed families, and infant mortality and morbidity. Nurses can assist with information and support. Women can be asked directly when they plan to have their next pregnancy and about their need for contraception. Many women who are sexually active or who are considering becoming sexually active can benefit from learning about contraception. Nurses who are involved in helping patients make contraceptive choices need to listen, take time to answer questions, and teach and assist patients in choosing the method they prefer. It is important for women to 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. Some women have received misinformation (i.e., contraception causes cancer or weight gain).

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.

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 no longer wish to have children, no matter how the circumstances in their life may change. Often, decisions made hastily may be regretted later. Some gynecologists suggest a waiting period to ensure that patients are certain about a potentially irreversible decision.

Tubal Ligation Sterilization by tubal ligation is one of the most common surgical procedures performed on women. Tubal ligation is usually performed as a same-day surgical procedure and is carried out by laparoscopy or hysteroscopy, with the patient receiving a general or local anesthetic. After the laparoscope is inserted, the fallopian tubes are visualized and may be coagulated, sutured (Pomeroy procedure), or ligated with silicone bands or a spring clip, thereby disrupting their patency. The use of spring clips is associated with the highest rate of pregnancy following sterilization. In a transcervical tubal occlusion procedure, a 1.5-cm metal coil or spring is inserted into the fallopian tubes through the cervix, thus avoiding the need for laparoscopy or a surgical incision. This method, referred to as the Essure procedure, is performed via hysteroscopy and obstructs the tubes by inducing scar tissue. Women who have had this procedure should abstain from unprotected intercourse for 3 months to avoid pregnancy until the scar tissue develops and the effectiveness of the procedure is verified by HSG.

Despite a very high rate of effectiveness, all women who have undergone tubal ligation but miss 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 bleeding and more cramping after tubal ligation. 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. If a laparoscopic procedure is performed, the patient may experience postoperative abdominal or shoulder discomfort for a few days, related to the carbon dioxide gas and the manipulation of organs. The patient is instructed to report heavy bleeding, fever, or pain that persists or increases. She should avoid intercourse, strenuous exercise, and lifting for 2 weeks. Risks associated with tubal ligation are minimal and are more often related to anesthesia than to the surgery itself. Risk is increased in women with diabetes, previous abdominal or pelvic surgery, or obesity.

Vasectomy Vasectomy (male sterilization) and hysteroscopic/laparoscopic tubal ligation are compared in Table 47-4. See Chapter 50 for a discussion of vasectomy.

Hormonal Contraception Oral contraceptives 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. Progestins (synthetic forms of progesterone) suppress the LH surge, prevent ovulation, and also render the cervical mucus impenetrable to sperm. Hormonal contraceptive agents may be oral, transdermal, vaginal, or injectable. Combined oral contraceptives that contain both estrogens and progestins are currently used by many women to prevent pregnancy.

Benefits and Risks Benefits of combined hormonal contraceptive use include a reduction in the incidence of benign breast disease; improvement in acne; and reduced risk of uterine and ovarian cancers, anemia, and pelvic infection. In general, prolonged hormonal contraceptive use has resulted in no definite long-term undesirable effects, although there is an increased risk of gallbladder problems (e.g., cholestasis). Resumption of normal menses is delayed 2 to 3 months or longer in about 20% of hormonal contraceptive users. Risks include venous thromboembolism, although its incidence has decreased because the estrogen concentrations used today are less than that used in early preparations. Venous thromboembolism is less than half as likely with hormonal contraceptives than with pregnancy. Fetal anomalies do not appear to be an issue, and normal reproductive tract function and fertility resume after hormonal contraceptive use is discontinued. However, most health care providers recommend that women who wish to become pregnant use a barrier contraceptive method for 1 to 2 months after stopping

CHAPTER 47

TABLE 47-4

●

Assessment and Management of Female Physiologic Processes

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Comparison of Sterilization Methods

Sterilization Method

Advantages

Disadvantages

Vasectomy

• • • • •

• •

• •

Highly effective Relieves female of contraceptive burden Inexpensive in long run Permanent Highly acceptable procedure to most patients Very safe Quickly performed

• • • •

Low incidence of complications Short recovery Leaves small or no scar Quickly performed

• • • •

Hysteroscopic and laparoscopic tubal sterilization

• • • •

• • •

hormonal contraceptives before attempting to become pregnant to permit a normal period for accurate dating of the pregnancy. A few patients experience adverse reactions when using hormonal contraceptives. These include nausea, depression, headache, 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 experience spotting in the first month of use of hormonal contraceptive or if they use it irregularly, so they need to be reassured and advised to use it as prescribed. Chart 47-12 compares different oral contraceptive regimens, and Chart 47-13 describes the benefits and risks of oral contraceptive use.

Expensive in short term Serious long-term effects suggested (although currently unproved) Permanent (although reversal is possible, it is expensive and requires highly technical and major surgery, and results cannot be guaranteed) Regret in 5–10% of patients No protection against STDs, including HIV Not effective until sperm remaining in reproductive system are ejaculated Permanent Reversal difficult and expensive Sterilization procedures technically difficult Requires surgeon, operating room (aseptic conditions), trained assistants, medications, surgical equipment (Essure [insertion of coil or spring in fallopian tubes] requires hysteroscopy rather than surgery) Expensive at the time performed If failure, high probability of ectopic pregnancy No protection against STDs, including HIV

Contraindications Absolute contraindications to hormonal contraceptives include active thromobophlebitis, venous thromoboembolic disorder, arterial thrombosis/ischemic heart disease migraines with focal neurologic signs, known or suspected breast cancer, known or suspected pregnancy, acute or chronic liver disease with increased liver enzyme levels or compromised liver function, smoking in women over 35 years; and undiagnosed genital bleeding (SexualityandU.ca, 2012). Relative contraindications include hypertension, diabetes complicated by vascular disease, systemic lupus erythromatosis, inflammatory bowel disease, nonfocal headaches, medication use of Rifamicin and Dilantin, and sickle cell disease (SexualityandU.ca, 2012). Controlled

CHART 47-12

Pharmacology: Comparison of Hormonal Contraceptive Regimens There are two kinds of hormonal contraceptives: combined (consisting of an estrogen and a progestin) and progestin only.

• About 40% of women taking progestin-only preparations

Combined Preparations (pills, transdermal patches,

• Progestin-only preparations are useful for women who have

vaginal rings) • Monophasic preparations supply the same dose of estrogen and progestin for 21 days. • Biphasic preparations and triphasic pills vary the amount of hormonal components during the cycle. • Usually leads to a lighter-than-normal menstrual flow, which results from withdrawal.

Progestin-Only “Mini” Preparations • Preparations provide less protection against conception than combined preparations.

have ovulatory cycles.

had estrogen-related side effects (e.g., headaches, hypertension, leg pain, chloasma or skin discoloration, weight gain, or nausea) on combination pills. • Progestin-only preparations are useful for lactating women who need a hormonal contraceptive method. • Depo-Provera, a progestin-only injection, lasts for 3 months. • Implanon, a subdermal implant lasts for 3 years.

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CHART 47-13

Pharmacology: Benefits and Risks of Combination Hormonal 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 (e.g., 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 tumours and gallbladder disorders • No protection from STDs/STIs (possible increased risk with unsafe sex)

lupus, depression, seizures, and HIV infection or AIDS. Contraception needs to be addressed individually in women with these conditions.

Methods of Hormonal Contraception Various hormonal methods of birth control are approved by Health Canada. Combination methods include the combination of oral contraceptive pills, vaginal ring (NuvaRing), and transdermal patch (Evra). Progestin-only methods include the progestin-only pills, progestin-only emergency contraception (Plan B), once-every-3-month injection (Depo-Provera), and levonorgestrel-releasing intrauterine system (IUS; Mirena).

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NURSING ALERT

Patients need to be aware that hormonal 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.

Oral Contraceptives hypertension in otherwise healthy young nonsmokers is generally not a contraindication to use of combination agents but does require a low dose and careful blood pressure monitoring. Women older than 35 years of age who smoke are at risk for cardiac problems and should not use hormonal contraceptives. Occasionally, neuro-ocular complications arise, but a cause-and-effect relationship has not been established. If visual disturbances occur, hormonal contraceptives should be discontinued. Chart 47-14 summarizes patient education guidelines that are important for women using combination hormonal contraceptives. Coexisting medical disorders may make contraception a complex issue. These disorders include chronic hypertension, lipid disorders, diabetes, migraines, fibroids, obesity,

CHART 47-14

Patient Education: Using Combination Contraceptives • Use condoms to protect against sexually transmitted diseases.

• Take pill at exactly the same time every day or put the

patch on once a week or remove the vaginal ring after 3 weeks. • 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

Many women currently use oral contraceptive preparations of synthetic estrogens and progestins. A variety of formulations are available. Extended regimens of oral hormonal contraceptive agents are an option for women who have heavy or uncomfortable menstrual bleeding or who wish to have fewer periods. With the use of these regimens, women may have an increased occurrence of breakthrough bleeding; the blood may be dark brown rather than red. It may be more difficult to tell if a pregnancy occurs with this method, although pregnancy is unlikely if pills are taken as prescribed. Studies are ongoing to assess the risks of exposure to increased estrogen resulting from this method.

Transdermal Contraceptives Ortho Evra is a thin, beige, matchbook-size skin patch that releases an estrogen and a progestin continuously. It is changed every week for 3 weeks, and no patch is used during the fourth week, resulting in 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. The patch is convenient and more easily remembered than a daily pill but is not as effective for women who weigh more than 198 lb (90 kg). In addition, it may also irritate skin conditions (e.g., psoriasis) in some women and results in higher blood estrogen levels than oral contraceptives.

Vaginal Contraceptives NuvaRing (etonogestrel/ethinyl estradiol vaginal ring) is a combination hormonal contraceptive that releases estrogen and progestin. It is inserted in the vagina for 3 weeks and

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then removed, resulting in withdrawal bleeding. It is as effective as oral contraceptives and results in lower hormone blood levels than oral contraceptives. NuvaRing is flexible, does not require sizing or fitting, and is effective when placed anywhere in the vagina. Patients are occasionally reluctant to consider vaginal methods of contraception unless discussed openly and as a convenient alternative to other routes of administration. Some women are uncomfortable with this method and may fear that the ring may migrate or be uncomfortable or be noticed by a partner. The nurse can be helpful in dispelling misconceptions. The patient can be informed that some women notice a slight increase in vaginal discharge (SexualityandU.ca, 2012). NuvaRing is usually more expensive than oral contraceptives.

Injectable Contraceptives An intramuscular injection of Depo-Provera (a long-acting progestin) every 3 months inhibits ovulation and provides a reliable, private, and convenient contraceptive method. It can be used by lactating women and those with hypertension, liver disease, migraine headaches, heart disease, and hemoglobinopathies. With continued use, women must be prepared for irregular bleeding episodes and spotting decrease, or amenorrhea. Advantages of Depo-Provera include reduction of menorrhagia, dysmenorrhea, and anemia due to heavy menstrual bleeding. It may reduce symptoms of PMS, chronic pelvic pain, endometriosis, and the risk of pelvic infection and ectopic pregnancy. It decreases the risk of endometrial cancer, ovarian cancer, and uterine fibroids. The frequency of seizures may be reduced for women with epilepsy. Possible side effects of Depo-Provera include irregular menstrual bleeding, bloating, mood alteration, headaches, hair loss, decreased sex drive, bone loss, and weight loss or weight gain. The contraceptive does not protect against STDs. 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. While Depo-Provera is used, bone density is decreased, and this may be a risk factor for future osteoporosis. Depo-Provera is absolutely contraindicated in women who are pregnant and those who have breast cancer. Relative contraindications include unexplained vaginal bleeding, history of ischemic heart disease or stroke, severe cirrhosis, active viral hepatitis, and liver tumours (SexualityandU.ca, 2012). The long-term effects on infants of nursing mothers who use Depo-Provera are unknown but are thought to be negligible.

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. Advantages include effectiveness over a long period of time, few if any systemic effects, and reduction of patient

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error. This reversible method of birth control is as effective as sterilization and more effective than barrier methods. Disadvantages include possible excessive bleeding, cramps, and backaches; a slight risk of tubal pregnancy; slight risk of pelvic infection on insertion; 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 a small nulliparous uterus may not tolerate it. It can be used for women over 35 who smoke. Women with multiple partners, women with heavy or crampy periods, or those with a history of ectopic pregnancy or pelvic infection should be encouraged to use other methods of contraception. Some clinicians test for chlamydia and gonorrhea prior to insertion to prevent PID. The IUD prevents fertilization by impairing sperm function, as copper has an antispermatic effect, and it lasts for 5 years. The Levonorgestrel Intrauterine System (IUS; Mirena), another IUD, releases levonorgestrel, a synthetic progestin used in oral contraceptives, and is effective for at least 5 years. It works by impairing sperm function, thickening cervical mucus, and suppressing the endometrium. It has also been used therapeutically to reduce heavy bleeding; it may prevent the need for hysterectomy in some women with heavy vaginal bleeding. IUS is also helpful in women with menorrhagia, dysfunctional uterine bleeding, and perimenopausal menstrual irregularities (SexualityandU.ca, 2012).

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 domelike 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 completely. 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 the woman uses the diaphragm, she should examine it carefully. By holding it up to a bright light, she should ensure that it has no pinpoint holes, cracks, or tears. She then applies spermicidal jelly or cream and inserts the diaphragm. The diaphragm should remain in place at least 6 to 8 hours after coitus (no more than 24 hours). Additional spermicide is necessary if more than 6 hours have passed before intercourse occurs and before each act of repeated intercourse. On removal, the diaphragm should be cleansed thoroughly with mild soap and water, rinsed, and dried before being stored in its original container. Disadvantages include allergic reactions in those who are sensitive to latex and an increased incidence of urinary tract infections. Some women may be sensitive to spermicides or have physical or neurological impairments which

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limit the ability to insert or remove the diaphragm. Toxic shock syndrome has been reported in some diaphragm users but is rare.

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NURSING ALERT

The nurse must assess the woman for possible latex allergy because use of latex barrier methods (e.g., diaphragm, cervical cap, male condoms) may cause severe allergic reactions, including anaphylaxis, in patients with latex allergy.

is left in place in the vagina for at least 6 hours after intercourse and can be kept in place for up to 24 additional hours without the need to replace it with repeated acts of intercourse during that period of time. The sponge is sold over the counter and does not require a prescription or special fitting by a health care provider. The sponge should not be used by women with allergy to polyurethane. It should not be used during menstruation. Women who have a history of toxic shock syndrome should not use the contraceptive sponge. The sponge can be used by breastfeeding women (SexualityandU.ca, 2012).

Female Condom Cervical Cap The cervical cap is much smaller (22 to 35 mm) than the diaphragm and covers only the cervix. The Lea’s shield is available in one size only (SexualityandU.ca, 2012). 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 after coitus. 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 is used with a spermicide and does not require additional spermicide for repeated intercourse.

Contraceptive Sponge The sponge, another barrier method of contraception, is made of soft, disposable polyurethane foam that is moistened with water and inserted into the vagina before intercourse. It contains and releases a spermicide (e.g., nonoxyl-9) that is continuously released into the vagina in small amounts through a 24-hour wear time. The sponge

The female condom was developed to give control of barrier protection to women—to provide them with protection from STDs and HIV as well as pregnancy. The female condom 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. 47-7). Advantages include some degree of protection from STDs (HPV, herpes simplex virus, and HIV). Disadvantages include the inability to use the female condom with some positions (i.e., standing). Women have found that it can be noisy and slippery.

Spermicides Spermicides are made from nonoxynol-9 or octoxynol and are available over the counter as foams, gels, films, and suppositories and also on condoms. Spermicides do not protect women from HIV or other STIs (SexualityandU.ca, 2012). In fact, nonoxynol-9 has been found to be associated with minute tears in vaginal tissue with frequent use (e.g., daily), possibly increasing the possibility of contracting HIV from an infected partner.

Inner ring

Outer ring

Inner ring

Inner ring

Outer ring

FIGURE 47-7. Female condom. To insert the female condom, hold the inner ring between the thumb and middle finger. Put the index finger on the pouch between the thumb and other fingers and squeeze the ring. Slide the condom into the vagina as far as it will go. The inner ring keeps the condom in place.

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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. Condoms are now available in large and small sizes. The latex condom also creates a barrier against transmission of STDs (gonorrhea, chlamydial infection, and HIV) by body fluids and may reduce the risk of herpes virus transmission. However, natural condoms (those made from animal tissue) do not protect against HIV infection. Oil-based lubricants should not be used with latex condoms. Nurses need to reassure women that they have a right to insist that their male partners use condoms and a right to refuse sex without condoms, although women in abusive relationships may increase their risk of abuse by doing so. Some women carry condoms with them to be certain that one is available. Nurses should be familiar and comfortable with instructions about using condoms because many women need to know about this way of protecting themselves from HIV and other STDs. Condoms do not provide complete protection from STDs because HPV 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. The nurse needs to consider the possibility 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 fruit, avocados, or chestnuts. Because many contraceptives are made of latex, patients who experience burning or itching while using latex contraceptives are instructed to see their primary health care provider. Alternatives to latex condoms may include the female condom (Reality) and the male condom (Avanti), made of polyurethane.

Coitus Interruptus or Withdrawal Coitus interruptus (removing the penis from the vagina before ejaculation) requires careful control by the male partner. Although it is a frequently used method of preventing pregnancy and better than no method, it is considered an unreliable method of contraception.

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: (1) they are not hazardous to health, (2) they are inexpensive, and (3) they are approved by some religions that do not approve of other methods of contraception. The disadvantage is that they require discipline by the couple, who must monitor the menstrual cycle and abstain from sex during the fertile phase. Current methods include the calendar method, the basal body temperature method, the ovulation method, and the symptothermal method. The calendar and basal body temperature methods are older than the ovulation method and

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the symptothermal method. Combinations of these methods are often used (SexualityandU.ca, 2012). The fertile phase (in which sexual abstinence is required) 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 (i.e., calendar) 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 (e.g., Clearblue Easy Fertility Monitor) 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. Over-the-counter test kits are easy to use and reliable but can be expensive. Ovulation prediction kits are more effective for planning conception than for avoiding it. But if they are used in combination with cervical mucus changes, they may be effective (Bouchard, Fehring, & Schneider, 2013). Douching is not a contraceptive method and may enhance rather than decrease the chances of conception.

Emergency Contraception The need for emergency contraception may arise after an episode of unprotected sexual intercourse. Therefore, nurses need to be aware of emergency contraception as an option for women and the indications for its use. It is clearly not suitable for long-term avoidance of pregnancy because it is not as effective as oral contraceptives or other reliable methods used regularly. However, it is valuable following intercourse when a pregnancy is not intended and in emergency situations such as rape, a defective or torn condom or diaphragm, or other situations that may result in unwanted conception. Women need to be made aware of emergency contraception and how to obtain it.

Methods of Emergency Contraception Hormonal Methods A properly timed, adequate dose of estrogen and a progestin or progestin-only medication after intercourse without effective contraception, or when a method has failed, can prevent pregnancy by inhibiting or delaying ovulation. This method does not interrupt an established pregnancy and does not cause an abortion. Generally, emergency contraception is currently available only with prescription and is not available over the counter. Emergency contraceptives may be dispensed by

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pharmacists without a prescription in some states. The sooner emergency contraception is taken, the more effective it is. It is considered safe and effective by the Canada Food and Drug Act and can be prescribed or purchased as Plan B (progestin only) packages of emergency contraception with patient literature. It can also be prescribed as a specific number of contraceptive pills, depending on the medication and dose used. This method must be used not more than 5 days following intercourse. Nausea, a common side effect, can be minimized by taking the medication with meals and with an antiemetic agent. Other side effects, such as breast soreness and irregular bleeding, may occur but are transient. Patients who use this method should be advised of the potential failure rate and also counseled about other contraceptive methods. There are no known contraindications to the use of this method, except an established pregnancy (International Federation of Gynecolgy and Obstetrics [FIGO], 2012). The nurse reviews with the patient instructions for emergency contraception based on the medication regimen prescribed. If the woman is breastfeeding, a progestin-only formulation is prescribed. To avoid exposing infants to synthetic hormones through breast milk, the patient can manually express milk and bottle feed for 24 hours after treatment. The patient should be informed that her next menstrual period may begin a few days earlier or a few days later than expected. She is instructed to 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.

Abortion

Postcoital Intrauterine Device Insertion

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, the patient is referred for genetic counselling and testing and other possible causes are explored. If bleeding occurs in a pregnant woman with a past history of habitual abortion, conservative measures, such as bed rest and administration of progesterone to support the endometrium, are attempted to save the pregnancy. Supportive counselling is crucial in this stressful condition. Bed rest, sexual abstinence, a light diet, and no straining on defecation may be 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, although its effectiveness is unclear. It 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. About 2 to 3 weeks before term or at the onset of labour, the suture is cut. Delivery is usually by cesarean section.

Postcoital IUD insertion, another form of emergency contraception, involves insertion of a copper-bearing IUD within 5 days of coitus in women who want this method of contraception; however, it may be inappropriate for some women or if contraindications exist. The copper IUD creates a foreign body reaction in the endometrium and is toxic to sperm and changes sperm mobility (SexualityandU, 2012). The patient may experience discomfort on insertion and may have heavier menstrual periods and increased cramping. Contraindications include a confirmed or suspected pregnancy, PID, Wilson’s disease 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. The nurse must be supportive and nonjudgmental and provide facts and appropriate patient teaching. If the 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. Nurses can educate and inform women about emergency contraception options to reduce unwanted pregnancies and abortions. See the list of resources at the end of this chapter for more information.

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 5th to 6th month of gestation.

Spontaneous Abortion It is estimated that 1 of every 5 to 10 conceptions ends 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 2nd or 3rd month of gestation. There are various types 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 not, an abortion is imminent. If only some of the tissue is passed, the abortion is referred to as incomplete. An emptying or evacuation procedure (D & C, or dilation and evacuation [D & E]) or administration of oral misoprostol (Cytotec) is usually required to remove the remaining tissue. If the fetus and all related tissue are spontaneously evacuated, the abortion is termed complete, and no further treatment is required.

Habitual Abortion

Medical Management After a spontaneous abortion, all tissue passed vaginally is saved for examination if possible. The patient and all

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personnel who care 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 D & E or uterine suctioning.

Nursing Management Because patients experience loss and anxiety, emotional support and understanding are important aspects of nursing care. Women may be grieving or relieved, depending on their feelings about the pregnancy. Providing opportunities for the patient to talk and express her emotions is helpful and also provides clues for the nurse in planning more specific care.

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 province 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. Surgical terminations include D & C or vacuum aspiration of uterine contents.

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Medical Management Before the abortion procedure is performed (Chart 47-15), a nurse or counsellor trained in pregnancy counselling should talk with the patient and explore her fears, feelings, and options. The nurse then identifies the patient’s choice (i.e., continuing pregnancy and parenthood; continuing pregnancy followed by adoption; or terminating pregnancy by abortion). If abortion is chosen, the patient has a pelvic examination to determine uterine size. A pelvic ultrasound may also be performed. Laboratory studies before an abortion must include a pregnancy test to confirm the pregnancy, hematocrit to rule out anemia, and Rh determination. Patients with anemia may need an iron supplement, and patients who are Rh-negative 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.

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NURSING ALERT

Women who have resorted to unskilled attempts to end a pregnancy are often critically ill because of infection, hemorrhage, or uterine rupture. If a woman has undergone such efforts to end a pregnancy, prompt medical attention, broad-spectrum antibiotics, and replacement of fluids and blood components may be required before careful attempts are made to evacuate the uterus.

CHART 47-15

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

Labour 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 (e.g., 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 labour.

Medical Abortion 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, 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 patient 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 about signs and symptoms (i.e., fever, heavy bleeding, or pain) that should be reported. 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. A woman who has used any method of birth control should be assessed for her understanding of the method and its potential side effects as well as her satisfaction with the method. If the woman has not been using contraception, the nurse explains all methods and their benefits and risks and helps the patient make a contraceptive choice for use after abortion. Related teaching issues, such as the need to use barrier contraceptive devices (i.e., condoms) for protection against transmission of STDs and HIV infection and the availability of emergency contraception, are becoming increasingly important. Psychological support is another important aspect of nursing care. The nurse needs to be aware that women terminate pregnancies for many reasons. Some women terminate pregnancies because of severe genetic defects. Women who have been raped or impregnated in incestuous relationships or by an abusive partner may elect to terminate their pregnancies. The care of a woman 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.

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 Canada, infertility affects 6 million couples. It is often a complex physical problem, and its causes are usually related to azoospermia, anovulation, or tubal obstruction.

Pathophysiology

phene (Clomid) to induce ovulation or insulin sensitizing agents. Once insulin levels are normalized, ovulation often occurs. Some women have high prolactin levels, which inhibit ovulation, and they are treated with dopaminergic drugs after a pituitary adenoma is ruled out by MRI. If a woman has premature ovarian failure, oocyte donation may be considered.

Tubal and Uterine Factors Hysterosalpingogram (HSG) is used to rule out uterine or tubal abnormalities. A contrast agent injected into the uterus through the cervix produces an outline of the shape of the uterine cavity and the patency of the tubes. This process sometimes removes mucus or tissue that is lodged in the tubes. Laparoscopy permits direct visualization of the tubes and other pelvic structures and can assist in identifying conditions that may interfere with fertility (e.g., endometriosis). Fibroids, polyps, and congenital malformations are possible causative factors affecting the uterus. Their presence may be determined by pelvic examination, hysteroscopy, saline sonogram (a variation of a sonogram), and HSG. Endometriosis, even if mild, is associated with reduced fertility.

Male Factors An analysis of semen provides information about 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 has 60 to 100 million sperm/mL. However, the incidence of impregnation is lessened only when the count decreases to less than 20 million sperm/mL. 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.

Medical Management The treatment of infertility is complex and often requires advanced technology. The specific type of treatment depends on the cause of the problem, if it can be identified. Many infertile couples have normal test results for ovulation, sperm production, and fallopian tube patency.

Ovarian and Ovulation Factors

Pharmacologic Therapy

Diagnostic studies performed to determine if ovulation is regular and whether the progestational endometrium is adequate for implantation may include a serum progesterone level and an ovulation index. The ovulation index involves a urine-stick test to determine whether the surge in LH that precedes follicular rupture has occurred. Ovulatory dysfunction is complex, but many women with ovulation disorders have polycystic ovary syndrome, described in Chapter 47, and may be treated with clomi-

Pharmacologically induced ovulation is undertaken when women do not ovulate on their own or ovulate irregularly. Women older than 37 years are less likely to be fertile. These couples are often treated with clomiphene to stimulate ovulation. Gonadotropin treatment may also be used if conception does not occur. Various other medications are used, depending on the primary cause of infertility (Chart 47-16). Blood tests and ultrasounds are used to monitor ovulation. Multiple pregnancies (i.e., twins, triplets or more)

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CHART 47-16

Pharmacology: Medications That Induce Ovulation • Clomiphene citrate (Clomid, Serophene) is an estrogen

antagonist that increases gonadotropin release, resulting in follicular rupture or ovulation. Clomiphene is used when the hypothalamus is not stimulating the pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH). This medication stimulates follicles in the ovary. It is usually taken for 5 days beginning on the 5th 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. • Menotropins (Repronex, Pergonal), a combination of FSH and LH, may be used to stimulate the ovaries to produce eggs. These agents are used for women with deficiencies in FSH and LH. When followed by administration of human chorionic gonadotropin, menotropins stimulates the ovaries, so monitoring by ultrasound and hormone levels is essential because overstimulation may occur. • Follitropin-alpha (Gonal-F), follitropin-beta (Follistim), and urofollitropin (Bravelle) may be used to treat ovulation disorders or to stimulate a follicle and egg production for intrauterine insemination or in vitro fertilization or other assisted reproductive technologies.

may occur with use of 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. The fluid shift can result in ascites, pleural effusion, and edema; hypovolemia may also occur. Risk factors include younger age, history of polycystic ovarian syndrome, high serum estradiol levels, a larger number of follicles, and pregnancy.

Artificial Insemination Artificial insemination is the deposit of semen into the female genital tract by artificial means. If the sperm cannot penetrate the cervical canal normally, artificial insemination using a partner’s or husband’s semen or that of a donor may be considered. When the sperm of the woman’s partner is defective or absent (azoospermia) 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. Certain conditions must be met before semen is transferred to the vagina or uterus. 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.

• Gonadotropin-releasing hormone agonists (leuprolide • • •

• • •

[Lupron, Synarel]) suppress FSH, prevent premature egg release, and shrink fibroids. Bromocriptine (Parlodel) may be used in treatment of infertility due to elevated prolactin levels. Progesterone (Prometrium Crinone, progesterone in oil) vaginal suppositories help improve the uterine lining after ovulation. Urofollitropin (Metrodin, Bravelle), which contains FSH with a small amount of LH, is used in some disorders (e.g., polycystic ovarian syndrome) to stimulate follicle growth. Clomiphene is then used to stimulate ovulation. Chorionic gonadotropin (Ovidrel, Novarel, Pregnyl), which mimics LH, releases an egg after hyperstimulation and supports the corpus luteum. Metformin (Glucophage, Fortamet) may be used in polycystic ovarian syndrome to induce regular ovulation. Aspirin and heparin may be used to prevent recurrent pregnancy loss in patients with elevated antiphospholipid antibodies.

Ultrasonography and blood studies of varying hormone levels are used to pinpoint the best time for insemination and to monitor for OHSS. 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. The woman may have received clomiphene or other medications to stimulate ovulation before insemination. 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. The sperm are washed before insertion to remove biochemicals and to select the most active sperm. Semen is drawn into a sterile syringe, and a cannula is attached. The semen is then directed to the external os. In IUI, semen is placed into the uterine cavity.

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 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 monitoring hormone 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. GIFT is considered in unexplained infertility and

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when there is religion-based discomfort with IVF. The most common indications for IVF and GIFT are irreparable tubal damage, endometriosis, unexplained infertility, inadequate sperm, and exposure to DES. Success rates for GIFT vary from 20% to 30%.

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 (i.e., premature ovarian failure) have the option of using the eggs of a donor after 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 that are appropriate when working with couples during infertility evaluations include assisting in reducing stress in the relationship, encouraging cooperation, protecting privacy, fostering understanding, and referring the couple to appropriate resources when necessary. Because infertility evaluations and treatments are expensive, time-consuming, invasive, stressful, and not always successful, couples need support in working together to deal with this process. The Infertility Awareness Association of Canada (IAAC) a nonprofit self-help group that provides information and support for infertile patients, was founded by a group of volunteers in Ottawa. The literature on infertility that is produced by this group is an important resource for patients and professionals. Most areas of the country have local support groups. More information can be obtained by visiting the website or contacting the Infertility Awareness Association of Canada. Smoking is strongly discouraged because it has an adverse effect on the success of assisted reproduction. Diet, exercise, stress reduction techniques, folic acid supplementation, health maintenance, and disease prevention are emphasized in many infertility programs. Couples may also consider adoption, child-free living, and gestational carriers (use of surrogate to carry the fetus for the infertile couple). Nurses can be helpful listeners and information resources in these deliberations.

tend to have better outcomes. This is an important issue because many pregnancies in Canada are unplanned. Nurses can make a difference through education and counselling; preconception counselling can decrease the incidence of birth defects. Women who smoke should be encouraged to stop smoking, and it may help to offer smoking cessation classes. Women should take folic acid supplements to prevent neural tube defects. Women with diabetes should have good glycemic control prior to conception. It is necessary to assess rubella immunity and other immunizations as well as a family history of genetic defects; genetic counselling may be appropriate. Women taking teratogenic medications and women concerned about genetic disorders should be encouraged to discuss effective contraception and childbearing plans with their health care provider (see Chart 47-2).

Ectopic Pregnancy The incidence of ectopic pregnancy and the risk of death due to ectopic pregnancy are decreasing. However, ectopic pregnancy remains the leading cause of pregnancy-related death in the first trimester. Ectopic pregnancy occurs when a fertilized ovum (a blastocyst) becomes implanted on any tissue other than the uterine lining (e.g., the fallopian tube, ovary, abdomen, cervix or scar tissue from previous caesarean section). The most common site of ectopic implantation is the fallopian tube (Fig. 47-8). Possible causes of ectopic pregnancy 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, previous tubal surgery, multiple previous induced abortions (particularly if followed by infection), tumours that distort the tube, and IUD and progestin-only contraceptives. PID appears to be the major risk factor. Improved antibiotic therapy for PID usually prevents total tubal closure but may leave a stricture or narrowing, predisposing to ectopic implantation. The odds of recurrent ectopic pregnancy are three times higher if an infectious pathology caused the first ectopic pregnancy. After a second ectopic pregnancy occurs, assisted reproduction is considered. Abdominal Interstitial

Tubal (isthmus)

Preconception/Periconception Health Care Nurses can be instrumental in encouraging all women of childbearing age, including those with chronic illness or disabilities, to consider issues that may affect health during pregnancy (Smeltzer, Robinson-Smith, Duffin, et al., 2010; Smeltzer & Wetzel-Effinger, 2009). Women who plan their pregnancies and are healthy and well informed

Tubal (ampullar)

Infundibular (ostial) Ovarian

Cervical

FIGURE 47-8. Sites of ectopic pregnancy.

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Risk factors are important, but all women need to be educated about early treatment and have a high index of suspicion in the case of a period that does not seem normal, the presence of pain, or pain with a suspected pregnancy. Women may have fatal hemorrhage with ruptured ectopic pregnancies if they delay seeking attention or if their health care providers are not alert to the possibility of this diagnosis.

Clinical Manifestations 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), and may proceed to sharp, colicky pain. Most patients experience some pelvic or abdominal pain and some spotting or bleeding. Gastrointestinal symptoms, dizziness, or lightheadedness may occur. Patients may think 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 remains undetected for 4 to 6 weeks or longer after conception. When the tube ruptures, the ovum is discharged into the abdominal cavity, and the woman experiences agonizing pain, dizziness, faintness, and nausea and vomiting due 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 Ectopic pregnancies must be diagnosed promptly to prevent life-threatening hemorrhage, the major complication of rupture. 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, although there are often no abnormal findings. If an ectopic pregnancy is suspected, the patient is evaluated by sonography and human chorionic gonadotropin (hCG) levels. If the ultrasound results are inconclusive, the hCG test is repeated. 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 less than 5 ng/mL are considered abnormal; levels greater than 25 ng/mL are associated with a normally developing pregnancy. Ultrasound, the usual method of diagnosis, can detect a pregnancy between 5 and 6 weeks from the time of the last menstrual period. Detectable fetal heart movement outside the uterus on ultrasound is firm evidence of an ectopic

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pregnancy. On occasion, an ultrasound study is not definitive and the diagnosis must be made with combined diagnostic aids (beta-hCG and progesterone levels, ultrasound, pelvic examination, and clinical judgment). Occasionally, the clinical picture makes the diagnosis relatively easy. However, when the clinical signs and symptoms are inconclusive, which is often the case, other procedures may be needed. Laparoscopy can be 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 includes “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 salpingotomy, 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 (Trexall), a chemotherapeutic agent and folic acid antagonist, may be used after surgery to treat any remaining embryonic or early pregnancy tissue, as indicated by a persistent or increasing beta-hCG level. The beta-hCG test is repeated 2 weeks after surgery to ensure that the level is decreasing.

Pharmacologic Therapy Another option is the use of methotrexate without surgery. Because methotrexate stops the pregnancy from progressing by interfering with DNA synthesis and the multiplication of cells, it interrupts early, small, unruptured ectopic pregnancies. The patient must be hemodynamically stable, have no active renal or hepatic disease, have no evidence of thrombocytopenia or leukopenia, and have a very small, unruptured ectopic pregnancy on ultrasound. Other indications may include no fetal cardiac activity, no active bleeding, and a beta-hCG level of less than 2,000 mIU/mL. The medication is administered intramuscularly or orally. Some patients may be treated with intratubal injection of methotrexate. Complete blood count and tests of liver and renal function are conducted to monitor the patient; blood typing is performed in anticipation of the need for transfusions. Until the pregnancy is resolved, the patient is advised to refrain from alcohol, intercourse, and vitamins containing folic acid, 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

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health care provider. Serum levels of beta-hCG are monitored carefully, and these levels should gradually decrease. Ultrasound may also be used for monitoring. Side effects of methotrexate include abdominal cramping, mucositis, and renal and hepatic damage. Allergic reactions have occurred in patients receiving high doses.

!!"##

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 pain and its 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). In addition, the nurse monitors vital signs, level of consciousness, and the nature and amount of vaginal bleeding. If possible, the nurse assesses how the patient is coping with the abnormal pregnancy and likely loss.

Diagnosis Nursing Diagnoses Based on the assessment data, 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 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; 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 was desired, 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 occur.

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 (IV) therapy. Bed rest is indicated. Hematocrit, hemoglobin, and blood gases 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 reestablishing tissue perfusion and adequate blood volume. See Chapter 15 for a discussion of the IV fluids and medications used in treating shock. The nurse has an important role in prevention by being alert to patients with abnormal bleeding who may be at risk for an ectopic pregnancy and referring them immediately for care. It is necessary to keep a high index of suspicion in daily practice when a woman of childbearing age, particularly one who is not using an effective method of contraception consistently, reports abdominal discomfort or abnormal bleeding.

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 in-depth teaching can begin. At this time, the patient’s and the nurse’s attention is focused on the crisis, not on learning. At a later time, the patient begins to ask questions about what happened and why certain

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Assessment and Management of Female Physiologic Processes

procedures were performed. Procedures are explained in terms that the distressed and apprehensive patient can understand. The patient’s partner is included in teaching and explanations when possible. After the patient recovers from postoperative discomfort, it may be more appropriate to address any questions and concerns that she and her partner have, including the effect of this pregnancy or its treatment on future pregnancies. The patient should be advised that ectopic pregnancies may recur. The patient is informed about possible complications and instructed to report early signs and symptoms. It is important to review signs and symptoms with the patient and instruct her to report an abnormal menstrual period promptly. CONTINUING CARE. Because of the risk of subsequent ectopic pregnancies, the patient is advised to seek preconception counselling before considering future pregnancies and to seek early prenatal care. Follow-up contact allows the nurse to answer questions and clarify information for the patient and her partner.

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 colour and turgor d. Exhibits stable vital signs and adequate urine output e. Levels of beta-hCG return to normal

Critical Thinking Exercises 1 A 50-year-old woman has been experiencing severe hot flashes and resultant insomnia. She is considering beginning hormone therapy (HT) but is concerned about its risks. What information would you give to her? What is the evidence base for that information? What criteria would you use to assess the strength of the evidence? What resources would you recommend to her? 2 A 19-year-old female college student comes to the student health clinic for a gynecologic examination because she anticipates having sex with her new girlfriend. She asks you for advice about avoiding sexually transmitted diseases. What advice would you give her? How would you modify your teaching if she informed you that her new

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partner has other partners? What other teaching would you provide? 3

You are working in a women’s health practice and are responsible for educating women about menopause and health promotion. Your 48-year-old patient has mild diabetes, and she is obese and has hypertension. She takes oral antidiabetic and antihypertensive medications. She reports that she has a strong family history of heart disease. She is concerned about menopause because her mother and sisters experienced “difficult” menopause. She indicates that she has little time for exercise and eats mostly fast food because of her high-pressure job. What health promotion strategies would you suggest to assist the patient in improving her health status as she approaches menopause? What is the evidence base for those strategies? How would you use that evidence to develop a teaching plan for her?

4 At a health clinic, you meet a 45-year-old woman with postpolio syndrome who uses a battery-powered scooter most of the time because of increasing muscle weakness. She is approaching menopause and is concerned about how her physical limitations secondary to postpolio syndrome 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 *Asterisk indicates nursing research article. **Double asterisks indicate classic reference.

BOOKS American Cancer Society. (2009). Cancer facts and figures 2009. Atlanta, GA: Author. Andrews, M. M., & Boyle, J. S. (Eds.). (2011). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Lippincott William & Wilkins. **Annon, J. S. (1974). The behavioral treatment of sexual problems (1st ed.). Honolulu, HI: Enabling Systems. Chow, J., Ateah, C. A., Schott, S. D., et al. (2012). Canadian maternity and pediatric nursing. Philadephia, PA: Lippincott Williams & Wilkins. Gibbs, R. S., Karlan, B. Y., Haney, A. F., et al. (2008). Danforth’s obstetrics and gynecology (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2011). Protocols for nurse practitioners in gynecologic settings (10th ed.). New York, NY: Tiresias Press. Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), & World Health Organization (WHO). (2011). Family planning: A global handbook for providers 2011 update. Baltimore and Geneva: Author. Krueger, M. V. (2011). Menstrual disorders. In J. E., South-Paul, S. C., Matherny, & E. L., Lews, Current diagnosis and treatment in family medicine (3rd ed.); McGraw-Hill. National Osteoporosis Foundation. (2013). Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: Author. North American Menopause Society. (2010). Menopause practice: A clinician’s guide (4th ed.). Cleveland, OH: Author. Osteoporosis Canada. (2013a). What is osteoporosis? Retrived from http:// www.osteoporosis.ca/osteoporosis-and-you/what-is-osteoporosis/ Osteoporosis Canada. (2013b). Drug treatments. http://www.osteoporosis. ca/osteoporosis-and-you/drug-treatments/ Porth, C. M., & Matfin, G. (2012). Pathophysiology: Concepts of altered health states (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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Speroff, L., & Darney, P. A. (2010). Clinical guide for contraception (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Speroff, L., & Fritz, M. (2010). Clinical gynecologic endocrinology and infertility (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Statistics Canada. (2013a). Disability in Canada: Initial findings from the Canadian Survey on Disability. Retrieved from http://www.statcan. gc.ca/pub/89-654-x/89-654-x2013002-eng.htm

JOURNALS AND ELECTRONIC DOCUMENTS General Burke, E. (2011). Female genital mutilation: Applications of nursing theory for clinical care. Nurse Practitioner, 36 (4), 45–50. Cejtin, H., Kalinowski, A., Bacchetti, P. et al. (2006). Effects of human immunodeficiency virus on protracted amenorrhea and ovarian dysfunction. Obstetrics & Gynecology, 108(6), 1423–1430. Perron, L., & Senikas, V. (2013). SOGC policy statement: FGC/mutilation. Journal of Obstetrics and Gynaecology Canada, 34(2), 197–200. Public Health Agency of Canada (PHAC). (2012). Specific populations: Sexual assault in postpubertal adolescents and adults. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-6-6eng.php Rape Victims Support Network. (2012). Sexual assault statistics. Retrieved from http://www.assaultcare.ca/index.php?option=com_con tent&view=article&id=49&Itemid=58 *Smeltzer, S. C., Avery, C., & Haynor, P. (2012). Interactions of people with disabilities and nursing staff during hospitalization. American Journal of Nursing, 112(4), 30–37. Smeltzer, S. C., Robinson-Smith, G., Ma, D., et al. (2010). Disabilityrelated content in nursing textbooks. Nursing Education Perspectives, 31(3), 148–155. Smeltzer, S. C., & Wetzel-Effinger, L. (2009). Pregnancy in women with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 15(1), 29–42. Statistics Canada. (2013). Disability in Canada: Initial findings from the Canadian Survey on Disability. Retrieved from http://www.statcan. gc.ca/pub/89-654-x/89-654-x2013002-eng.htm Willis, D. S., Wishart, J. G., & Muir, W. J. (2010). Carer knowledge and experiences with menopause in women with intellectual disabilities. Journal of Policy and Practice in Intellectual Disabilities, 7(1), 42–48. Abortion Statistics Canada. (2013b). Measuring violence against women: Statistical trends. Retrieved from http://www.statcan.gc.ca/pub/85-002-x/2013001/ article/11766-eng.pdf World Health Organization (WHO). (2013). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/

Contraceptive Technology Update. (2012). Hormone therapy focus of new joint statement. Contraceptive Technology Update, 33(10), 118–120. Dormire, S. L. (2009). The potential role of glucose transport changes in hot flash physiology: A hypothesis. Biological Research for Nursing, 10(3), 241–247. El-Nashar, S. A., Hopkins, M. R., Barnes, S. A., et al. (2010). Healthrelated quality of life and patient satisfaction after global endometrial ablation for menorrhagia in women with bleeding disorders. American Journal of Obstetrics and Gynecology, 202(4), 348.e1–e7. Hearth and Stroke Foundation. (2014). Women and Heart Disease and Stroke. Retrieved from http://www.heartandstroke.com/site/c. ikIQLcMWJtE/b.3484041/k.D80A/Heart_disease__Women_and_ heart_disease_and_stroke.htm LaCroix, A. Z., Chlebowski, R. T., Manson, J. E., et al. (2011). Health outcomes after stopping conjugated equine estrogens among post menopausal women with prior hysterectomy: A randomized controlled trial. Journal of the American Medication Association, 305(3), 1305–1314. Levine, J. P. (2011). Treating menopausal symptoms with a tissue-selective estrogen complex. Gender Medicine, 8(2), 57–68. Shoupe, D. (2012). Individualizing hormone therapy: Weighing risks and benefits. Contemporary Obstetrics and Gynecology, 57 (8), 16–24. SOGC. (2009). Menopause and osteoporosis update 2009. Journal of Obstetrics and Gynaecology Canada, 31(1), S3–S46. **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 Abercrombie, P. D., & Learman, L. A. (2012). Providing holistic care for women with chronic pelvic pain. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 41(5), 668–679. Gibbons, L. (2011). Dealing with the effects of domestic violence. Emergency Nurse, 19(4), 12–17. Hooker, L., Ward, B., & Verrinder, G. (2012). Domestic violence screening in maternal and child health nursing practice: A scoping review. Contemporary Nurse: A Journal for the Australian Nursing Profession, 42(2), 198–215. Pap Smears and Follow-Up Treatment Bentley, J. (2012). Colposcopic management of abnormal cervical cytology and histology. Journal of Obstetrics and Gynaecology Canada, 34(12), 1188–1203.

Conception Control Bouchard, T., Fehring, R. J., Schneider, M. (2013). Efficacy of a new postpartum transition protocol for avoiding pregnancy. Journal of the American Board of Family Medicine, 26 (1), 35–44. International Federation of Gynecology and Obstetrics (FIGO). (2012). Emergency contraceptive pills: Medical and service delivery guidelines. Retrieved from http://sexualityandu.ca/uploads/files/Medical_ and_Service_Delivery_Guidelines_Eng_2012.pdf Lopez, L. M., Kaptein, A., & Helmerhorst, F. M. (2012). Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database of Systematic Reviews, 2, CD006586. SexualityandU.ca. (2012). Birth control: Non-hormonal methods. Retrieved from http://www.sexualityandu.ca/birth-control/birth_ control_methods_contraception/non-hormonal-methods Cultural Differences in Health Care of Women Clark, A. R., Goddu, A. P., Nocon, R. W., et al. (2013). Thirty years of disparities intervention research: What are we doing to close racial and ethnic gaps in health care. Medical Care, 51(11), 1020–1026. Shafii, T., & Burstein, G. R. (2009). The adolescent sexual health visit. Obstetrics and Gynecology Clinics of North America, 36 , 99–117. Menstruation, Irregular Bleeding, Perimenopause, PMS, and Menopause Chlebowski, R. T., & Anderson, G. L. (2012). Changing concepts: Menopausal hormone therapy and breast cancer. Journal of the National Cancer Institute, 104(7), 517–27.

RESOURCES Amnesty International (resource for activists to end female genital mutilation), www.amnesty.org Association of Reproductive Health Professionals, www.arhp.org Association of Women’s Health, Obstetrical and Neonatal Nurses (AWHONN), www.awhonn.org Canadian Association of Perinatal and Women’s Health Nursing (CAPWHN), www.capwhn.ca/en/capwhn/News_p2469.html Canadian Women’s Health Network, www.cwhn.ca/en D.E.S. Action Canada, www.desaction.ca Family Violence Prevention Fund, www.endabuse.org Female Genital Mutilation Education and Networking Project (provides fact sheets, state policies, periodicals), www.fgmnetwork.org Guttmacher Institute, www.guttmacher.org Health Promotion for Women with Disabilities Project, Villanova University College of Nursing, www.nurseweb.villanova.edu/womenwithdisabilities Infertility Awareness Association of Canada, http://www.iaac.ca/content/ contact National Association of Nurse Practitioners in Women’s Health (NPWH), www.npwh.org National Coalition Against Domestic Violence, www.ncadv.org North American Menopause Society, www.menopause.org Planned Parenthood Federation of America, www.plannedparenthood. org

CHAPTER

48 Management of Patients With Female Reproductive Disorders Adapted by Jean Chow

Learning Objectives On completion of this chapter, the learner will be able to: 1. Compare the various types of vaginal infections and the signs, symptoms, and treatments of each. 2. Develop a teaching plan for the patient with a vaginal infection. 3. Use the nursing process as a framework for care of the patient with a vulvovaginal infection. 4. Use the nursing process as a framework for care of the patient with genital herpes. 5. Discuss the signs and symptoms, management, and nursing care implications of malignant disorders of the female reproductive tract. 6. Use the nursing process as a framework for care of the patient undergoing a hysterectomy. 7. Describe indications for a wide excision of the vulva, or vulvectomy, and the preoperative and postoperative nursing interventions. 8. Compare nursing interventions indicated for the patient undergoing radiation therapy and chemotherapy for cancer of the female reproductive tract.

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Disorders of the female reproductive system can be minor or serious but are usually anxiety producing and often distressing. 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 that nurses have knowledge, understanding, and skill in patient teaching. Nurses must also be sensitive to the woman’s concerns and possible discomfort in discussing and dealing with these disorders.

VULVOVAGINAL INFECTIONS Vulvovaginal infections are common, and nurses have an important role in providing information that may prevent their occurrence. To help prevent these infections, women need to understand their own anatomy and vulvovaginal health. 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

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 tumour candidiasis: infection caused by Candida species or yeast; also referred to as monilial vaginitis or yeast infection colporrhaphy: repair of the vagina condylomata: warty growths indicative of the human papillomavirus (HPV) conization: procedure in which a cone-shaped piece of cervical tissue is removed as a result of detection of abnormal cells; also called cone biopsy cryotherapy: destruction of tissue by freezing (e.g., with liquid nitrogen) cystocele: bulging of the bladder downward into the vagina 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 endometriosis: endometrial tissue in abnormal locations; causes pain with menstruation, scarring, and possible infertility enterocele: is a protrusion of the intestinal wall into the vagina fibroid tumour: usually benign tumour of the uterus that may cause irregular bleeding; also called myoma or leiomyoma fistula: abnormal opening between two organs or sites (e.g., vesicovaginal, between bladder and vagina; rectovaginal, between rectum and vagina) 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 visualization and surgical 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: 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 polycystic ovary syndrome (PCOS): disorder in the hypothalamic–pituitary and ovarian network, resulting in chronic anovulation, androgen excess, and polycystic ovaries rectocele: bulging of the rectum into the vagina salpingitis: inflammation of the fallopian tube salpingo-oophorectomy: removal of the ovary and its fallopian tube (removal of the fallopian tube alone is a salpingectomy) 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 often causes pain with intercourse (dyspareunia) vestibulodynia: most common type of vulvodynia, characterized by sharp pain in response to pressure applied to the vestibular area of the vulva. 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

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Management of Patients With Female Reproductive Disorders

CHART 48-1

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

maintains normal pH. They also produce hydrogen peroxide, which is toxic to anaerobes. The risk of infection increases if a woman’s resistance is reduced by stress or illness, if the pH is altered, or if a pathogen is introduced. 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 or predispose to infections include contact with an infected partner and wearing tight, nonabsorbent, and heat-retaining and moistureretaining clothing (Chart 48-1). Vaginitis (inflammation of the vagina) is a group of conditions that cause vulvovaginal symptoms such as itching, irritation, burning, and abnormal discharge. Bacterial vaginosis is the most common cause (10% to 30% of pregnant women), followed by vulvovaginal candidiasis (75% of women will have at least one episode) and trichomoniasis (Public Health Agency of Canada [PHAC], 2008c) (Table 48-1). Other types include desquamative vaginitis, atrophic vaginitis, various vulvar dermatologic conditions, and vulvodynia. 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 vaginitis because of the proximity of the urethra to the vagina. Discharge that occurs with vaginitis may produce itching, odour, redness, burning, or edema, which may be aggravated by voiding and defecation. After the causative organism has been identified, appropriate treatment

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(discussed later) is prescribed. This may include an oral medication or a local medication that is inserted into the vagina using an applicator.

Candidiasis Vulvovaginal candidiasis is a fungal or yeast infection caused by strains of Candida (see Table 48-1). Candida albicans accounts for most cases, but other strains, such as Candida glabrata, may also be implicated. Many women with a healthy vaginal ecosystem harbour Candida but are asymptomatic. Certain conditions favour 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. Although infections can occur at any time, they occur more commonly in pregnancy or with a systemic condition such as diabetes mellitus or human immunodeficiency virus (HIV) infection, or when patients are taking medications such as 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 may be 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), clotrimazole (Gyne-Lotrimin), and Fluconazole however Fluconazole is not used during pregnancy. Oral medication (fluconazole [Diflucan]) is available in a one-pill dose. Relief should be noted within 3 days. Some 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. Patients often use these remedies for problems other than yeast infections. If a woman is uncertain about the cause of her symptoms or if relief has not been obtained after using these creams, she should be instructed to seek health care promptly. Yeast infections can become recurrent or complicated. Women may have more than four infections in a year and severe symptoms due to preexisting conditions such as diabetes or immunosuppression. Cell-mediated immunity may be a factor. Women with recurrent yeast infections benefit from a comprehensive gynecologic assessment.

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 48-1).

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TABLE 48-1

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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

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 (e.g., antibiotic therapy, nylon underwear, tight clothing, pregnancy, oral contraceptives). Assess for diabetes and HIV infection in patients with recurrent monilia.

Gardnerellaassociated bacterial vaginosis

Gardnerella vaginalis and vaginal anaerobes

Usually no edema or erythema of vulva or vagina Grey-white to yellow-white discharge clinging to external vulva and vaginal walls

Administer metronidazole (Flagyl), with instructions about avoiding alcohol while taking this medication. If infection is recurrent may treat partner.

Trichomonas vaginalis vaginitis (STD)

Trichomonas vaginalis

Inflammation of vaginal epithelium, producing burning and itching Frothy yellow-white or yellow-green vaginal discharge

Relieve inflammation, restore acidity, and reestablish normal bacterial flora; provide oral metronidazole for patient and partner.

Bartholinitis (infection of greater vestibular gland)

Escherichia coli Trichomonas vaginalis Staphylococcus Streptococcus Gonococcus

Erythema around vestibular gland Swelling and edema Abscessed vestibular gland

Drain the abscess; provide antibiotic therapy; excise gland of patients with chronic bartholinitis.

Cervicitis: acute and chronic

Chlamydia Gonococcus Streptococcus Many pathogenic bacteria

Profuse purulent discharge Backache Urinary frequency and urgency

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.

Atrophic vaginitis

Lack of estrogen; glycogen deficiency

Discharge and irritation from alkaline pH of vaginal secretions

Provide topical vaginal estrogen therapy; improve nutrition if necessary; relieve dryness through use of moisturizing medications.

Risk factors include douching after menses, smoking, multiple sex partners, and other sexually transmitted diseases (STDs) (also referred to as sexually transmitted infections [STIs]).

Clinical Manifestations Bacterial vaginosis can occur throughout the menstrual cycle and does not produce local discomfort or pain. More than half of patients with bacterial vaginosis do not notice any symptoms. Discharge, if noticed, is heavier than normal and grey to yellowish white in colour. It is characterized by a fishlike odour that is particularly noticeable after sexual intercourse or during menstruation as a result of an increase in vaginal pH. The pH of the discharge is usually greater than 4.7 because of the amines that result from enzymes from anaerobes. The fishlike odour can be detected readily by adding a drop of potassium hydroxide to a glass slide with a sample of vaginal discharge, which releases amines; this is referred to as a positive “whiff” test. Under the microscope, vaginal cells are coated with bacteria and are described as “clue cells.” Lactobacilli, which serve as a natural host defense, are usually absent. Bacterial vaginosis is not usually considered a serious con-

dition, although it can be associated with premature labour, premature rupture of membranes, 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 in vaginal cream or oral doses) are also effective. Treatment of patients’ partners is not indicated and does not prevent recurrence.

Trichomoniasis Trichomonas vaginalis is a flagellated protozoan that causes a common, usually sexually transmitted vaginitis that is often called “trich.” Trichomoniasis may be transmitted by an asymptomatic carrier who harbours the organism in the urogenital tract (see Table 48-1). It may increase the risk of contracting HIV from an infected partner and may play a role in development of cervical neoplasia, postoperative infections, adverse pregnancy outcomes, pelvic inflammatory disease (PID), and infertility.

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Management of Patients With Female Reproductive Disorders

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 most often by microscopic detection of the motile causative organisms or less frequently by culture. Inspection with a speculum often reveals vaginal and cervical erythema (redness) with multiple small petechiae (“strawberry spots”). Testing of a trichomonal discharge demonstrates a pH greater than 4.5.

Medical Management The most effective treatment for trichomoniasis is metronidazole. Both partners receive a one-time loading dose or a smaller dose two times a day for 1 week. The one-time dose is more convenient; consequently, compliance tends to be greater. Some patients complain of an unpleasant but transient metallic taste when taking metronidazole. Nausea and vomiting, as well as a hot, flushed feeling (disulfiram-like reaction), occur when this medication is taken with an alcoholic beverage. In view of these side effects, patients taking metronidazole are strongly advised to abstain from alcohol during and for 24 hours after treatment (PHAC, 2008c). Metronidazole is not prescribed without examination. It is contraindicated in patients with some blood dyscrasias or central nervous system diseases. It can be used in symptomatic pregnant women. The sexual partner(s) should be treated and abstinence is recommended during treatment to avoid reinfection (PHAC, 2010a).

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 48-1). 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.

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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 should be 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.

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Each of the infection-producing organisms produces its own characteristic discharge and effect (see Table 48-1). The patient is asked to describe any discharge and other symptoms, such as odour, 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, soaps, bubble bath, poor hygiene, and use of feminine hygiene products • Psychogenic factors (e.g., stress, fear of STDs, abuse) • Medical conditions or endocrine factors, such as a predisposition to Monilia in a patient who has diabetes • 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 factors that could contribute to infection, including hygiene practices (douching), and use or nonuse of condoms and other 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 odour when mixed with potassium hydroxide. Testing the pH of the discharge with Nitrazine paper assists in proper diagnosis.

Diagnosis Nursing Diagnoses Based on the nursing assessment and other data, major nursing diagnoses may include the following: • Discomfort related to burning, odour, 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

Planning and Goals Major goals may include relief of discomfort, reduction of anxiety related to symptoms, prevention of

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Reproductive Function

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 may be occasionally recommended and may provide temporary relief of symptoms.

Reducing Anxiety Vulvovaginal infections are upsetting and require treatment. The patient who experiences such an infection may be very anxious about the significance of the symptoms and possible causes. Explaining the cause of symptoms may reduce anxiety related to fear of a more serious illness. Discussing ways to help prevent vulvovaginal infections may help patients adopt specific strategies to decrease infection and the related symptoms.

Preventing Reinfection or Spread of Infection The patient needs to be informed about 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 several days after use, 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 hairdryer on a cool setting will dry the area and application of topical corticosteroids may decrease 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 a 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 could be serious 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 (HealthLinkBC, 2011; Luong, Libman, Dahhou, et al., 2010). In the case of recurrent yeast infections, the perineum should be kept as dry as possible. Loosefitting cotton instead of tight-fitting synthetic, nonabsorbent, heat-retaining underwear is recommended. Use of talcum powder should be discouraged. Vulvar self-examination is a good health practice for all women. Becoming familiar with one’s own anatomy and reporting anything that seems new or different may result in early detection and treatment of any new disorders. Nurses can also play a role in teaching women about the risks of unprotected intercourse, particularly with partners who have had sex with others.

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, odour, 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 e. Performs vulvar self-examination regularly and reports any new findings to care provider

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Management of Patients With Female Reproductive Disorders

Human Papillomavirus Human papillomavirus (HPV) infection is sexually transmitted and is the most common STD in young, sexually active people. The prevalence of HPV in young women is approximately 29% (PHAC, 2008a). Most infections are self-limiting and without symptoms, and others can cause cervical and anogenital cancers. 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).

Pathophysiology More than 100 types of HPV exist. The most common strains of HPV, 6 and 11, usually cause condylomata (warty growths) on the vulva. These are often visible or may be palpable by patients. 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 HPV strains (16, 18, 31, 33, and 45) may not cause condylomata but do affect the cervix, resulting in abnormal Papanicolaou (Pap) smears. The effects of these strains are usually invisible on examination but may be seen on colposcopy. They may cause cervical changes that may appear as koilocytosis on Pap smear. Seventy percent of all cervical cancers are caused by strains 16 and 18 (PHAC, 2008a). However, most women with HPV infection do not develop cervical cancer. The incidence of HPV in young, sexually active women is high. The infection often disappears as the result of an effective immune system response. It is thought that two proteins produced by high-risk types of HPV interfere with tumour suppression by normal cells. Risk factors include being young, being sexually active, having multiple sex partners, and having sex with a partner who has or has had multiple partners. In 2006, the Public Health Agency of Canada recommended that a newly licensed vaccine (Gardasil) against the four strains of HPV that cause the majority of cases of cervical cancer be routinely administered to females 9 to 26 years of age. In 2011, Gardasil was approved for use in women up to age 45 and in the same year, it was approved for the use in males ages 9 to 26 years of age. Although this vaccine is considered an important medical breakthrough, it does not replace other strategies important in prevention of HPV or the need for cervical cancer screening. It is administered in three intramuscular doses, with the initial dose followed by second dose in 2 months and a third dose 6 months after the first dose. This vaccine, along with regular Pap smears, has the potential to decrease the impact of HPV-related disease (PHAC, 2012b). In 2010, Cervarix was approved for use in females 10 to 25 years of age to protect against dysplastic lesions caused by HPV 16 and 18. The vaccine is administered in a 0, 1, and 6 month schedule.

Medical Management Treatment consists of patient applied medications or treatment in the health provider’s office. Treatment of external genital warts includes topical application of Imiquimod

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and Podofilox/podophyllotoxin 5% (Wartec, Condyline) by the patient. Because the safety of imiquimod and podofilox/podophyllotoxin during pregnancy has not been determined, these agents should not be used during pregnancy. Office-based treatments include cryotherapy, bi- or trichloracetic acid, electro-fulguration, CO2 laser ablation, excision and podophyllin 10% to 25% (not used during pregnancy) (PHAC, 2008a). Treatment does not guarantee eradication of HPV. However, they may resolve spontaneously without treatment and new lesions may also recur even in different sites (PHAC, 2008a). If the treatment includes application of a topical agent by the patient, the patient 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. Women with HPV should have annual Pap smears because of the potential of HPV to cause dysplasia (changes in cervical cells). Much remains unknown about subclinical and latent HPV disease. Women are often exposed to HPV by partners who are unknowing carriers. Use of condoms can reduce the likelihood of 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 external genitalia and occasionally the vagina and cervix. It is an STD but may also be transmitted asexually from wet surfaces or by self-transmission (i.e., 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—all situations that may tax the immune system. The incidence of herpes infection in Canada is unknown (PHAC, 2008b). Transmission is possible even when a carrier does not have symptoms (subclinical shedding). Lesions increase vulnerability to HIV infection and other STDs. Vaccines for herpes genitalis are in clinical trials.

Pathophysiology Of the known herpesviruses, six affect humans: (1) herpes simplex type 1 (HSV-1), which usually causes cold sores

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of the lips; (2) herpes simplex type 2 (HSV-2), or genital herpes; (3) varicella zoster, or shingles; (4) Epstein–Barr virus; (5) cytomegalovirus (CMV); 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, infants delivered vaginally may become infected with the virus. There is a risk of 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 occur as the infected area becomes red and edematous. Primary infection may begin with macules and papules and progress to vesicles and ulcers. 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 (enlarged 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 1 to 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, neonatal transmission, 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 include preventing the spread of infection, making patients comfortable, decreasing potential health risks, and initiating a counselling and education program. The antiviral agents acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) can suppress symptoms and shorten the course of the infection. These 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 often milder than the initial episode.

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Nursing Process

The Patient With a Genital Herpesvirus Infection Assessment The health history and a physical and pelvic examination are important in establishing the nature of the infectious condition. In addition, patients are assessed for risk of STDs. The perineum is inspected for painful lesions. Inguinal nodes are assessed and are often enlarged and tender during an occurrence of HSV.

Diagnosis Nursing Diagnoses Based on the assessment data, 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 Major goals 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 self-care, 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.

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Management of Patients With Female Reproductive Disorders

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 women.

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 patient anxiety. Nurses can be an important support, listening to patients’ concerns and providing information and instruction. The patient may be angry with her partner if the partner is the probable source of the infection. The patient

may need assistance and support in discussing the infection and its implications with her current sexual partners and in future sexual relationships. The nurse can refer the patient to a support group to assist in coping with the diagnosis (see Resources at the end of the chapter).

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 (Chart 48-2).

CHART 48-2

HOME CARE CHECKLIST •

The Patient With Genital Herpes

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• State that herpes is transmitted mainly by direct contact.

✔

✔

• State that abstinence from sex is required for a brief period (intercourse is avoided during

✔

✔

• State that intercourse during a herpes outbreak not only increases the risk of transmission

✔

✔

• 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

✔

✔

• Describe appropriate hygiene practices (hand washing, perineal cleanliness, gentle washing

✔

✔

• State that control of the condition may require changes in sexual behaviour and use of

✔

✔

• Describe strategies to avoid self-infection (e.g., avoid touching lesions during an outbreak).

✔

✔

• Explain rationale for avoiding self-infection (i.e., lesions can become infected from germs on

✔

✔

• Describe health promotion strategies: wear loose, comfortable clothing; eat a balanced

✔

✔

• State rationale for avoiding exposure to the sun as it can cause recurrences (and skin cancer).

✔

✔

• Identify importance of taking medications as prescribed, keeping follow-up appointments

✔

✔

• Describe possible benefits of joining a group to share solutions and experiences and hear

✔

✔

treatment, but other options such as hand holding and kissing are acceptable). but also increases the likelihood of contracting HIV and other STDs.

of recurrence at time of delivery, cesarean section may be considered.

of lesions with mild soap and running water and lightly drying lesions) and importance of avoiding occlusive ointments, strong perfumed soaps, or bubble bath. medications.

the hand, and the virus from the lesion can be transmitted from the hand to another area of the body or another person). diet; get adequate rest and relaxation.

with health care provider, and reporting repeated recurrences (may not be as severe as the initial episode). about newer treatments.

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Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Self-care measures for people with genital herpes appear in Chart 48-2.

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. Assesses own current 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 partners 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

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.

reproductive age have had one occasion of PID (PHAC, 2010c). There are 100,000 reports of symptomatic PID annually but two thirds of the cases are unrecognized and underreported. 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 pregnant women are infected, stillbirth, neonatal death, and premature labour may occur. Infants born to infected mothers may experience prematurity, conjunctivitis, and pneumonia. Chlamydial infection and gonorrhea often coexist. Females who have chlamydial infections may be coinfected with gonorrhea (PHAC, 2010d). 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. Women with gonorrhea may have no symptoms, but without treatment, many women 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 PHAC (2010d) recommends treating chlamydia with doxycycline (Vibramycin) for 1 week or with a single dose of azithromycin (Zithromax). Because of the high incidence of coinfection with chlamydia and gonorrhea, treatment for gonorrhea should include treatment for chlamydia as well (PHAC, 2010d). 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. The PHAC (2010d) no longer recommends quinolones (e.g., ciprofloxacin, or ofloxacin for the treatment of gonorrhea and associated conditions (e.g., PID). Instead, Cefixime is recommended for the treatment of gonorrhea with alternatives (e.g., Ceftriazone, Spectinomycin). 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. Screening for chlamydia is recommended for all sexually active young women and older women with new sex partners or multiple partners (PHAC, 2010d).

Chlamydia and Gonorrhea

Nursing Management

Chlamydia and gonorrhea are the most common causes of endocervicitis, although Mycoplasma may also be involved. Rates of infection have been increasing since 1997 and in 2006, 202/100,000 cases of chlamydia were reported (PHAC, 2010b). It is most commonly found in young, sexually active people with more than one partner and is transmitted through sexual intercourse. It can result in serious complications, including pelvic infection, an increased risk for ectopic pregnancy, and infertility. PID is a major sequela of infection. At least 10% to 15% of Canadian women of

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 behaviour occur. Patients should be discouraged from assuming that a partner is “safe” without open, honest discussion. Nonjudgmental attitudes, educational counselling, and role playing may be helpful. Because chlamydia, gonorrhea, and other STDs may have a serious effect on future health and fertility and

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because many of these disorders can be prevented by the use of condoms and spermicides and careful choice of partners, nurses can play a major role in counselling patients about safer sex practices. Exploring options with patients, addressing knowledge deficits, and correcting misinformation may reduce morbidity and mortality.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Nurses can educate women and help them develop communication skills and initiate discussions about sex with their partners. Communicating with partners about sex, risk, postponing intercourse, and using safer sex behaviours, including use of condoms, may be lifesaving. Some young women report having sex but not being comfortable enough to discuss sexual risk issues. Nurses can help women to advocate for their own health by discussing safety with partners prior to sexual activity. Reinforcing the need for annual screening for chlamydia and other STDs is an important part of patient teaching. Sexual partners should be traced back 60 days from the onset of symptoms and treated (PHAC, 2010b). The PHAC (2010b) does not recommend rescreening women with chlamydial infections if the recommended medication has been taken, symptoms disappear, and there is no re-exposure to an untreated partner. However, pregnant women, prepubertal children, populations in whom there is suboptimal compliance, and people in whom alternative treatment regimens have been used should be retested.

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. Endogenous organisms, anaero-

Spread of bacterial infection

A

bic and aerobic bacteria are also implicated. This condition can result in the fallopian tubes becoming narrowed and scarred, which increases the risk of 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. PID is a common gynecologic cause of hospital admissions in Canada. The true incidence of PID is unknown because some cases are asymptomatic.

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. 48-1). 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 to the fallopian tubes and into the pelvis (see Fig. 48-1). The infection is usually bilateral. In rare instances, organisms (e.g., tuberculosis) gain access to the reproductive organs by way of the bloodstream from the lungs (see Fig. 48-1). 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 insertion of an intrauterine device. 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

Spread of gonorrhea

B

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Spread through blood via circulatory system

C

FIGURE 48-1. 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).

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without condoms, sex with a partner with an STD, and a history of STDs or previous pelvic infection.

evaluating the status of the infection. Treatment of sexual partners is necessary to prevent reinfection.

Nursing Management

Clinical Manifestations Symptoms of pelvic infection usually begin with vaginal discharge, dyspareunia, lower abdominal pelvic pain, and tenderness that occur after menses. Pain may increase with 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.

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, usually a combination of oral azithromycin and metronidazole. Women with mild infections may be treated as outpatients, but hospitalization may be necessary. Intensive therapy includes bed rest, intravenous (IV) fluids, and IV antibiotic therapy. If the patient has abdominal distention or ileus, nasogastric intubation and suction are initiated. Careful monitoring of vital signs and symptoms assists in

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. A 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. In addition, 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 protect herself from reinfection. If a partner is not well known or has had other sexual partners recently, use of condoms is essential to prevent infection and 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 Chart 48-3.

CHART 48-3

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

Caregiver

• State that any pelvic pain or abnormal discharge, particularly after sexual exposure,

✔

✔

• State that antibiotics may be prescribed after insertion of intrauterine devices (IUDs).

✔

✔

• Describe proper perineal care procedures (wiping from front to back after defecation

✔

✔

• State that douching reduces the natural flora that combat infecting organisms and may

✔

✔

• Identify the importance of consulting a health care provider if unusual vaginal discharge

✔

✔

• Discuss the importance of following health practices (i.e., proper nutrition, exercise, and weight

✔

✔

• Explain the importance of consistent use of condoms before intercourse or any

✔

✔

• State that a gynecologic examination should be performed at least once a year.

✔

✔

childbirth, or pelvic surgery, should be evaluated as soon as possible.

or urination).

introduce bacteria upward. or odour is noted.

control), and safer sex practices (i.e., using condoms, avoiding multiple sexual partners). penile–vaginal contact if there is any chance of transmitting infection.

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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 Chapter 47 for a discussion of ectopic pregnancy.)

Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome Any discussion of vulvovaginal infections and STDs must include the topic of HIV and acquired immunodeficiency syndrome (AIDS), which is described in Chapter 53. Because HIV infection may be detected through prenatal testing and screening for STDs, nurses and other women’s health care clinicians are often the first professionals to provide care for a woman with HIV infection. Thus, they need to be knowledgeable about this disorder and sensitive to women’s issues and concerns. The incidence of HIV infection and AIDS in women is increasing with over 25% of the HIV positive results coming from women (PHAC, 2008b). The major risk behaviours for HIV include heterosexual exposure and intravenous drug use. Most women with HIV infection are in the reproductive age group. Younger women are disproportionately at higher risk; there has been a large increase in the 15 to 19 age group (PHAC, 2008b). Heterosexual contact and intravenous drug use are the major risk behaviours for women. The presence of sexual transmitted infections such as ulcerative genital infections (e.g., a herpetic or syphilitic lesion) and nonulcerative infections (e.g., chlamydia, trhichomoniasis) increases the risk of transmission. Bacterial vaginosis, not a sexual transmitted infection, may also increase the risk of transmission. 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 of HIV (which may be related to inflammatory changes of the cervix, providing entry sites). HIV-positive women have a higher rate of HPV. Infections with HPV and HIV together increase the risk of malignant transformation and cervical cancer. 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. Women with HIV and women with partners who have HIV must be counselled about safer sex and informed about the dangers of unprotected sex. Inconsistent use of condoms results in a higher seroconversion rate. Because there is a risk of perinatal transmission, decisions to conceive or to use contraception must be based on teaching, accurate information, and care. Pregnant women are advised to have an HIV test. The use of antiretroviral agents by pregnant women significantly decreases perinatal transmission of HIV infection. Therefore, the use of these agents during pregnancy is critical and must also be discussed. For women who choose to avoid conception, use of condoms alone and with oral contraceptives are possible choices.

After informed consent is obtained, women who are at risk for HIV are offered testing by a nurse or counsellor. Because patients may be reluctant to discuss risk-taking behaviour, routine screening should be offered to all women. Early detection permits early treatment to delay progression of the disease. Use of antiretroviral therapy has been improving, but barriers to use of health services by disadvantaged women include current drug use and difficulty keeping appointments. Depression and abuse are issues that affect women’s use of health care services. Prevention of cervical neoplasia and PID need to be part of the teaching for women at risk. The nurse also needs to remember that many women do not see themselves as at risk for acquiring HIV infection. See Chapter 53 for further discussion 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. 48-2). Fistulas may be congenital in origin. However, in adults, breakdown usually occurs because of tissue damage resulting from injury sustained during surgery, vaginal delivery, irritable bowel disease, radiation therapy, infections, or disease processes such as carcinoma (Taylor & Rakinic, 2011).

Clinical Manifestations Symptoms depend on the specific defect. For example, in a patient with a vesicovaginal fistula, urine escapes continuously into the vagina. With a rectovaginal fistula,

Uterus Bladder Ureterovaginal Vesicovaginal Urethrovaginal Vagina Rectovaginal Vaginoperineal Rectum FIGURE 48-2. 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.

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there is fecal incontinence, 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 IV 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 promote healing include proper nutrition, cleansing douches and enemas, rest, and administration of prescribed intestinal antibiotics. A rectovaginal fistula heals faster when the patient eats a low-residue diet and when the affected tissue drains properly. Warm perineal irrigations 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. In addition, attending to the patient’s social and psychological needs is an essential aspect of care.

A

If the patient is to 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. Tissue transfer techniques (skin or tissue grafting) may be used (Taylor & Rakinic, 2011). Because fistulas usually are typically 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 Age and parity can put strain on the ligaments and structures that make up the female pelvis and pelvic floor. Childbirth can result in tears of the levator sling musculature, resulting in structural weakness. Hormone deficiency also may play a role. Some degree of prolapse (weakening of the vaginal walls allowing the pelvic organs to descend and protrude into the vaginal canal) may be found in many older women. Risk factors include age, parity, increased intra-abdominal pressure (e.g., smoking, constipation, obesity), and vaginal delivery (Lazarou & Bogdan, 2012). Cystocele is a downward displacement of the bladder toward the vaginal orifice (Fig. 48-3), resulting from damage to the anterior 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 is an upward pouching of the rectum that pushes the posterior wall of the vagina forward. Both rectoceles and perineal lacerations, which occur because of

B

C

FIGURE 48-3. 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.

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muscle tears below the vagina, may affect the muscles and tissues of the pelvic floor and may occur during childbirth. Sometimes the lacerations may completely sever the fibres of the anal sphincter (complete tear). An enterocele is a protrusion of the intestinal wall into the vagina. Prolapse results from a weakening of the support structures of the uterus itself; the cervix drops and may protrude from the vagina. (If complete prolapse occurs, it may also be referred to as procidentia.)

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, patients 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 perform and are recommended for all women, including those with strong pelvic floor muscles (Chart 48-4). A pessary 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 ring shaped or doughnut shaped and are made of various materials, such as rubber or plastic (Fig. 48-4). Rubber pessaries must be avoided in women

A

CHART 48-4

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.

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 these checkups, vaginal walls should be 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. A Colpexin sphere is another nonsurgical device used to treat pelvic organ prolapse. This intravaginal device is similar to a pessary, but it supports the pelvic floor muscles and facilitates exercise of these muscles. It is removed daily for cleaning.

Surgical Management In many cases, surgery helps correct structural abnormalities. The procedure to repair the anterior vaginal wall is called anterior colporrhaphy, repair of a rectocele is called

B

FIGURE 48-4. Examples of pessaries. A, Various shapes and sizes of pessaries available. B, Insertion of one type of

pessary.

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D

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Reproductive Function

B

C

E

FIGURE 48-5. 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.

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 with the body of the uterus inclined slightly forward. The uterus is normally freely movable on 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. 48-5). 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. 48-6). 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 symptoms are aggravated when a woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may aggravate the symptoms.

Medical Management Surgery and pessaries are two options for treatment. With surgery, 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) or repaired by colpopexy. Colpocleisis, or vaginal closure, may be an option for women who do not wish to have sexual intercourse or to bear children and want to

FIGURE 48.6 Complete prolapse of the uterus through the introitus.

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avoid hysterectomy (Plowright & Davila, 2012). Pessaries may be the treatment of choice in older women or those who are too ill to tolerate surgery.

Nursing Management Implementing Preventive Measures Some disorders 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 and then to continue them as a preventive action. 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 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 19.

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 needs 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 46. 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, the perineum is kept as clean as possible. 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, not on the patient. Routine postoperative care is similar to that given after abdominal surgery. The patient is positioned in bed with her 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.

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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, stoolsoftening 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 cleanliness, prevention of constipation, recommended exercises, and avoiding lifting heavy objects or standing for prolonged periods. The patient is instructed to report any pelvic pain, unusual discharge, inability to carry out personal hygiene, and vaginal bleeding. CONTINUING CARE. The patient is advised to continue with perineal exercises, which are recommended to improve muscle strength and tone. She 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.

BENIGN DISORDERS Vulvitis and Vulvodynia 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. Vulvodynia is a chronic vulvar pain syndrome (SOGC, 2012). Symptoms may include burning, stinging, irritation, or stabbing pain. The syndrome 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. Vulvodynia may be classified as organic if it has a known cause (infection, trauma, or irritants) or idiopathic if no cause is known. It can be chronic or unremitting, intermittent or episodic, or may occur only in response to contact. The pathophysiology is unknown. Vestibulodynia is the most frequent type of vulvodynia, producing sharp pain on pressure on the vestibule. Treatment methods for vulvodynia vary. Topical treatments (i.e., estrogens, xylocaine), surgery, biofeedback, anticonvulsants, antidepressants, and pelvic floor physiotherapy (SOGC, 2012), have been used. Some cases seem to be similar to peripheral neuralgia and may respond to treatment with tricyclic antidepressants.

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 vulvar tumour. 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 Staphylococcus aureus and can cause

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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. Cysts can be treated by resection or with laser, ablation with silver nitrate, and puncture. Asymptomatic cysts do not require treatment. Malignancy can occur, usually in women older than 50 years of age, so drainage and biopsy may be considered.

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 reepithelializes. 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 patients 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.

Medical Management Topical corticosteroids (i.e., hydrocortisone creams) are the usual treatment. Petrolatum jelly may relieve pruritus. Use is decreased as symptoms resolve. 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 completed. 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 self-monitoring 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 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 selfexaminations 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. The risk of malignancy is much greater in postmenopausal women than in premenopausal patients. Almost all pelvic masses in premenopausal women are benign (Teng & Simon, 2012). Ovarian cysts are often detected on routine pelvic examination. Although these cysts are typically benign, they nevertheless should be evaluated to exclude ovarian cancer, particularly in postmenopausal women (Teng & Simon, 2012). 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. 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 very large cyst usually leads to considerable abdominal distention. This 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 bilateral ovary removal because of a suspicious mass; it may increase life expectancy and avoid a later second surgery. Patient preference is a priority in determining its appropriateness. Polycystic ovary syndrome (PCOS) is another type of cystic disorder that affects the ovaries. This complex endocrine condition involves a disorder in the hypothalamic–pituitary and ovarian network or axis, resulting in chronic anovulation and clinical androgen excess, along

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with multiple small ovarian cysts called polycystic ovaries. Onset of PCOS may be at menarche or later; it occurs in approximately 5% to 10% of women of childbearing age (Vause & Cheung, 2010). Features include obesity, insulin resistance, impaired glucose tolerance, dyslipidemia, sleep apnea, and infertility. Symptoms are related to androgen excess. Irregular menstrual periods, resulting from lack of regular ovulation, infertility, obesity, and hirsutism, may be a presenting complaint. Cysts form in the ovaries because the hormonal milieu cannot cause ovulation on a regular basis. Women with PCOS may develop insulin resistance and metabolic syndrome, and they may be at higher risk for diabetes and cardiac disorders in later life. Metformin (Glucophage) is also used to decrease the hyperinsulinemia that occurs with PCOS.

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Intramural myomas

Pedunculated intracavitary myoma Pedunculated serosal myoma Protruding intracavitary myoma

Medical Management The treatment of large ovarian cysts is usually surgical removal. However, oral contraceptives may be used in young, healthy patients to suppress ovarian activity and resolve small cysts that appear to be fluid filled or physiologic. Oral contraceptives are also usually prescribed to treat PCOS. When pregnancy is desired, medications to stimulate ovulation (clomiphene [Clomid]) are often effective. Lifestyle modification is critical, and weight management is part of the treatment plan.

Benign Tumours of the Uterus: Fibroids (Leiomyomas, Myomas) Myomatous or fibroid tumours of the uterus are estimated to occur in one in three women during their reproductive years (SOGC, 2013). It is thought that women are genetically predisposed to develop this condition, which is almost always benign. Fibroids arise from the muscle tissue of the uterus and can be solitary or multiple, in the lining (intracavitary), muscle wall (intramural), and outside surface (serosal) of the uterus. They usually develop slowly in women between 25 and 40 years of age and may become quite large. A growth spurt with enlargement of the fibroid tumour may occur in the decade before menopause, possibly related to anovulatory cycles and high levels of unopposed estrogen. Fibroids are a common reason for hysterectomy because they often result in menorrhagia, which can be difficult to control.

Clinical Manifestations Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms result from pressure on the surrounding organs and include pain, backache, pressure, bloating, constipation, and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may occur because fibroids may distort the uterine lining (Fig. 48-7). Fibroids may interfere with fertility.

FIGURE 48-7. Myomas (fibroids). Those that impinge on the uterine

cavity are called intracavitary myomas.

Medical Management Treatment of uterine fibroids may include medical or surgical intervention and depends to a large extent on the size, symptoms, and location, as well as the woman’s age and her reproductive plans. Fibroids usually shrink and disappear during menopause, when estrogen is no longer produced. Simple observation and follow-up may be all the management that is necessary. The patient with minor symptoms is closely monitored. If she plans to have children, treatment is as conservative as possible. As a rule, large tumours that produce pressure symptoms should be removed (myomectomy). A hysterectomy may be performed 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 (SGOC, 2003; CWHN, 2012). These include the following: • Hysteroscopic myomectomy as a first-line treatment: small incision is made to remove fibroid (SOGC, 2003) • Laparoscopic myolysis-energy is used to dessicate or disrupt blood supply to the fibroid • Uterine artery occlusion embolization (UAE): polyvinyl alcohol or gelatin particles are injected into the blood vessels that supply the fibroid via the femoral artery, resulting in infarction and resultant shrinkage. This percutaneous image–guided therapy offers an alternative to hormone therapy or surgery. UAE may result in infrequent but serious complications such as pain, infection, amenorrhea, necrosis, and bleeding. Although rare, deaths and ovarian failure may occur. Women need to weigh the risks and benefits carefully, especially if they have not completed childbearing • GNRH agonists shrink leiomyomas by affecting the growth effect of estrogen and progesterone (Hoffman, Schorge, Hlavorson, et al., 2012)

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• Antiprogestins to shrine leiomyoma volume (Hoffman et al., 2012) • MRgGUS-magnetic resonance imagery (Hoffman et al., 2012) • Hysterectomy (Hoffman et al., 2012) Medications (e.g., leuprolide [Lupron]) or other gonadotropin-releasing hormone (GnRH) analogues, which induce a temporary menopause-like environment, may be prescribed to shrink the fibroids. This treatment consists of monthly injections, which may cause hot flashes and vaginal dryness. Treatment is usually short term (i.e., before surgery) to shrink the fibroids, allowing easier surgery, and to alleviate anemia, which may occur as a result of heavy menstrual flow. This treatment is used on a temporary basis because it leads to vasomotor symptoms and loss of bone density.

Endometriosis Endometriosis is a chronic disease that affects 1 in 10 women of reproductive age. A benign lesion or lesions with cells similar to those lining the uterus grow aberrantly anywhere in the pelvic cavity outside the uterus. Often, extensive endometriosis causes few symptoms, whereas an isolated lesion may produce severe symptoms. It is a major cause of chronic pelvic pain and infertility. Endometriosis has been diagnosed more frequently as a result of the increased use of laparoscopy, but diagnosis can often be delayed, and women with this problem often feel as if their complaints are being dismissed. Before laparoscopy became widely available, 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 favours 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 25 and 35 years of age and in adolescents, particularly those with dysmenorrhea that does not respond to nonsteroidal anti-inflammatory drugs (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/grey powder-burn appearance and brown or blue-black appearance, indicating concealed bleeding. Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudocyst or chocolate cyst. Adhesions, cysts, and scar tissue may result, causing pain and infertility.

Endometriosis may increase the risk of ovarian, hematopoietic malignancies (mainly non-Hodgkin lymphoma), and breast cancer (Kokeu, 2011). 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. Why some women with retrograde menstruation develop endometriosis 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.

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 stage the disease. In stage 1, patients have superficial or minimal lesions; stage 2, mild involvement; stage 3, moderate involvement; and stage 4, extensive 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 often used. Infrequently, side effects may occur with oral contraceptives, such as fluid retention, weight gain, and nausea. These can usually be managed by changing brands or formulations. Depo-Provera, an injectable contraceptive agent, may also be used. Several types of hormonal therapy are also available in addition to 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

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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 atrophy. GnRH agonists decrease estrogen production and cause subsequent amenorrhea. Side effects are related to low estrogen levels (e.g., hot flashes and vaginal dryness). Loss of bone density is often offset by concurrent use of estrogen. Leuprolide, an GnRH agonist, is injected monthly to suppress hormones and induce an artificial menopause, thus avoiding menstrual effects and relieving 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. Hormonal medications are not used 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 years of age 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 (e.g., 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 (Endometriosisinfo.ca) is a helpful resource for patients seeking further information and support for this condition, which can cause disabling pain and severe emotional distress.

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Chronic Pelvic Pain Chronic pelvic pain is a common disorder of women that may be related to several of the previously discussed gynecologic disorders. Fifteen percent to 20% of women have chronic pelvic pain—that is, pelvic pain that persists for more than 6 months. It may be cyclic or intermittent and noncyclic. Causes may be reproductive, genitourinary, or gastrointestinal. A history of abuse, PID, endometriosis, interstitial cystitis, musculoskeletal disorders, irritable bowel syndrome, and previous surgery resulting in abdominal adhesions may be associated with chronic pelvic pain. Chronic pelvic pain is often difficult to treat. Treatment depends on physical and diagnostic test results and may include antidepressants, analgesics, oral contraceptives, GnRH agonists, exercise, and surgery.

Adenomyosis In adenomyosis, the tissue that lines the endometrium invades the uterine wall. The incidence is highest in women 40 to 50 years of age. 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.

Endometrial Hyperplasia This condition, a build-up of endometrial tissue, can be a precursor to endometrial cancer and often results from unopposed estrogen from any source. Estrogen therapy alone without progesterone in a woman with a uterus can cause this condition. Women with anovulatory cycles, PCOS, or obesity may all have high circulating levels of estrogen. Tamoxifen (Nolvadex) may also be a causative factor (Wolfman, 2010). Routine biopsy on asymptomatic women is not required. Hyperplasia with atypia on a pathology or biopsy report indicates risk of progression. Progestin treatment may be effective, but hysterectomy may be advised if pathology from an endometrial biopsy shows atypia. Abnormal bleeding is the most common symptom.

MALIGNANT CONDITIONS The projected incidence and estimated mortality for female reproductive cancers in Canada: • Cervical cancer: about 1350 new cases and 7 deaths • Uterine cancer: about 5300 new cases and 22 deaths • Ovarian cancer: about 2600 new cases and 11 deaths Cervical cancer is the second most prevalent cancer in women worldwide and the fifth leading cause of cancer deaths. Worldwide, the incidence is declining. Pap smears

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in developed countries have resulted in increased detection of preinvasive lesions and decreased cancer death rates. Eighty percent of all cases of cervical cancer are found in developing countries, where early detection methods are often not available (Golz, Kenny, & Rosella, 2011). Although death rates from all cancers are decreasing Canada and other developed countries, cancer in developing countries is increasing. Many of these cases affect women. Although infectious diseases and HIV are often high priorities in these countries, the toll of increasing malignancies needs to be considered. Although some cancers are difficult to detect or prevent, annual 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 offer women an opportunity to ask questions and clarify misinformation. If more women understood that gynecologic examinations and Pap smears do not have to be uncomfortable or embarrassing, early detection rates would likely improve and lives would be saved. Many women diagnosed with gynecologic malignancies experience depression and anxiety. The occurrence of physical symptoms may cause psychological distress. Intervention directed toward physical and psychological symptoms requires a multidisciplinary approach. Nurses should be aware of ongoing clinical trials that are being conducted to identify effective treatments for many conditions. They are often in a position to answer questions about clinical trials and to encourage patients to consider participation if appropriate. Women’s participation in cancer research may occur in part because women are unaware of ongoing relevant research.

Cancer of the Cervix Carcinoma of the cervix is predominantly squamous cell cancer. Cervical cancer is less common than it once was because of early detection of cell changes by Pap smear. Risk factors are presented in Chart 48-5. Preventive measures include regular pelvic examinations and Pap tests for all women, especially older women past childbearing age. This decreases the chance of dying from cervical cancer from 1 in 250 to 1 in 2,000. Preventive counselling should encourage delaying first intercourse, avoiding HPV infection, participating in safer sex only, smoking cessation, and receiving HPV immunization (see earlier discussion). There are several different types of cervical cancer. Most of these cancers are squamous cell carcinomas and the remainder are adenocarcinomas or mixed adenosquamous carcinomas. Adenocarcinomas begin in mucous-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.

Clinical Manifestations 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 douch-

CHART 48-5

Risk Factors for Cervical Cancer • Sexual activity:

• • • • • • • • • • • •

Multiple sex partners Early age (younger than 20) at first coitus (exposes the vulnerable young cervix to potential viruses from a partner) Sex with uncircumcised males Sexual contact with males whose partners have had cervical cancer Early childbearing Exposure to human papillomavirus, types 16 and 18 HIV infection and other causes of immunodeficiency Smoking and exposure to secondhand smoke Exposure to diethylstilbestrol (DES) in utero Family history of cervical cancer 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 Overweight status

ing. When symptoms such as discharge, irregular bleeding, or pain 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 to care and its utilization is crucial. In advanced cervical cancer, the vaginal discharge gradually increases and becomes watery and, finally, dark and foul-smelling from necrosis and infection of the tumour. The bleeding, which occurs at irregular intervals between periods (metrorrhagia) or after menopause, may be slight (just enough to spot the undergarments) and occurs usually after mild trauma or pressure (e.g., 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 the 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 analgesics. 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

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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. 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 reasonably predicted. The tumour, nodes, and metastases (TNM) system is the most widely used staging system. The TNM classification is also used in describing cancer stages. In this system, T refers to the extent of the primary tumour, 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 may include dilation and curettage (D & C), computed tomography (CT), magnetic resonance imaging (MRI), IV urography, cystography, positron emission tomography, and barium x-ray studies.

Medical Management Precursor or Preinvasive Lesions When precursor lesions, such as low-grade squamous intraepithelial lesion (LGSIL; also referred to as LSIL) (CIN I and II or mild to moderate dysplasia), are found by colposcopy 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 coneshaped 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 simple hysterectomy (removal of the uterus only) is usually recommended. If a woman has not completed childbearing and invasion is less than 1 mm, conization may be sufficient. Frequent follow-up examinations are necessary to monitor for recurrence.

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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 slow-growing 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. Surgical procedures that may be used to treat cervical cancer are summarized in Chart 48-6. When tumour 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 tumours are treated with radical hysterectomy and radiation. Stage 1B2 tumours are treated individually, because no single correct course of treatment has been identified and many variable options may be considered. A procedure called a radical trachelectomy is an alternative to hysterectomy in women with invasive cervical cancer who are young and want to have children. In this procedure, the cervix is gripped with retractors and pulled down 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 used to close the cervix. 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

CHART 48-6

Surgical Procedures for Cervical Cancer • Total hysterectomy—removal of the uterus, cervix, and ovaries

• Radical hysterectomy—removal of the uterus, ovaries, fal-

• • • •

lopian 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

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pelvic pain may be signs of lymphatic obstruction and metastasis. Micrometastases have been found in patients with negative lymph nodes. 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 tumour) or both. The field to be irradiated and dose of radiation are determined by stage, volume of tumour, 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 because of tumour or stricture. 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. This is a complex, extensive surgical procedure that is reserved for women with a high likelihood of cure. 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, obstruction of the 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. Anti-embolism stockings are prescribed to reduce the risk of deep vein thrombosis (DVT). Nursing care of these patients is complex and requires coordination and care by experienced health care professionals. Pelvic exenteration is discussed in further detail later in this chapter.

Cancer of the Uterus (Endometrium) Although the incidence of cancer of the uterine endometrium (fundus or corpus) has stabilized, the death rate from this cancer has increased, possibly because of increased lifespan and coexisting comorbidities. This cancer is the most frequently occurring gynecological cancer in Canada. After breast, lung, and colorectal cancer, endometrial cancer is the fourth most common cancer in women. 5300 new cases of uterine cancer occurred in 2012, with 22/1000,000 deaths (Canadian Cancer Society Steering Committee on Cancer Statistics, 2012). Most women are diagnosed between 55 and 64 years of age. Seventy percent of women with endometrial cancer are obese; obesity increases the risk of morbidity and mortality

CHART 48-7

Risk Factors for Uterine Cancer • Age: at least 55 years; median age, 61 years • 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 use of tamoxifen

from this disease. Cumulative exposure to estrogen is considered the major risk factor (Chart 48-7). This exposure occurs with the use of estrogen therapy without the use of progestin, early menarche, late menopause, nulliparity, and anovulation. Other risk factors include obesity, infertility, and diabetes, as well as use of tamoxifen. This medication, taken for treatment or prevention of breast cancer, may cause proliferation of the uterine lining (Canadian Cancer Society, 2011a). Women who take it should be monitored by their oncologists and gynecologic health care providers.

Pathophysiology Most uterine cancers are endometrioid (i.e., originating in the lining of the uterus). There are three types. Type 1, which accounts for the majority of cases, is estrogen related and occurs in younger, obese, and perimenopausal women. It is usually low grade and endometrioid. Type 2, which occurs in about 10% of cases, is high grade and usually serous cell or clear cell. It affects older women. Type 3, which also occurs in about 10% of cases, is the hereditary and genetic types, some of which are related to Lynch II syndrome. (This syndrome is associated with the occurrence of breast, ovarian, colon, endometrial, and other cancers throughout a family.)

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 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 usually 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 estrogen; a thicker lining warrants further investigation.) A biopsy or aspiration for tissue pathology is diagnostic.

Medical Management Treatment of endometrial cancer consists of total or radical hysterectomy (discussed later in this chapter) and

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bilateral salpingo-oophorectomy and node sampling. It is necessary to monitor cancer antigen 125 (CA-125) levels, because elevated levels are a significant predictor of extrauterine disease or metastasis. Depending on the stage, the therapeutic approach is individualized and is based on stage, type, differentiation, degree of invasion, and node involvement. Adjuvant radiation may be used in a patient who is considered high risk. Vaginal brachytherapy is being studied as adjuvant therapy. Whole pelvis radiotherapy may be used if there is any spread beyond the uterus. 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 progestin therapy.

Cancer of the Vulva Primary cancer of the vulva represents 4% 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 50 years, whereas the median age for invasive vulvar cancer is 70 years. Possible risk factors include smoking, HPV infection, HIV infection, and immunosuppression. Squamous cell carcinoma accounts for most primary vulvar tumours. Less common are Bartholin’s gland cancer, vulvar sarcoma, and malignant melanoma. Little is known about what causes this disease; however, increased risk may be related to chronic vulvar irritation. In younger women, HPV infection may be implicated, especially types 16, 18, and 31. Prevention includes delaying onset of sexual activity to avoid early exposure to HPV and avoidance of smoking. Regular pelvic examinations, Pap smears, and vulvar self-examination are helpful in early detection. Women with persistent irritation or itching should be encouraged to seek evaluation.

Clinical Manifestations Long-standing pruritus and soreness are the most common symptoms of vulvar cancer. Itching occurs in half of all patients with vulvar malignancy. Bleeding, foulsmelling 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, patients 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. Nurses are in an ideal position to encourage women to perform vulvar self-examinations regularly. Using a mirror, patients can see what constitutes normal female anatomy and learn about changes that should be reported

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(e.g., lesions, ulcers, masses, and persistent itching). Nurses must urge women to seek health care if they notice anything abnormal, because vulvar cancer 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, application of chemotherapeutic creams, or cryosurgery. 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 (i.e., scarring, wound breakdown, leg swelling, vaginal stenosis, or rectocele). To reduce complications, only necessary tissue is removed. External beam radiation may be used, resulting in sunburn-like irritation that usually resolves in 6 to 12 months. Laser therapy and chemotherapy are other possible treatment options. If a widespread area is involved or the disease is advanced, a radical vulvectomy with bilateral groin dissection may be performed. Antibiotic and heparin prophylaxis may be prescribed preoperatively and continued postoperatively to prevent infection, DVT, and pulmonary emboli. Anti-embolism stockings are applied to reduce the risk of DVT. Although the role of systemic chemotherapy in the treatment of vulvar cancer remains to be determined, chemotherapy may be useful when used in combination with radiation therapy for the treatment of advanced disease. The combination of radiation and chemotherapy may reduce the size of the cancer, resulting in less extensive subsequent surgery (Canadian Cancer Society, 2011). Clinical trials to determine the most effective treatment are difficult to conduct because there are few patients with this condition. Morbidity with recurrence of the disease is high, and patterns of recurrence vary. Reconstruction after vulvectomy is performed by plastic surgeons when appropriate and desired.

Nursing Management 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 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.

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Preoperative Nursing Interventions RELIEVING ANXIETY. Prior to surgery, the patient must be allowed time to talk and ask questions. Fear often decreases when a woman 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 reinforces the information the physician has given to the patient and addresses 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. Therefore, analgesic agents are administered preventively (i.e., around the clock at designated times) to relieve pain, increase the patient’s comfort level, and allow mobility. Patient-controlled analgesia (see Chapter 14) may be used to relieve pain 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 reduces pain by relieving tension on the incision; however, efforts must be made to avoid pressure behind the knees, which increases the risk of DVT. 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. 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 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. Dressings are changed as needed to ensure patient comfort, to perform wound care and irrigation (if prescribed), and to permit observation of the surgical site. The wound is usually cleansed daily with warm, normal saline irrigations or other antiseptic solutions as prescribed, or a transparent dressing 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 patient is always protected 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 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 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. Referral of the patient and her partner to a sex counsellor may help them address these changes and resume satisfying sexual activity. MONITORING AND MANAGING POTENTIAL COMPLICATIONS. Location, extent, and exposure 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 increased white blood cell count. The nurse assists in obtaining 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 along with wearing masks whenever there is an extensive area of exposed tissue. Catheters, drains, and dressings are handled carefully with gloves on to avoid cross-contamination. A low-residue diet prevents straining on defecation and wound contamination. The patient is at risk for DVT because of the positioning required during surgery, postoperative edema, and the usually prolonged immobility needed to promote healing. Anti-embolism stockings are applied, and the patient is encouraged and reminded to perform ankle exercises to minimize venous pooling, which leads to DVT. The patient is encouraged and assisted in changing positions by using the overhead trapeze bar. 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 DVT (leg pain, redness, warmth, edema) and pulmonary embolism (chest pain, tachycardia, dyspnea). Fluid intake is encouraged to prevent dehydration, which also increases the risk of DVT. 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 (e.g., 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. See Chapter 16 for a detailed discussion of shock.

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. Depending on the changes resulting from the surgery, the patient and her family may need instruction about wound

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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 site. A referral for home care is made as indicated. CONTINUING CARE. Shortened hospital stays may result in the patient’s discharge during the early postoperative recovery stage to home or a subacute facility. During this phase, the patient’s physical status and psychological responses to the surgery are assessed. In addition, the patient is assessed for complications and healing of the surgical site. During home visits, the nurse assesses the home to determine if modifications are needed to facilitate care. The home visit is used 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.

Cancer of the Vagina Cancer of the vagina is rare and usually takes years to develop. Primary cancer of the vagina is usually squamous in origin. Malignant melanoma and sarcomas can occur. 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, prescribed from 1938 to 1971 to enhance pregnancy outcomes, affected female offspring who were exposed in utero. DES was prescribed under many brand names, and it is unclear how many pregnant women received it. All patients should be asked about DES exposure if they were born or were pregnant between 1938 and 1971. Benign genital tract abnormalities, such as vaginal adenosis (abnormal tissue growth), cervical irregularities (collars, hoods, septae, cockscombs), and uterine abnormalities, have occurred in approximately one third of exposed women. Clear cell carcinoma of the vagina or cervix may also occur as a result of DES exposure; the risk is 0.14 to 1.4 in 1000 women. However, most female offspring of mothers who took DES are now between 40 and 75 years of age, and diagnosis of this condition has been decreasing. Vigilance is still necessary because it is unknown how long women remain at risk (Wilson, 2011). Colposcopy is indicated for all women exposed to DES in utero. If colposcopic examination discloses adenosis or a significant cervical or vaginal lesion, follow-up is essential. In addition, health care providers should be aware that men who were exposed to DES in utero may have an increased risk of developing epididymal cysts.

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Vaginal pessaries, used to support prolapsed tissues, can be a source of chronic irritation. As such, they have been associated with vaginal cancer, but only when the devices were not cared for properly (i.e., the device was not cleaned regularly or the patient did not return to the health care provider regularly for vaginal examinations). Patients often do not have symptoms but may report slight bleeding after intercourse, spontaneous bleeding, vaginal discharge, pain, and urinary or rectal symptoms (or both). Diagnosis is often by Pap smear of the vagina. Encouraging close follow-up by health care providers is the primary focus of nursing interventions with women who were exposed to DES in utero. Emotional support for mothers who received DES before its risks were discovered and their daughters who were exposed to DES in utero is essential.

Medical Management Treatment of early lesions may include local excision, topical chemotherapy, or laser. Laser therapy is a common treatment option in early vaginal and vulvar cancer. Surgery for more advanced lesions depends on the size and the stage of the cancer. If radical vaginectomy is required, a vagina can be reconstructed with tissue from the intestine, muscle, or skin grafts. After vaginal reconstructive surgery and radiation, regular intercourse may be helpful in preventing vaginal stenosis. Water-soluble lubricants are helpful in reducing pain with intercourse (dyspareunia). Following surgery, radiation therapy may be administered by a variety of methods, including external beam radiation, which is usually an outpatient procedure, or brachytherapy, which is internal radiation therapy. Internal radiation may be given with intracavitary radioactive material contained in a seed, wire, needle, or tube, which is placed into a cavity such as the uterus or vagina. Interstitial radiation is another type of internal radiation treatment in which the radioactive material is placed in or near the cancer but not into a body cavity and is used in cervical and ovarian malignancies. These treatments may be high dose for a short period or low dose, which may take longer. Treatment during hospitalization or during outpatient therapy depends on several factors, including the status of the patient and the mode of delivery.

Cancer of the Fallopian Tubes Malignancies of the fallopian tube are the least common type of genital cancer. Although this type of cancer can occur at any age, the average age at diagnosis is 55 years. Symptoms include abdominal pain, abnormal bleeding, and vaginal discharge. An enlarged fallopian tube may be found on sonogram if dilated and fluid filled or it may appear or be palpated as a mass. Surgery followed by radiation therapy is the usual treatment.

Cancer of the Ovary Despite careful physical examination, ovarian tumours are often difficult to detect because they are usually deep in the pelvis. No early screening mechanism exists at present,

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although tumour markers are being explored. Transvaginal ultrasound and CA-125 antigen testing may be reassuring for women who have a high risk for this condition, and clinical trials are under way to evaluate the effect of these screening modalities on mortality from ovarian cancer. Tumour-associated antigens are helpful in determining follow-up care after diagnosis and treatment but not in early general screening.

Epidemiology The incidence of ovarian cancer increases after 50 years of age and peaks in the early 80s; the median age of affected women is 63 years. The frequency of ovarian cancer is highest in industrialized countries, except for Japan, where it is low. Pregnancy and use of oral contraceptives decrease risk. Mutations of BRCA1 and BRCA2 increase risk; the lifetime risk for women with these mutations is 28% to 40% (the higher percentage is in Ashkenazi Jews). A woman with ovarian cancer has a three- to fourfold increased risk of breast cancer, and a woman with breast cancer has an increased risk of ovarian cancer. A family history, older age, low parity, and obesity may increase risk of ovarian cancer. However, most women who develop ovarian cancer have no known risk factors, and no definitive causative factors have been determined. Genetic testing is indicated when three or more cases of closely related family members have 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. This testing is available at centres with genetics counsellors or nurses with expertise in genetics counselling. Many health care providers advocate pelvic examinations every 6 months for women who have one or two relatives with ovarian cancer. It is recommended that women with a family history of breast or ovarian cancer undergo periodic screening. Much more needs to be learned about the risks associated with some mutations, the reliability of testing, and the efficacy of follow-up. Because there are no primary methods of preventing breast or ovarian cancer, emotional distress is also an issue. Patients with concerns about their family history should be referred to a cancer genetics centre 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 at the time of diagnosis. Prophylactic oophorectomy in women with genetic mutations has been found to be associated with decreased risk of ovarian and other gynecologic cancers as well as breast cancer and is an option for women who have completed childbearing (Lanceley, 2011). Hereditary nonpolyposis colon cancer increases the risk of uterine cancer and slightly increases the risk of ovarian cancer.

Pathophysiology Types of tumours include germ cell tumours, which arise from the cells that produce eggs; stromal cell tumours, which arise in connective tissue cells that produce hormones; and epithelial tumours, which originate from the outer surface of the ovary. Most ovarian cancers are epithelial in origin. Of the many different cell types in ovar-

ian cancer, epithelial tumours constitute 90%. Germ cell tumours and stromal tumours make up the other 10%. Primary peritoneal carcinoma is closely related to ovarian cancer. Extraovarian primary peritoneal carcinoma (EOPPC) resembles ovarian cancer histologically and can occur in women with and without ovaries. Symptoms and treatment are similar. Because of the possibility of EOPPC, oophorectomy does not guarantee that the patient will not develop carcinoma following hysterectomy.

Clinical Manifestations Symptoms of ovarian cancer are nonspecific and may include increased abdominal girth, pelvic pressure, bloating, back pain, constipation, abdominal pain, urinary urgency, indigestion, flatulence, increased waist size, leg pain, and pelvic pain. Symptoms are often vague, so many women tend to ignore them. Ovarian cancer is often silent, but enlargement of the abdomen from an accumulation of fluid is the most common sign. All women with gastrointestinal symptoms and without a known diagnosis must be evaluated for potential ovarian cancer. 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 immediately 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. Ovarian tumours are classified as benign if there is no proliferation or invasion, borderline if there is proliferation but no invasion, and malignant if there is invasion. Fifteen percent of all new cases of ovarian tumours are classified as borderline and have low malignancy potential. However, by the time of diagnosis, most ovarian cancers are advanced (Rooth, 2013).

Surgical Management Surgical staging, exploration, and reduction of tumour mass are the basics of treatment. Surgical removal is the treatment of choice; the preoperative workup may include a barium enema or colonoscopy, upper gastrointestinal series, MRI, ultrasound, chest x-rays, and IV urography. CT may be used preoperatively to rule out intra-abdominal metastasis. Staging the tumour by the TNM system is performed to guide treatment (Chart 48-8). Likely treatment involves a total abdominal hysterectomy with removal of the fallopian tubes and ovaries and possibly the omentum (bilateral salpingo-oophorectomy and omentectomy); tumour debulking; para-aortic and pelvic lymph node sampling; diaphragmatic biopsies; random peritoneal biopsies; and cytologic washings. Postoperative management may include taxanes or platinum-based chemotherapy (discussed in next section). Borderline tumours resemble ovarian cancer but have much more favourable outcomes. Women diagnosed with

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CHART 48-8

Stages of Ovarian Cancer I Cancer is contained within the ovary (or ovaries). II Cancer is in one or both ovaries and has involved other organs (i.e., uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis. III Cancer involves one or both ovaries, and one or both of the following are present: (1) cancer has spread beyond the pelvis to the lining of the abdomen; (2) cancer has spread to lymph nodes. IV The most advanced stage of ovarian cancer. Cancer is in one or both ovaries. There is distant metastasis to the liver, lungs, or other organs outside the peritoneal cavity; ovarian cancer cells in the pleural cavity are evidence of stage IV disease.

this type of cancer tend to be younger (early 40s). A conservative surgical approach is now used. The affected ovary is removed, but the uterus and the contralateral ovary may remain in place. Adjuvant therapy may not be warranted.

Pharmacologic Therapy Chemotherapy is usually administered IV on an outpatient basis using a combination of platinum and taxane agents. Paclitaxel (Taxol) plus carboplatin (Paraplatin) are most often used because of their excellent clinical benefits and manageable toxicity. Leukopenia, neurotoxicity, and fever may occur. Because paclitaxel often causes leukopenia, patients 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. Patients should be prepared for inevitable hair loss. Carboplatin may be used in the initial treatment and in patients with recurrence. It should be used with caution in patients with renal impairment. Usually, six cycles are given. A positive clinical response is normalization of the tumour marker CA-125, negative CT results, and a normal physical and gynecologic examination. Liposomal therapy, delivery of chemotherapy in a liposome, allows the highest possible dose of chemotherapy to the tumour 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 (Doxil) lessens the incidence of nausea, vomiting, and alopecia. Patients must be monitored for bone marrow suppression and gastrointestinal and cardiac effects.

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Combination IV and intraperitoneal chemotherapy is an option for some patients. However, this treatment may result in pain; fatigue; and hematologic, gastrointestinal, metabolic, and neurologic toxicities, thus decreasing the quality of life (Silver & Zgheib, 2011). Because of these effects, the decision to use intraperitoneal chemotherapy is individualized. Genetic engineering and identification of cancer genes may make gene therapy a future possibility; gene therapy is under investigation. Emerging proteomic technologies (tissue-based protein analysis) look promising; they may allow earlier diagnosis and treatment decision making. New biomarkers need further validation, but protein signature patterns are now being tested. These technologies may result in individualized treatment strategies for epithelial ovarian cancer. Recurrence of ovarian cancer is common, and many patients may require treatment with multiple agents. Therefore, ovarian cancer may be considered a chronic disease, with treatment directed toward control of the cancer, maintenance of quality of life, and palliation. Liposomal preparations, intraperitoneal drug administration, anti-cancer vaccines, monoclonal antibodies directed against cancer antigens, gene therapy, and antiangiogenic treatments (to prevent formation of new blood vessels in an effort to halt growth of ovarian cancer) may be used in the treatment of recurrence.

Nursing Management Nursing measures include those related to the patient’s treatment plan, which may include surgery, chemotherapy, palliative care, or a combination of these. Emotional support, comfort measures, and information, plus attentiveness and caring, are important components of nursing care for the patient and her family. Nursing interventions after pelvic surgery to remove the tumour are similar to those after other abdominal surgeries. If ovarian cancer occurs in a young woman and the tumour is unilateral, it is removed. Childbearing, if desired, is encouraged in the near future. After childbirth, surgical reexploration may be performed, and the remaining ovary may be removed. If both ovaries are involved, bilateral oophorectomy is performed and chemotherapy follows. Chart 48-9 describes symptom clusters in women who are survivors of ovarian cancer. Patients with advanced ovarian cancer may develop ascites and pleural effusion. Nursing care may include administering IV fluids prescribed to alleviate fluid and electrolyte imbalances, administering parenteral nutrition to provide adequate nutrition, providing postoperative care after intestinal bypass to alleviate any obstruction, controlling pain, and managing drainage tubes. 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 to relieve these symptoms. The patient with ovarian cancer often has complex needs and benefits from the assistance and support of an oncology nurse specialist.

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NURSING RESEARCH PROFILE

Chart 48-9. Increasing Awareness about Ovarian Cancer Fitch, M., McAndrew, A., Turner, F., Ross, E., & Pison, I. (2011). Survivors teaching students: Increasing awareness about ovarian cancer. Purpose The purpose of this study was to increase awareness of ovarian cancer, one of the leading five cancers and with one of the highest mortality rates of all gynecologic cancers, among students in health-related fields. A new program was developed in Canada called Survivors Teaching Students. The study describes the program and the evaluation results from the initial 2 years of the program. The Survivors Teaching Students program facilitates women with the disease to provide free 1-hour presentations about the signs and symptoms and the experience of the disease to medical and nursing. The students are provided with opportunity to dialogue with the survivors after the presentation. Design Pre- and postsurveys were used for evaluation. Before the presentation, the students were asked to complete a short survey and submit it without identification to the facilitator. A second survey measuring knowledge about ovarian cancer,

HYSTERECTOMY Hysterectomy is the surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus. In Canada, approximately 346 of every 100,000 women undergo hysterectomy each year (Women’s Health Data Directory, 2011). Canada has one of the highest rates in the world. A total hysterectomy involves removal of the uterus and the cervix. Hysterectomy can be supracervical or subtotal, in which the uterus is removed but the cervix is spared. Radical hysterectomy involves removal of the uterus as well as the surrounding tissue, including the upper third of the vagina and pelvic lymph nodes. The procedure can be performed through the vagina, through an abdominal incision, or laparoscopically (in which the uterus is removed in sections through small incisions using a laparoscope). Malignant conditions usually require a total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries). A laparoscopically assisted approach can also be used for vaginal hysterectomy, with excellent results and rapid recovery. This procedure is performed as a short-stay procedure or ambulatory surgery in carefully selected patients.

Preoperative Management Patients are advised to discontinue anticoagulant medications, NSAIDs such as aspirin, and vitamin E prior to

risk factors, symptoms, assessments, and patient concerns was completed after the presentation and the surveys were sent to the research coordinator. Six months after the presentation the students were given an on-line address to complete a survey identical to the initial post session survey. Findings Between fall 2006 and March 2009, presentations were provided to 7 medical (n = 798) and 12 nursing (n = 2822) faculties. The response rate for the surveys was 41.4% presurveys, 23% postsurveys, and 19% for the 6-month survey. The answers for the postsurvey improved although there was lack of knowledge about screening tests and symptoms. The medical and nursing students found the presentations to be effective in providing the survivor perspective and the challenges faced by them. Nursing Implications Recruitment and training of the survivors is an important aspect for the success of the program. Since the population of Canada is aging and with aging, the incidence of cancers increase, it is vital for nursing students to understand the perspectives of the patients and the need for early diagnosis.

surgery to reduce the risk of bleeding. Pregnancy is ruled out on the day of surgery. Prophylactic antibiotics may be administered prior to surgery and discontinued the next day. Prevention of thromboembolic events is critical, and methods may include heparin and use of anti-embolism stockings or an intermittent pneumatic compression device.

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Nursing Process

The Patient Undergoing a Hysterectomy Assessment The health history and the physical and pelvic examination are completed, and laboratory tests 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 tumour, anxiety related to fear of cancer and its consequences adds to the stress of the patient and her family. Women who have had a hysterectomy may be at risk for psychological and physical symptoms. Alternatively, women may note improved physical and mental health after hysterectomy as troublesome symptoms may be alleviated.

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Diagnosis Nursing Diagnoses Based on all the assessment data, the major nursing diagnoses may include the following: • Anxiety related to the diagnosis of cancer, fear of pain, possible perception of loss of femininity or childbearing potential • 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 DVT Bladder dysfunction Infection

Planning and Goals The major goals 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. The nurse determines what the experience means to the patient and encourages her to verbalize her concerns. Throughout the preoperative, 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 and they require support from their health care providers, and access to professional and lay support systems.

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

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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 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 hormonal balance is upset, as often occurs with reproductive system disorders, 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. A nurse who exhibits interest, concern, and willingness to listen to the patient’s fears will help the patient progress through the surgical experience.

Relieving Pain Postoperative pain and discomfort are common. Therefore, the nurse assesses the intensity of the patient’s pain and assists the patient with analgesia as prescribed. Excision of a large tumour 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 should be encouraged.

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. Because many women may go home the day of surgery or within a day or two, they are instructed to contact the nurse or surgeon if bleeding is excessive. DEEP VEIN THROMBOSIS. Because of positioning during surgery, postoperative edema, and decreased activity postoperatively, the patient is at risk for DVT and pulmonary embolism (PE). To minimize the risk, anti-embolism stockings are applied. In addition, the patient is encouraged and assisted to change positions frequently, although pressure under the knees is avoided, and to exercise her legs and feet while in bed.

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The nurse helps the patient ambulate early in the postoperative period. In addition, the nurse assesses for DVT or phlebitis (leg pain, redness, warmth, edema) and PE (chest pain, tachycardia, dyspnea). If the patient is being discharged home soon after surgery, she is instructed to avoid prolonged sitting in a chair with pressure at the knees, sitting with crossed legs, and inactivity. Furthermore, she is instructed to contact her health care provider if symptoms of DVT or PE occur. BLADDER DYSFUNCTION. Because of possible difficulty in voiding postoperatively, occasionally 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 (e.g., assisting the patient to the bathroom, pouring warm water over the perineum). If the patient cannot void, catheterization may be necessary. On rare occasions, the patient may be discharged home with the catheter in place and is instructed in its management.

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 occurs. 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 she is likely to recover quickly, but that postoperative fatigue is not unusual. 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 of 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 these activities (BC HealthLink, 2012). Vaginal discharge, foul odour, excessive bleeding, any leg redness or pain, or an elevated temperature should be reported to the primary health care provider promptly. The nurse reinforces information given to patients by their surgeons regarding activities and restrictions. 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 and she finds vasomotor symptoms troublesome, hormone therapy (HT, previously referred to as hormone replacement therapy [HRT]) may be considered. Estrogen and progesterone use is contraindicated with unexplained vaginal bleeding, known or suspected breast carcinoma, and active liver disease (SOGC, 2010). Estrogen is contraindicated in active thromboembolic disease and should be used with caution if there is a history of cardiovascular disease and hypertriglyceridemia. Since the risk of breast cancer recurrence is unknown, estrogen should be used with caution. The patient is reminded to discuss risks and benefits of HT and alternative therapies with her primary care provider. Decisions about use of HT need to be made individually in consultation with this provider.

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 anxiety 3. Experiences minimal pain and discomfort a. Reports relief of abdominal pain and discomfort b. Ambulates without pain 4. Verbalizes knowledge and understanding of selfcare 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

Postoperative Management The principles of general postoperative care for abdominal surgery apply. 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. Also, edema or nerve trauma may cause temporary loss of bladder tone (bladder atony), and an indwelling catheter may be inserted.

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RADIATION THERAPY Radiation may be used in the treatment of cervical, uterine, and ovarian cancers either alone or in combination with surgery and chemotherapy. 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 can serve as a receptacle for radioactive sources for internal radiation therapy.

Tandem Ovoid

Uterus Cervix Vagina

Methods of Radiation Therapy 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 tumour) and the ability during treatment to block sensitive organs from radiation. IORT is usually combined with external beam irradiation preoperatively or postoperatively.

Internal (Intracavitary) Irradiation After the patient receives an anesthetic agent and an examination, 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 tumour. When this step is completed, the radiation oncologist loads 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 physicians, nurses, 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 (e.g., Heyman capsules). Others consist of a central tube (a tandem or intrauterine “stem”) 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. 48-8). 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,

FIGURE 48-8. Placement of tandem and ovoids for internal radiation

therapy.

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, which may last 24 to 72 hours, depending on dose calculations made by the radiation physicist. Automated high-dose rate (HDR) 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 Special precautions for the safety of the patient and the nurse are important considerations when the patient is receiving radiation therapy. The Radiation Safety Department will identify specific safety precautions to those people who will be in contact with the patient, including health care providers and family. Of the many nursing concerns, primary concerns include providing the patient with emotional support and physical comfort. Further details about nursing management are provided in Chapter 17.

Critical Thinking Exercises 1

A 55-year-old patient has been diagnosed with ovarian cancer. She reports that she has a strong family history of cancer; two sisters have breast cancer. Her mother died of cancer when the patient was a child, and she is not certain of the type of cancer. Because of her strong family history, she is concerned about the health status of her twin daughters who are in their early 30s. She has asked you to discuss the risks for cancer with them. Explain what counselling and education you will provide to the patient and her daughters. Identify the evidence base for the counselling and education and the

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strength of that evidence. How will you approach your counselling and education? 2 A 65-year-old woman with rheumatoid arthritis who has had surgery for breast cancer is scheduled to undergo radical vulvectomy to treat vulvar cancer. She reports that she is very anxious because of her previous surgery. Describe the preoperative teaching for her and the postoperative care that can be anticipated. How will her history of breast cancer and rheumatoid arthritis affect her care? What modifications in care, postoperative teaching, and discharge planning may be necessary because of these health issues? How will your discharge planning be modified if the patient tells you that she provides care at home for her husband who has signs of early Alzheimer’s disease? 3 A 38-year-old woman with a diagnosis of fibroids has been admitted to the outpatient surgery centre for uterine artery embolization. When you are completing the preoperative admission procedures, she asks you about the effect of the procedure on future sexual relationships and on her ability to become pregnant in the future. What teaching is indicated for this woman based on her concerns and on her risk for future fertility? What nursing care is important to minimize the risk of complications? 4

A 17-year-old patient is seeking contraception. She explains that she has not had a sexual relationship but wants to be prepared for future sexual relationships. She also asks you for your recommendation about receiving the new HPV vaccine. What recommendations would you give her about contraception and the HPV vaccine? What is the evidence base for your recommendations? How would you approach the topic of safer sex, contraception, and HPV vaccine with her in responding to her request for information?

REFERENCES AND SELECTED READINGS BOOKS Canadian Cancer Society Steering Committee on Cancer Statistics. (2012). Canadian cancer statistics 2012. Toronto, ON: Canadian Cancer Society. Retrieved from www.cancer.ca/Canada-wide/About%20cancer/ ∼/media/CCS/Canada%20wide/Files%20List/English%20files%20 heading/PDF%20-%20Policy%20-%20Canadian%20Cancer%20Statistics%20-%20English/Canadian%20Cancer%20Statistics%202012%20 -%20English.ashx Chow, J., Ateah, C. A., Schott, S. D., et al. (2012). Canadian maternity and pediatric nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Emans, J., Laufer, M., & Goldstein, D. (2012). Pediatric and adolescent gynecology (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Gibbs, R. S., Karlan, B. Y., Haney, A. F., et al. (2008). Danforth’s Obstetrics and Gynecology (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hoffman, B., Schorge, J., Hlavorson, L., et al. (2012). Williams Obstetrics. New York, NY: McGraw-Hill. Gretchen, M. L., Lobo, R. A., Gershenson, D. M., et al. (2012). Comprehensive gynecology (6th ed). St. Louis, MO: Mosby Elsevier. Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), & World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2011). Family planning: A global handbook for providers 2011 update. Baltimore and Geneva: Author. Speroff, L., & Darney, P. D. (2010). A clinical guide for contraception (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Lazarou, G., & Bogdan, A. G. (2012). Pelvic organ prolapse. Retrieved from http://emedicine.medscape.com/article/276259-overview#a0102 Society of Obstetricians and Gynecologists. (2010). Hormone therapy products available in Canada for treatment of menopausal symptoms (2nd ed). Retrieved from http://www.menopauseandu.ca/documents/ HTbooklet11.pdf Taylor, D., & Rakinic, J. (2011). Rectovaginal fistulas. Retrieved from http://emedicine.medscape.com/article/193277-overview#a0102 Benign Ovarian Disorders Teng, N., & Simon, E. J. (2012). Adnexal tumors. Retrieved from http:// emedicine.medscape.com/article/258044-overview Society of Obstetricans and Gynecologists. (2012). What are vulvar diseases? Retrieved from http://www.sexualityandu.ca/sexual-health/ physical-problems/what-is-a-vulvar-disease Vause, T. D., & Cheung, A. P. (2010). Ovulation induction in polycystic ovary syndrome. Journal of Obstetrics and Gynaecology Canada, 242, 495–502. Benign Uterine Disorders, Endometriosis, Prolapse, Fibroids Canadian Women’s Health Network (CWHN). (2012). Fibroids. Retrieved from http://www.cwhn.ca/en/yourhealth/faqs/fibroids Kokeu, A. (2011). Relationship between endometriosis and cancer from current perspective. Archives of Gynecology and Obstetrics, 284 (6), 1473–1479. Plowright, L. N., & Davila, G. W. (2012). Colpocleisis. Retrieved from http://emedicine.medscape.com/article/2047195-overview Society of Obstetricians and Gynecologists of Canada. (2013). SOGC news release: New treatment option for women suffering with uterine fibroids. Retrieved from http://sogc.org/media_updates/new-treatmentoption-for-women-suffering-with-uterine-fibroids/ Society of Obstetricians and Gynecologists of Canada. (2003) Leiomyomas. Journal of Obstetrics and Gynaecology, 23(5), 396–403. Human Papillomavirus Golz, S., Kenny, A., & Rosella, K. (2011). Developing cervical cancer prevention in the developing world. Retrieved from http://www.womendeliver.org/assets/CervicalCancer_final.pdf World Health Organization. (n.d.). Women, girls, HIV and AIDS. HIV unit. www.searo.who.int/LinkFiles/World_AIDS_Day_women-hiv.pdf Hysterectomy Dutton, S., Hirst, A., McPherson, K., et al. (2008). A UK multicenter retrospective cohort study Kim, K. H., & Lee, K. A. (2009). Sleep and fatigue symptoms in women before and 6 weeks after hysterectomy. Journal of Obstetrics, Gynecologic, and Neonatal Nursing, 38(3), 344–352. Women’s Health Data Directory (2011). Hysterectomy rate. Retrieved from http://www.womenshealthdata.ca/category.aspx?catid=125&rt=3 Reproductive Malignancy Canadian Cancer Society. (2011a). Causes of uterine cancer. Retrieved from www.cancer.ca/Canadawide/About%20cancer/Types%20of%20 cancer/Causes%20of%20uterine%20cancer.aspx?sc_lang=en Canadian Cancer Society. (2011b). Treatment of uterine cancer. Retrieved from http://www.cancer.ca/Canada-wide/About%20cancer/Types%20 of%20cancer/Treatment%20for%20uterine%20cancer.aspx? sc_lang=en BC Healthlink. (2012). Hysterectomy. Retrieved from http://www.healthlinkbc.ca/kb/content/special/hw212587.html Lanceley, A. (2011). Ovarian cancer: Symptoms, treatment and longterm patient management. Cancer Nursing Practice, 10(4), 29–36. Rooth, C., (2013). Ovarian cancer: Risk factors, treatment and management. British Journal of Nursing, 22(17), S23030. Silver, D., & Zgheib, N. B. (2011). Outpatient intraperitoneal chemotherapy for all stages of ovarian, fallopian tube, and peritoneal cancers: A pilot study. Clinical Ovarian Cancer, 4 (1), 7–11. Wolfman, W. (2010). Routine endometrial biopsy not needed in asymptomatic women. Journal of Obstetrics and Gynaecology Canada, 249, 990–999. Retrieved from www.sogc.org/guidelines/documents/ gui249CPG1010E.pdf

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STDs, Vaginitis, and Vulvovaginal Infections and Pelvic Infections HealthLinkBC. (2011). Vaginitis. Retrieved from http://www.healthlinkbc.ca/kb/content/special/zx1776.html Luong, M., Libman, M., Dahhou, M., et al. (2010). Vaginal douching, Bacterial Vaginosis, and spontaneous preterm birth. Journal of Obstetrics and Gynaecology Canada, 32(4), 313–320. Public Health Agency of Canada (PHAC). (2008a). Genital human papillomavirus (HPV) infections. Retrieved from http://www.phac-aspc. gc.ca/std-mts/sti-its/pdf/505hpv-vph-eng.pdf Public Health Agency of Canada (PHAC). (2008b). Human immunodeficiency virus (HIV) infections. Retrieved from http://www.phac-aspc. gc.ca/std-mts/sti-its/pdf/508hiv-vih-eng.pdf Public Health Agency of Canada (PHAC). (2008c). Vaginal discharge (Bacterial Vaginosis, Vulvovaginal Candidiasis, Trichomoniasis). Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/guidelignesdir-eng.php Public Health Agency of Canada (PHAC). (2010a). Management and treatment of specific guidelines-Pelvic inflammatory disease (PID). Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/ section-4-4-eng.php Public Health Agency of Canada (PHAC). (2010b). Chlamydial infections. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/ pdf/502chlamydia-eng.pdf http://www.phacPublic Health Agency of Canada (PHAC). (2010c). Gonococcal infections. Retrieved from aspc.gc.ca/std-mts/sti-its/pdf/506gonococcal-eng.pdf Public Health Agency of Canada (PHAC). (2010d). Pelvic inflammatory disease. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/ pdf/404pelviinfla-eng.pdf Public Health Agency of Canada (PHAC). (2010e). Pregnancy. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/guide-lignesdir-eng. php

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Public Health Agency of Canada (PHAC). (2012). Canada communicable disease report-update on human papillomavirus (HPV) vaccines, 38(ACS-1) Retrieved from http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/12vol38/acs-dcc-1/assets/pdf/acs-dcc-1-eng.pdf Wilson, R.D. (2011). Genetic considerations for a woman’s pre-conception evaluation. Journal of Obstetrics and Gynaecology Canada, 33(1), 57–64. Retrieved from http://www.sogc.org/guidelines/documents/ gui253CO1101E.pdf

RESOURCES Association of Reproductive Health Professionals, www.arhp.org Association of Women’s Health, Obstetrical and Neonatal Nurses (AWHONN), www.awhonn.org Canadian Association of Perinatal and Women’s Health Nurses, http:// www.capwhn.ca/en/capwhn/index.php?page=3788 Canadian Cancer Society, http://www.cancer.ca Canadian Federation for Sexual Health, http://www.cfsh.ca Canadian Women’s Health Network, http://www.cwhn.ca/en Centers for Disease Control and Prevention, Office of Women’s Health, www.cdc.gov/women/ Endometriosisinfo.ca, www.endometriosisinfo.ca/index_e.aspx Endometriosis Association, www.endometriosisassn.org Gay and Lesbian Medical Association, www.glma.org Health Canada, http://www.hc-sc.gc.ca/index-eng.php Infertility Awareness Association of Canada, www.iaac.ca/front Ovarian Cancer Canada, www.ovariancanada. Planned Parenthood Associations in Canada, http://www.anac.on.ca/ sourcebook/resource_planned.htm Public Health Agency of Canada, http://www.phac-aspc.gc.ca/index-eng. php

CHAPTER

49 Assessment and Management of Patients With Breast Disorders Adapted by Jean Chow

Learning Objectives On completion of this chapter, the learner will be able to: 1. Summarize the guidelines for the early detection of breast cancer. 2. Develop a teaching plan for breast self-examination for patients and consumer groups. 3. Identify and describe the different types of breast disorders, both benign and malignant. 4. Identify the examinations and biopsy procedures used to diagnose breast disorders. 5. Describe the different modalities used to treat breast cancer. 6. Use the nursing process as a framework for care of the patient undergoing surgery for the treatment of breast cancer. 7. 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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In many cultures, the breast plays a significant role in a woman’s sexuality and self-identity. A breast disorder, whether benign or malignant, can cause great anxiety and fear of potential disfigurement, loss of sexual attractiveness, and even death. Nurses, therefore, need the expertise in the assessment and management of not only the physical symptoms but also the psychosocial symptoms associated with breast disorders.

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BREAST ASSESSMENT Anatomic and Physiologic Overview Male and female breasts mature comparably until puberty, when in females estrogen and other hormones initiate

Glossary adjuvant chemotherapy: use of anticancer medications in addition to other treatments to delay or prevent a recurrence of the disease adjuvant hormonal therapy: use of synthetic hormones or other medications given after primary treatment to increase the chances of a cure by stopping or slowing the growth of certain cancers that are affected by hormone stimulation (sometimes called endocrine or antiestrogen therapy) aromatase inhibitors: medications that block the production of estrogens by the adrenal glands 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 brachytherapy: form of partial breast radiation in which a radioactive source is placed within the lumpectomy site BRCA1 and BRCA2: genes on chromosome 17 that, when damaged or mutated, increase a woman’s risk for breast and/or ovarian cancer compared with women without the mutation breast conservation treatment: surgery to remove a breast tumour and a margin of tissue around the tumour without removing any other part of the breast; may or may not include lymph node removal and radiation therapy dose-dense chemotherapy: administration of chemotherapeutic agents at standard doses with shorter time intervals between each cycle of treatment ductal carcinoma in situ (DCIS): cancer cells starting in the ductal system of the breast not penetrating surrounding tissue estrogen and progesterone receptor assay: test to determine whether the breast tumour is nourished by hormones; this information helps to determine prognosis and 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): 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): 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 lymphedema: chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary lymph node dissection mammoplasty: surgery to reconstruct or change the size or shape of the breast; can be performed for reduction or augmentation mastalgia: breast pain, usually related to hormonal fluctuations or irritation of a nerve mastitis: inflammation or infection of the breast 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 of breast cancer in women considered to be at high risk sentinel lymph node: first lymph node(s) in the lymphatic basin that receives drainage from the primary tumour in the breast; identified by a radioisotope and/or blue dye stereotactic core 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: Surgical removal of all or a portion of a mass for microscopic examination by a pathologist tissue expander followed by permanent implant: series of breast-reconstructive surgeries 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 transverse rectus abdominis myocutaneous (TRAM) flap: method of breast reconstruction in which a flap of skin, fat, and muscle from the lower abdomen, with its attached blood supply, is rotated to the mastectomy site ultrasonography: imaging method using high-frequency sound waves to diagnose whether masses are solid or fluid filled

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Clavicle Pectoralis major muscle Intercostal muscles Ribs Lobules Ductule Milk duct Tail of Spence

Fat

Upper outer

Upper inner

Nipple pore

Lower inner

Suspensory ligaments of Cooper

Lower outer

FIGURE 49-1. A, Anatomy of the breast.

Inframammary fold

A

B, Areas of breast, including the tail of Spence.

B

breast development. This development usually occurs from 10 to 16 years of age, 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). • 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 breasts are located between the second and sixth ribs over the pectoralis muscle from the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the axilla. Fascial bands, called Cooper’s ligaments, support the breast on the chest wall. The inframammary fold (or crease) is a ridge of fat at the bottom of the breast. Each breast contains 12 to 20 cone-shaped lobes, which are made up of glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together. Milk is produced in the lobules and then carried through the ducts to the nipple. Figure 49-1 shows the anatomy of the fully developed breast.

ASSESSMENT Health History When a patient presents with a breast problem, the nurse conducts a general health assessment, including history of medical disorders and previous surgery; family history of diseases, particularly cancer; gynecologic and obstetric history; present medications (including prescriptions, vitamins, and herbal); past and present use of hormonal

contraceptives, hormone therapy (HT) (formerly referred to as hormone replacement therapy [HRT]), or fertility treatments; and social habits (e.g., smoking, drinking alcohol). Psychosocial information, such as the patient’s marital status, occupation, and availability of resources and support people, is obtained. Any recent x-rays or other diagnostic tests are noted. Focused questions pertaining to the breast disorder are asked concerning the onset of the disorder and the length of time it has been present. In addition, the patient is asked if any masses are palpable and if there is any associated pain, swelling, redness, nipple discharge, or skin changes. Knowledge and comfort in practicing Know Your Breasts (KYB) should also be ascertained from the patient.

Physical Assessment: Female Breast A female breast examination can be conducted during any general physical or gynecologic examination or whenever the patient reports an abnormality. A thorough breast examination, including instruction in KYB, takes at least 10 minutes.

Inspection Examination begins with inspection. The patient is asked to disrobe to the waist and sit 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 colour, venous pattern, 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 tumour. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance (peau d’orange), a classic sign of advanced breast cancer. Nipple inversion of

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CHART 49-1

Abnormal Findings During Inspection of the Breasts Retraction Signs

Nipple Inversion

• Signs include skin dimpling, creasing, or changes in the

• Considered normal if

contour of the breast or nipple • May be secondary to contraction of fibrotic tissue that can occur with underlying malignancy • May be secondary to scar tissue formation after breast surgery • Retraction signs may appear only with position changes

long-standing

• Associated with fibrosis

and malignancy if recent development

Nipple inversion

Acute Mastitis (Inflammation of the Breasts) • • • • •

Dimpling Flattening of nipple

Retraction signs

Retraction with compression

Paget’s Disease (Malignancy of Mammary Ducts) • Early signs: erythema of

Increased Venous Prominence

nipple and areola

• Late signs: thickening,

scaling, and erosion of the nipple and areola

• Unilateral localized increase in venous pattern associated with malignant tumours • Normal with bilateral and symmetrical breast enlargement associated with pregnancy and lactation

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

Increased venous prominence

Peau d’Orange (Edema) • Associated with inflammatory 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, and immobile

Peau d’orange

one or both breasts is not uncommon and is significant only when of recent origin. Ulceration, rashes, or spontaneous nipple discharge requires evaluation. Examples of abnormal breast findings on inspection can be found in Chart 49-1. To elicit skin dimpling or retraction that may otherwise go undetected, the examiner instructs the patient to raise both arms overhead. This manoeuvre usually elevates both breasts equally. The patient is then instructed to place her hands on her waist and push in. These movements, which cause contraction of the pectoral muscles, do not usually alter the breast contour or nipple direction. If the patient has large breasts, have her lean forward from

the waist. Note any changes in contours. Any dimpling or retraction during these position changes suggests an underlying mass. The clavicular and axillary regions are inspected for swelling, discolouration, lesions, or enlarged lymph nodes.

Palpation If the breasts are pendulous, they are palpated with the patient sitting and leaning forward (Fig. 49-2). The breasts are palpated with the patient sitting up (upright) and lying down (supine). In the supine position the patient’s shoulder is first elevated with a small pillow to help

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FIGURE 49-2. Palpating the breasts using bimanual technique.

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. The entire surface of the breast and the axillary tail is systematically palpated using the flat part (pads) of the second, third, and fourth fingertips, held together, making dime-size circles. 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. 49-3). Palpation of the axillary and clavicular areas is easily performed with the patient seated (Fig. 49-4). To examine the axillary lymph nodes, the examiner gently abducts the patient’s arm from the thorax. With the left hand, the patient’s left forearm is grasped and supported. The right hand is then free to palpate the axillae. Any lymph nodes that may be lying against the thoracic wall are noted. Usually, these lymph nodes are not palpable, but if they are enlarged, their location, size, mobility, and consistency are noted. During palpation, the examiner notes any patient-reported tenderness or masses. If a mass is detected, it is described by its location (e.g., left breast, 2 cm from the nipple at 2 o’clock position). Size, shape, Horizontal

Vertical strip

FIGURE 49-3. Breast palpation parametres: below clavicle to 3 cm

below breast; mid axillary line to midsternal line on each side. Breast palpation patterns: palpate in small circles along horizontal strips (Canadian Cancer Society), or vertical strips (American Cancer Society). Only these two systematic approaches are recommended.

FIGURE 49-4. Palpating for central axillary nodes.

consistency, border delineation, and mobility are included in the description. The breast tissue of the adolescent is usually firm and lobular, whereas that of the postmenopausal woman is more likely to feel thinner and fattier. 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 commonly found in menstruating women and are usually well defined and freely movable. Premenstrually, cysts may be larger and more tender. Malignant tumours, on the other hand, tend to be hard, poorly defined, and nontender. A physician should further evaluate any abnormalities detected during inspection and palpation.

Physical Assessment: Male Breast Breast cancer can occur in men. Examination of the male breast and axillae should be included in a physical examination. The nipple and areola are inspected for masses and nipple discharge. The same procedure for palpating the female axillae is used when assessing the male axillae. Gynecomastia is the firm enlargement of glandular tissue beneath and immediately surrounding the areola of the male. This is different from the enlargement of soft, fatty tissue, which is caused by obesity.

DIAGNOSTIC EVALUATION Know Your Breasts The nurse plays an important role in KYB education, a modality used for the early detection of breast cancer. KYB

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can be taught in a variety of settings—either on a one-toone basis or in a group. It can also be initiated by a health care practitioner during a patient’s routine physical examination. Variations in breast tissue occur during the menstrual cycle, pregnancy, and the onset of menopause. Women on HT can also experience fluctuations. Normal changes must be distinguished from those that may signal disease. Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, KYB is best performed after menses (day 5 to day 7, counting the first day of menses as day 1). Also, many women have grainytextured breast tissue, but these areas are usually less nodular after menses. Younger women may find KYB particularly difficult because of the density of their breast tissue. As women age, their breasts become fattier and may be easier to examine. It is estimated that only 25% to 30% of women perform KYB proficiently and regularly each month. Some find KYB to be anxiety producing; others find it too difficult to differentiate between normal changes and worrisome findings. Even women who perform KYB and detect a change may delay seeking medical attention because of fear, economic factors, lack of education, and modesty. Despite these factors, many women discover their own breast cancers when bathing. For this reason, KYB should be taught and encouraged but not overemphasized. The CCS recommends that women know what is normal for their breasts and notify the doctor of any changes. Survivors of breast cancer report that they detected the cancer by selfexamination (25%) or by accident (18%) (Roth, Elmore, Yi-Frazier, et al., 2011). Instructions about KYB should also be provided to men if they have a family history of breast cancer, because they may have an increased risk of male breast cancer. Patients who elect to perform KYB should receive proper instruction on technique (Chart 49-2). They should be informed that routine KYB will help them become familiar with their “normal abnormalities.” If a change is detected, they should seek medical attention. Patients should be instructed about optimal timing for KYB (5 to 7 days after menses begin for premenopausal women and once monthly for postmenopausal women). When demonstrating examination techniques, the feel of normal breast tissue should be reviewed and ways to identify breast changes discussed. Patients should then perform a KYB demonstration on themselves or on a breast model. Patients who have had breast cancer surgery should be instructed to examine their breast or chest wall for any new changes or nodules that may indicate a recurrence of the disease. KYB videos, shower cards, and pamphlets can be obtained from local chapters of the CCS.

Mammography Mammography is a breast-imaging technique that has been shown to reduce breast cancer mortality rates. It can detect nonpalpable lesions and assist in diagnosing palpable masses. The procedure takes about 15 minutes and can be performed in a hospital radiology department or independent imaging centre. Two views are taken of each breast. The breast is mechanically compressed from top to

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X-ray tube

X-ray

Compression paddle

A

X-ray film cassette

B

FIGURE 49-5. The mammography procedure (A) relies on x-ray imag-

ing to produce the mammogram (B), which in this case reveals a breast lump.

bottom (craniocaudal view) and side to side (mediolateral oblique view) (Fig. 49-5). Women may experience some fleeting discomfort because maximum compression is necessary for proper visualization. The new mammogram is compared with previous mammograms, and any changes may indicate a need for further investigation. Mammography may detect a breast tumour before it is clinically palpable (i.e., smaller than 1 cm); however, it has limitations. The false-negative rate ranges between 5% and 10%. Younger women, or those taking HT, may have dense breast tissue, making it more 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 to have many mammograms in a year to increase their cancer risk. The benefits of this test outweigh the risks. To ensure that a mammogram is reliable, it is important to note that the responsibility for the quality of mammograms in Canada is shared among the federal, provincial, and territorial governments and is directed by the Canadian Mammogram Quality Guidelines. Current mammographic screening guidelines of the CCS (2014a) recommend that between ages 40 and 49, a woman should discuss with her physician the risks of breast cancer and the risks and benefits of mammograms. Between ages 50 and 69, a woman should have a mammogram every 2 years. After 70 years of age, a woman should discuss with her physician about the frequency of mammograms. Women who are at increased risk because of a strong family history should seek the opinion of a breast specialist regarding the optimal age to begin screening mammography. A general guideline is to begin screening 10 years earlier than the age at which the youngest family member developed breast cancer but not before

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CHART 49-2

Patient Education The “Know Your Breasts” Approach STEP 1 1. Stand before a mirror. 2. Checks both breasts for anything unusual. 3. Look for discharge from the nipple, puckering, dimpling, or scaling of the skin. The next two steps are done to check for any changes in the contour of your breasts. As you do them, you should be able to feel your muscles tighten.

STEP 2 1. Watch closely in the mirror as you clasp your hands behind your head and press your hands together. 2. Note any change in the contour of your breasts.

STEP 3 1. Next, press your hands firmly on your hips, and bow slightly toward the mirror as you pull your shoulders and elbows forward. 2. Note any change in the contour of your breasts. 3. Bend forward, and check the contour of your breasts. 4. Lift each breast, and check the condition of the skin. Some women do the next part of the examination in the shower. Your fingers will glide easily over soapy skin, so you can concentrate on feeling for changes inside the breast.

STEP 4 1. Raise your left arm. 2. Use the flat part (top one third of finger) of four fingers of your right hand to feel the left side of your chest and your left breast firmly, carefully, and thoroughly. 3. Beginning below your collarbone at the middle of your chest, press the flat part of your fingers in small circles, moving back and forth across the chest or up and down the chest along imaginary lines. 4. Be sure to cover from below the collarbone to 3 cm below the breast, from the centre of your chest to the opposite side. This includes all of the breast tissue and the nipple. 5. Pay special attention to the area between the breast and the underarm, including the underarm itself. 6. Feel for any unusual lumps or masses under the skin. 7. If you have any spontaneous discharge during the month, see your doctor. 8. Repeat the examination on your right breast.

STEP 5 1. Step 4 should be repeated lying down. 2. Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. (This position flattens your breast and makes it easier to check.) 3. Use the same circular motion described above, and cover the same areas. 4. Repeat on your right breast.

Adapted from Stephen, T. C., Skillen, D. L., Day, R. A., et al. (Eds.). (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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25 years of age. In families with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen (e.g., grandmother diagnosed with breast cancer at 48 years of age, mother diagnosed with breast cancer at 38 years of age, then daughter should begin screening at age 28 years of age). Despite the decreased mortality rates associated with mammographic screening, many women are not undergoing this simple procedure. Nurses are in key positions to educate women about the current CCS screening guidelines and the benefits of mammography. They can also help identify and provide information to women who may benefit from such screening programs. Newer techniques for breast screening include digital mammography and computer-assisted detection (CAD) programs. Digital mammography records x-ray images on a computer instead of on film, thus allowing radiologists to adjust the contrast and focus on an image without having to take additional x-rays. Compared with conventional film mammography, digital mammography has been shown to be significantly better at detecting breast cancer in women younger than 50 years of age, women with dense breast tissue, and premenopausal and perimenopausal women. CAD is designed to assist radiologists in the identification of suspicious areas on a mammogram. Trials of CAD programs have generally, but not always, shown improvements in detection rates. The effectiveness of both digital mammography and CAD continues to be evaluated.

Galactography Galactography is a diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into a ductal opening on the areola, which is followed by a mammogram. It is performed to evaluate an abnormality within the duct when the patient has bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography.

Ultrasonography Ultrasonography (ultrasound) is used as a diagnostic adjunct to mammography to help distinguish fluid-filled cysts from other lesions. A thin coating of lubricating jelly is spread over the area to be imaged. A transducer is then placed on the breast. The transducer transmits highfrequency sound waves through the skin toward the area of concern. The sound waves that are reflected back form a two-dimensional image, which is then displayed on a computer screen. No radiation is emitted during the procedure. Ultrasonography has advantages and disadvantages. Although it can diagnose cysts with great accuracy, it cannot definitively rule out malignant lesions. Microcalcifications, which are detectable on mammography, cannot be identified on ultrasonography. Finally, examination techniques and interpretation criteria are not standardized.

Magnetic Resonance Imaging Magnetic resonance imaging (MRI) of the breast is rapidly gaining in popularity. This highly sensitive test has become

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a useful diagnostic adjunct to mammography. A magnet is linked to a computer that creates detailed images of the breast without exposure to radiation. An intravenous (IV) injection of gadolinium, a contrast dye, is given to improve visibility. The patient lies face down and the breast is placed through a depression in the table. A coil is placed around the breast, and the patient is placed inside the MRI machine. The entire procedure takes about 30 to 40 minutes. MRI is most useful in patients with proven breast cancer when assessing for multifocal (more than one tumour in the same quadrant of the breast) or multicentric (more than one tumour in different quadrants of the breast) disease, chest wall involvement, tumour recurrence, or response to chemotherapy. The procedure can also identify occult (undetectable) breast cancer and determine the integrity of saline or silicone breast implants. MRI is a highly sensitive screening tool that can find the primary tumour in the breast, examine the extent of breast cancer in the tissue, and better examine abnormalities (CCS, 2014). MRI should be used in addition to mammography, not instead of it. Some disadvantages of MRI include wait time to get an MRI, high cost if done at a private clinic not covered by provincial health care, variations in technique and interpretation, and the potential for patient claustrophobia. The procedure cannot always accurately distinguish between malignant and benign breast conditions. MRI is contraindicated in patients with implantable metal devices (e.g., aneurysm clips, pacemakers, ports of tissue expanders) because of the metallic force. Foil-backed medication patches (e.g., nicotine, nitroglycerine, fentanyl) must be removed prior to MRI to avoid burns to the skin.

Procedures for Tissue Analysis Percutaneous Biopsy Percutaneous biopsy is performed on an outpatient basis to sample palpable and nonpalpable lesions. Less invasive than a surgical biopsy, percutaneous biopsy is a needle or core biopsy that obtains tissue by making a small puncture in the skin. Table 49-1 outlines the different types of biopsies that can be performed to obtain a tissue diagnosis. FINE-NEEDLE ASPIRATION. Fine-needle aspiration (FNA) is a noninvasive biopsy technique that is generally well tolerated by most women. A local anesthetic may or may not be used. A small gauge needle (25- or 22-gauge) attached to a syringe is inserted into the mass or area of nodularity. Suction is applied to the syringe, and multiple passes are made through the mass. A simple cyst often disappears on aspiration, and the fluid is usually discarded. If no fluid is obtained, any cellular material obtained in the hub of the needle is spread on a glass slide or placed in a preservative and sent to the laboratory for analysis. For nonpalpable masses, the same procedure can be performed by a radiologist using ultrasound guidance (ultrasound-guided FNA). FNA is less expensive for the health care system than other diagnostic methods and results are usually available quickly. However, false-negative or false-positive results are possible, and appropriate follow-up depends on the clinical judgment of the treating physician. CORE NEEDLE BIOPSY. Core needle biopsy is similar to FNA, except that a larger gauge needle is used (usually

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TABLE 49-1

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Types of Breast Biopsies

Procedure

Palpable Mass

Fine-needle aspiration Core needle biopsy Stereotactic core biopsy Ultrasound-guided core biopsy MRI-guided core biopsy Excisional biopsy Incisional biopsy Wire needle localization biopsy; may be guided by mammogram, ultrasound, or MRI

Yes Yes No No No Yes Yes No

14-gauge). A local anesthetic is applied, and tissue cores are removed via a spring-loaded device. This procedure allows for a more definitive diagnosis than FNA, because actual tissue, not just cells, is removed. It is often performed for relatively large tumours that are close to the skin surface. STEREOTACTIC CORE BIOPSY. Stereotactic core biopsy is performed on nonpalpable lesions detected by mammography. The patient lies prone on the stereotactic table. The breast is suspended through an opening in the table and compressed between two x-ray plates. Images are then obtained using digital mammography. The exact coordinates of the lesion to be sampled are located with the aid of a computer. Next, a local anesthetic is injected into the entry site on the breast. A small nick is made in the skin, a core needle is inserted, and samples of the tissue are taken for pathologic examination. Often, several passes are taken to ensure that the lesion is well sampled. Postbiopsy films are then taken to check that sampling has been adequate. A small titanium clip is often placed at the biopsy site so that the site can easily be located if further treatment is indicated. Stereotactic biopsy is quite accurate and often allows the patient to avoid a surgical biopsy. However, there is a small false-negative rate. Appropriate follow-up depends on the final pathologic diagnosis and the clinical judgment of the treating physician. Use of a titanium clip does not preclude subsequent MRIs. ULTRASOUND-GUIDED CORE BIOPSY. The principles for ultrasound-guided core biopsy are similar to those of stereotactic core biopsy, but by using ultrasound guidance, computer coordination and mammographic compression are not necessary. Ultrasound-guided core biopsy does not use radiation and is also faster and less expensive than stereotactic core biopsy. MAGNETIC RESONANCE IMAGING–GUIDED CORE BIOPSY. Recently, the technology has become available to

perform core biopsies under MRI guidance. The number of facilities that are equipped to perform this procedure is increasing.

Surgical Biopsy Surgical biopsy is usually performed using local anesthesia and IV sedation. After an incision is made, the lesion is excised and sent to a laboratory for pathologic examination. TYPES OF SURGICAL BREAST BIOPSY

Excisional Biopsy. Excisional biopsy is the standard procedure for complete pathological assessment of a palpable

Health Professional Who Performs Procedure

Nature of Breast Tissue Removed

Surgeon Surgeon Radiologist Radiologist Radiologist Surgeon Surgeon Radiologist inserts wire, surgeon performs biopsy

Cellular material Tissue core Tissue core Tissue core Tissue core Entire mass Tissue core Entire mass

breast mass. The entire mass, 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 analysis of the specimen may be performed at the time of the biopsy by the pathologist, who does an immediate reading intraoperatively and provides a provisional diagnosis. This can help confirm a diagnosis in a patient who had no previous tissue analysis performed. Incisional Biopsy. Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies (e.g., ER/PR, HER-2/neu [also referred to as ERBB2]; see later discussion for explanation of these terms) that will aid in determining treatment, which are discussed later in this chapter. 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 on women with locally advanced breast cancer or on women with suspected cancer recurrence, whose treatment may depend on the results of these special studies. However, pathological information may be easily obtained from core needle biopsy, and incisional biopsy is becoming less common. Wire Needle Localization. Wire needle localization is a technique used to locate nonpalpable masses or suspicious calcium deposits detected on a mammogram, ultrasound, or MRI that require an excisional biopsy. The radiologist inserts a long, thin wire through a needle, which is then inserted into the area of abnormality using x-ray or ultrasound guidance (whichever imaging technique originally identified the abnormality). The wire remains in place after the needle is withdrawn to ensure the precise location. The patient is then taken to the operating room, where the surgeon follows the wire to the tip and excises the area. NURSING MANAGEMENT. During the preoperative visit, the nurse assesses the patient for any specific educational, physical, or psychosocial needs that she may have. This can be accomplished by reviewing her medical and psychosocial history and encouraging her to verbalize her fears, concerns, and questions. Patients are often worried not only about the procedure but also about the potential implications of the pathology results. Providing a thorough explanation about what to expect in a supportive manner can help alleviate anxiety. Patients often have difficulty absorbing all the information given to them; therefore, written materials should be provided to reinforce teaching.

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The nurse instructs the patient to discontinue any agents that can increase the risk of bleeding, including products containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin E supplements, herbal substances (such as ginkgo biloba and garlic supplements), and warfarin (Coumadin). The patient may be instructed not to eat or drink for several hours or after midnight the night before the procedure, depending on the type of biopsy planned. Most breast biopsy procedures today are performed with the use of moderate sedation and local anesthesia. Immediate postoperative assessment includes monitoring the effects of the anesthesia and inspecting the surgical dressing for any signs of bleeding. Once the sedation has worn off, the nurse reviews the care of the biopsy site, pain management, and activity restrictions with the patient. Prior to discharge from the ambulatory surgical centre or the office, the patient must be able to tolerate fluids, ambulate, and void. The patient must have somebody to accompany her home. The dressing covering the incision is usually removed after 48 hours, but the SteriStrips, which are applied directly over the incision, should remain in place for approximately 7 to 10 days. The use of a supportive bra following surgery is encouraged to limit movement of the breast and reduce discomfort. A followup telephone call from the nurse 24 to 48 hours after the procedure can provide the patient with the opportunity to ask any questions and can be a source of great comfort and reassurance. 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, and most women find acetaminophen sufficient for pain relief, although 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 benign, the nurse reviews incision care and explains what the patient should expect as the biopsy site heals (i.e., changes in sensation may occur weeks or months after the biopsy due to nerve injury 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.

CONDITIONS AFFECTING THE NIPPLE Nipple Discharge Nipple discharge in a woman who is not lactating may be related to many causes, such as carcinoma, papilloma, pituitary adenoma, cystic breasts, and various medications. Oral contraceptives, pregnancy, HT, chlorpromazine (Thorazine)-type medications, and frequent breast stimulation may be contributing factors. In some athletic women, nipple discharge may occur during running or aerobic exercises. Nipple discharge should be evaluated by a health care provider, but it is not often a cause for alarm. One in three women has clear discharge on expression,

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which is usually normal. A green discharge could indicate an infection. Any discharge that is spontaneous, persistent, or unilateral is of more concern. Although bloody discharge can indicate a malignancy, it is often caused by a benign wartlike growth on the lining of the duct called an intraductal papilloma. Nipple discharge should be evaluated for the presence of occult (hidden) blood by performing a guaiac test. A galactogram can also be performed to detect abnormalities within the duct that may be causing the discharge. If there is a high level of suspicion, a surgical biopsy called a duct excision may be indicated.

Fissure A fissure is a longitudinal ulcer that may 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 be continued with the use of 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 breastfeeding can be resumed. Persistent ulceration requires further diagnosis and therapy. Guidance from a nurse or lactation consultant may be helpful because nipple irritation can result from improper positioning (i.e., the infant has not grasped the areola fully) during breastfeeding.

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 from a breastfed infant with an oral, eye, or skin infection. Mastitis may also be caused by blood-borne organisms. As inflammation progresses, the breast texture becomes tough or doughy, and the patient reports of dull to severe pain in the infected region. A nipple that is discharging purulent material, serum, or blood should be investigated. Treatment consists of antibiotics and local application of cold compresses to relieve discomfort. A broad-spectrum 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. The area affected becomes tender and red. Purulent matter can usually be aspirated with a needle, but incision and drainage may be required. Specimens of the aspirated material are obtained for culture so that an organism-specific antibiotic can be prescribed.

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BENIGN CONDITIONS OF THE BREAST Breast Pain Breast pain (mastalgia) may be cyclical or noncyclical. Cyclical pain is usually related to hormonal fluctuations and accounts for nearly 75% of all reports. Noncyclical pain is far less common and does not vary with the menstrual cycle. Women who experience injury or trauma to the breast or those who had a breast biopsy may experience noncyclical pain. Patients are reassured that breast pain is rarely indicative of cancer. However, if the pain persists after menses begins, the patient should see her primary health care professional.

Fibroadenomas

Nursing Management The nurse may recommend that the patient wear a supportive bra both day and night for a week, decrease her salt and caffeine intake, and take ibuprofen 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.

Cysts Cysts are fluid-filled sacs that develop as breast ducts dilate. Cysts occur most commonly in women 30 to 55 years of age and may be exacerbated during perimenopause.

TABLE 49-2

Although their cause is unknown, cysts usually disappear after menopause, suggesting that estrogen is a factor. Cystic areas often fluctuate in size and are usually larger premenstrually. They may be painless or may become very tender premenstrually. Occasionally, a patient may report an intermittent shooting sensation or a dull ache. Various breast masses are compared in Table 49-2. Cysts that are confirmed on an ultrasound and are not bothersome can often be left alone. To confirm a diagnosis or to relieve pain, FNA can be performed. Cysts do not increase the risk of breast cancer. Fibrocystic breast changes, which are often called fibrocystic breast disease, is a nonspecific term used to describe an array of benign findings. The changes do not necessarily indicate a cystic process.

Fibroadenomas are firm, round, movable, benign tumours. They can occur from puberty to menopause with a peak incidence at 30 years of age. These masses are nontender and are sometimes removed for definitive diagnosis.

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. These diagnoses increase a woman’s risk of breast cancer.

Comparison of Various Breast Masses

The most common breast masses are due to cysts, fibroadenomas, or malignancy. Biopsy is usually needed for confirmation, but the following characteristics are diagnostic clues: Characteristics

Cysts

Fibroadenomas

Malignancy

Age

30–55 yrs, regress after menopause except with use of estrogen therapy

Puberty to menopause

30–90 yrs; most common, 40–80 yrs

Number Shape Consistency Mobility Tenderness Retraction signs

Single or multiple Round Soft to firm, usually elastic Mobile Usually tender Absent

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

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Atypical Hyperplasia Atypical hyperplasia is an abnormal increase in the ductal (atypical ductal hyperplasia) or lobular (atypical lobular hyperplasia) cells in the breast and is usually found incidentally in mammographic abnormalities. Atypical hyperplasia increases a woman’s risk of breast cancer about four to five times compared with that of the general population.

Lobular Carcinoma In Situ Lobular carcinoma in situ (LCIS) is characterized by a proliferation of cells within the breast lobules. LCIS is usually found incidentally on pathologic diagnosis because it cannot be seen on mammography and does not form a palpable lump. The term LCIS is misleading because it is not a carcinoma. Historically, LCIS was considered a premalignant condition but is now considered a marker for increased risk of invasive carcinoma. A patient with LCIS may later develop an invasive carcinoma in either breast that is either ductal or lobular in origin. LCIS increases a woman’s risk of breast cancer but many women do not develop invasive breast cancer (CCS, 2014). It is not known how to identify which women will develop LCIS. Early detection and screening are important for women with LCIS.

Other Benign Conditions Cystosarcoma phyllodes is a rare fibroepithelial lesion that tends to grow rapidly. It is rarely malignant and is treated with surgical excision. If it is malignant, mastectomy may follow. Lymph node removal is usually not performed because metastasis is rare. Fat necrosis is a condition of the breast that is often associated with a history of trauma. Surgical procedures such as a breast biopsy can cause fat necrosis. It may be indistinguishable from carcinoma, and the entire mass is usually excised. Intraductal papilloma is a wartlike growth that often involves the large milk ducts near the nipple, causing bloody nipple discharge. Surgery usually involves removal of the papilloma and a segment of the duct where the papilloma is found. Superficial thrombophlebitis of the breast (Mondor 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.

MALIGNANT CONDITIONS OF THE BREAST Breast cancer is the second most common cancer among Canadian women, 23,000 cases in 2013, (excluding nonmelanoma skin cancers) (Canadian Cancer Society [CCS], 2014b). Breast cancer is the second leading cause of death

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from cancer in Canadian women with just over 5,000 deaths in 2013. Based on 2007 estimates, 1 in 9 Canadian women will develop breast cancer and 1 in 29 women will die from it (CCS, 2014).

Types of Breast Cancer Ductal Carcinoma In Situ The increased use of mammography as a screening tool has contributed to the dramatic increase in the diagnosis of ductal carcinoma in situ (DCIS). DCIS is characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue. Therefore, it is a noninvasive form of cancer (also called intraductal carcinoma). DCIS is frequently manifested on a mammogram with the appearance of calcifications, and it is considered breast cancer stage 0. If DCIS is left untreated, there is an increased likelihood that it will progress to invasive cancer. Deciding on the best surgical treatment option can be very complex. DCIS can be categorized in terms of its aggressiveness depending on a variety of factors, including histological subtype (comedo is more aggressive than noncomedo), size of tumour, and whether it is multicentric (present in different quadrants of the breast). These factors, together with patient preference, are important determinants in making treatment decisions. Mastectomy results in low rates of reoccurrence but is viewed as overtreatment for most patients with DCIS (Benson & Wishart, 2013). Less aggressive surgery; breast conservation treatment (limited surgery followed by radiation) is associated with higher rates of ipsilateral tumour occurrences. Treatment offers excellent prognosis but uncertainties exist about the disease progression and treatment options (Benson & Wishart, 2013; Prinjha, Evans, Ziebland, et al., 2011).

Invasive Cancer The National Comprehensive Cancer Network (NCCN), a nonprofit group of the world’s 23 leading cancer centres, disseminates estimates for various types of cancer.

Infiltrating Ductal Carcinoma Infiltrating ductal carcinoma, the most common histologic type of breast cancer, accounts for 80% of all cases. The tumours arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast.

Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 10% to 15% of breast cancers. The tumours arise from the lobular epithelium and typically occur as an area of ill-defined thickening in the breast. They are often multicentric and can be bilateral.

Medullary Carcinoma Medullary carcinoma accounts for about 5% of breast cancers. It has a well-defined edge. It is difficult to differentiate

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from common invasive ductal carcinoma and should be treated as common invasive ductal carcinoma.

Colloid Carcinoma Colloid carcinoma, also called mucinous carcinoma, is rare. The cancer cells are mucous producing and have a better prognosis and lower chance of metastasis.

Tubular Carcinoma Tubular carcinoma accounts for about 2% of breast cancers. Women with this cancer have a better prognosis because it is less likely to spread beyond the breast.

Inflammatory Breast Cancer Inflammatory carcinoma occurs in 1% to 3% of all breast cancers. Cancer cells spread to the lymph node channels in the skin of the breast. The cancer is characterized by edema, larger breast size in the diseased breast and erythema of the skin, often referred to as peau d’orange (resembling an orange peel). This is caused by malignant cells blocking the lymph channels in the skin.

Paget’s Disease Paget’s disease of the breast accounts for 1% of diagnosed cases of breast cancer and is more common in women over 50 years of age (CCS, 2014). Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple. Paget’s disease often represents ductal carcinoma in situ of the nipple but may have an invasive component. If no lump TABLE 49-3

can be felt in the breast tissue and the biopsy shows DCIS without invasion, the prognosis is very favourable.

Risk Factors There is no single, specific cause of breast cancer. A combination of genetic, hormonal, and possibly environmental factors may increase the risk of its development (Table 49-3). More than 80% of all cases of breast cancer are sporadic, meaning that patients have no known family history of the disease. The remaining cases are either familial (there is a family history of breast cancer but it is not passed on genetically) or genetically acquired. There is no evidence that smoking, silicone breast implants, use of antiperspirants, underwire bras, or abortion (induced or spontaneous) increases the risk of the disease.

Process of Epidemiological Transmission It is challenging for immigrant families to understand the effects of immigration on their risk for breast cancer. For example, by immigrating to Australia, female family members have a 40% higher risk of developing breast cancer than their counterparts in China (Grulich, McCredie, & Coates, 1995). Another example is that Asian-American women born in the United States have a 60% higher risk for breast cancer than those born in China. The risks for the next generation are even higher. These Asian women

Risk Factors for Breast Cancer

Risk Factor

Comments

Female gender Increasing age Personal history of breast cancer

99% of cases occur in women. Increasing age is associated with an increased risk. Once treated for breast cancer, the risk of developing breast cancer in same or opposite breast is significantly increased. Having first-degree relative with breast cancer (mother, sister, daughter) increases the risk twofold; having two first-degree relatives increases the risk fivefold. The risk is higher if the relative was premenopausal at the time of diagnosis. The risk is increased if a father or brother had breast cancer (exact risk is unknown). BRCA1 and BRCA2 mutations account for the majority of inherited cases of breast cancer (see additional information in text).

Family history of breast cancer

Genetic mutation Hormonal Factors • Early menarche • Late menopause • Nulliparity • Late age at first full-term pregnancy • Hormone therapy (formerly referred to as hormone replacement therapy) Exposure to ionizing radiation during adolescence and early adulthood History of benign proliferative breast disease Obesity

High-fat diet (controversial) Alcohol intake (beer, wine, or liquor)

Before 12 yrs of age After 55 yrs of age No full-term pregnancies After 30 yrs of age Current or recent use of combined postmenopausal hormone therapy (estrogen and progesterone) Long-term use (several years or more) The risk is highest if breast tissue was exposed while still developing (during adolescence) such as women who received mantle radiation (to the chest area) for treatment of Hodgkin lymphoma in their younger years. Having had atypical ductal or lobular hyperplasia or lobular carcinoma in situ increases the risk. Obesity and weight gain during adulthood increases the risk of postmenopausal breast cancer. During menopause, estrogen is primarily produced in fat tissue. More fat tissue can increase estrogen levels, thereby increasing breast cancer risk. More research is needed. Two to five drinks daily increases the risk about one and a half times.

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are going through the process of epidemiological transitions (Kwok, Fetheney, & White, 2012). Despite being at increased risk for breast cancer, Chinese women are less likely to take part in screening opportunities in the United States (Gomez, Tan, Keegan, et al., 2007), Canada (Sun, Xiong, Kearney, et al., 2010), and Australia (Kwok et al., 2012). As stated previously, breast cancer can be genetically inherited, resulting in significant risk. Factors that may indicate a genetic link include multiple first-degree relatives with early-onset breast cancer, breast and ovarian cancer in the same family, male breast cancer, and Ashkenazi Jewish background. BRCA1 and BRCA2 are tumour suppressor genes that usually function to identify damaged DNA and thereby restrain abnormal cell growth. Mutations in these genes are responsible for the majority of hereditary breast cancer. BRCA1 mutations have been associated with a 60–70% estimated lifetime risk, and BRCA2 mutations have been associated with a 40–60% risk (Maxwell & Domcheck, 2012). Carriers also have a significantly increased risk for ovarian cancer, approaching 45% Men with BRCA mutations, particularly the BRCA2 mutation, also have an increased risk of breast cancer and gastric cancer (Shiloh, Dagan, Friedman, et al., 2013).

Protective Factors Certain factors may be protective in relation to the development of breast cancer. Physical activity carried out for 30 minutes or more 5 days per week may decrease the risk of breast cancer (Graf & Wessely, 2010). In a study by Friedenreich et al., (2010), sedentary postmenopausal women who adhere to aerobic exercise as an intervention can change estradiol and sex hormone-binding globulin (SHBG) concentrations, which are associated with a lower the risk for postmenopausal breast cancer. Breastfeeding is also thought to decrease risk because it prevents the return of menstruation, thereby decreasing exposure to endogenous estrogen. Having completed a full-term pregnancy before 30 years of age is also thought to be protective.

Breast Cancer Prevention Strategies in the High-Risk Patient Patients often overestimate or underestimate their risk of developing breast cancer. A consultation with a breast specialist is of paramount importance prior to embarking on any of the prevention strategies that follow. Once patients have an accurate assessment of their risk, along with the knowledge of the pros and cons of each prevention strategy, they can make a decision that is most appropriate for their situation.

Long-Term Surveillance Long-term surveillance is a form of secondary prevention that focuses on early detection of the disease. As recommended by the CCS, women with a strong family history

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of breast cancer, genetic mutations of BRCA1 or BRCA2, or history of breast changes may need to test earlier and more often. The frequency of clinical breast examinations and mammograms may be discussed with a physician. Data concerning the effectiveness of KYB are limited. In a study of women 55 years and older with a family history of breast cancer, nursing researchers found the women had a “guarding against cancer” approach. This includes regular mammograms, health check-ups, eating well, exercising, and being optimistic (Greco, Nail, Kendall, et al., 2010).

Chemoprevention Chemoprevention is a primary prevention modality that aims to prevent the disease. In April 1998, the results of the Breast Cancer Prevention Trial were released to the general public. This national, randomized, double-blind clinical trial evaluated tamoxifen (20 mg daily for 5 years) versus a placebo in more than 13,000 women considered to be at high risk for breast cancer. The women who received tamoxifen had a 49% reduction in the incidence of breast cancer (Fisher, Constantino, Wickerham, et al., 1998), suggesting that tamoxifen was an effective chemopreventive agent. Selective estrogen-receptor modulators (SERM) are antiestrogenic drugs that block the effect of estrogen on breast tissue. Tamoxifin (Nolvdex) is a SERM that is in use in Canada to reduce the risk of breast cancer, but there is still a risk of developing uterine cancer. Women with BRCA2 mutations may benefit from tamoxifin since they are prone to developing tumours that are estrogen receptor positive. Nurses can help women who are considering this option by providing them with information about the benefits, risks, and possible side effects of tamoxifen. Raloxifene (Evista) is a medication that is used for the prevention and treatment of osteoporosis. The results of the Multiple Outcomes of Raloxifene Evaluation trial in postmenopausal women with osteoporosis showed that women who received raloxifene instead of placebo had a 76% reduction in invasive breast cancer (Cummings, Eckert, Krueger, et al., 1999). A national, randomized clinical trial, the Study of Tamoxifen and Raloxifene (STAR), compared these two agents for the prevention of breast cancer in postmenopausal women (Vogel, Costantino, Wickerham, et al., 2006). Results showed that raloxifene is as effective as tamoxifen in reducing breast cancer risk and has fewer side effects, including fewer uterine cancers, blood clots, and cataracts.

Prophylactic Mastectomy Prophylactic mastectomy is another primary prevention modality. This procedure can reduce the risk of breast cancer by 85% to 100% (Lostumbo, Carbine, & Wallace, 2010) and is sometimes referred to as a “risk-reducing” mastectomy. The procedure consists of a total mastectomy (removal of breast tissue only) and is usually accompanied by immediate breast reconstruction. Possible candidates include women with a strong family history of breast cancer, a diagnosis of LCIS or atypical hyperplasia, a mutation in a BRCA gene, an extreme fear of cancer (“cancer phobia”), or previous cancer in one breast.

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A patient who is considering prophylactic mastectomy is often faced with a very controversial and emotional decision. A multidisciplinary approach should be used to help the patient arrive at a decision that is best for her. Consultation with a genetics counsellor, plastic surgeon, medical oncologist, and psychiatrist can be invaluable. The patient needs to understand that this surgery is elective and not emergent. The nurse can play a valuable role in providing the patient with information, clarification, and support during the decision-making process. One woman summed up her decision to have bilateral prophylactic mastectomies: “I don’t want to spend the rest of my life wondering, worrying, or thinking about it. Just go ahead and get it over with, they are boobs.” (Crotser & Dickerson, 2010, p. 375).

Clinical Manifestations Breast cancers can occur anywhere in the breast but are usually found in the upper outer quadrant, where the most breast tissue is located. Generally, the lesions are nontender, fixed rather than mobile, and hard with irregular borders. Reports of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. With the increased use of mammography, more women are seeking treatment at earlier stages of the disease. These women often have no signs or symptoms other than a mammographic abnormality. Unfortunately, some women with advanced disease seek initial treatment after ignoring symptoms. Advanced signs may include skin dimpling, nipple retraction, or skin ulceration.

Assessment and Diagnostic Findings Techniques to determine the diagnosis of breast cancer include various types of biopsy, which have been described previously. Tumour staging and analysis of additional prognostic factors are used to determine the prognosis and optimal treatment regimen (see below).

Staging Staging involves classifying the cancer by the extent of disease. Clinical staging involves the physician’s estimate of the size of the breast tumour and the extent of axillary lymph node involvement. Such staging is determined by physical examination and imaging studies. Pathological staging is done when the pathologist examines the surgically excised breast tissue under the microscope and determines the exact size of the breast tumour and the exact number of lymph nodes involved. The staging of breast cancer has become complex. Classification of tumours that are stage 0 (DCIS, LCIS, or Paget’s disease of the nipple with no invasion), stage I (tumours that are 2 cm or less with no involvement of axillary lymph nodes), and stage IV (tumours of any size, with distant metastases) is fairly straightforward. However,

classification of tumours that are stage II and stage III, which represent a wide spectrum of breast cancers, is more difficult. Factors that play a role in determining stages II and III include the number and characteristics of axillary lymph nodes, the status of other regional lymph nodes such as internal mammary nodes or supraclavicular nodes, and the presence or absence of involvement of the skin or underlying muscle. Based on these factors, stage II and stage III breast cancers are further subdivided into stage IIA, IIB, IIIA, IIIB, and IIIC. For a detailed explanation of the staging system, the reader is referred to the American Joint Committee on Cancer Staging Manual (Edge, Byrd, Compton, et al., 2011) or to the CCS Web site (see Resources below). Other diagnostic tests may be performed before or after the surgery to help in the staging of the disease. The extent of testing often depends on the clinical presentation of the disease and may include chest x-rays, computed tomography (CT), MRI, positron emission tomography (PET) scan, bone scans, and blood work (complete blood count, comprehensive metabolic panel, tumour markers [i.e., carcinoembryonic antigen, cancer antigen 15-3]).

Prognosis Several different factors must be taken into consideration when determining the prognosis of a patient with breast cancer. The two most important factors are tumour size and whether the tumour has spread to the lymph nodes under the arm (axilla). Generally, the smaller the tumour, 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 and takes time to divide and double in size. A carcinoma may double in size 30 times to become 1 cm or larger, at which point it becomes clinically apparent. Doubling time varies, but breast tumours are often present for several years before they become palpable. Nurses can reassure patients that once breast cancer is diagnosed, they have a safe period of several weeks to make decisions regarding treatment. Prognosis also depends on the extent of spread of the breast cancer. The 5-year relative survival rate can be as high as 100% for a stage I breast cancer and as low as 20% for a stage IV breast cancer (CCS, 2014). Relative survival examines the likelihood of survival after cancer diagnosis compared to the general population who are cancer free with the same demographic criteria such as age and sex. The most common route of regional spread is to the axillary lymph nodes. Other sites of lymphatic spread include the internal mammary and supraclavicular nodes (Fig. 49-6). Distant metastasis can affect any organ, but the most common sites are bone, lung, liver, pleura, adrenals, skin, and brain. In addition to the type of breast cancer and the stage, other factors may help determine prognosis (Chart 49-3). Excessive number of copies of certain genes (amplification) or excessive amounts of their protein product (overexpression) may represent a poorer prognosis. The HER-2/ neu (also known as ERBB2) oncogene is the classic example; approximately 20% to 25% of breast cancers, which typically involve the more aggressive tumours, have

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Supraclavicular lymph nodes

Surgical Treatment Options for Noninvasive and Invasive Breast Cancer

TABLE 49-4

Internal mammary lymph nodes

Noninvasive Breast Cancer a

Axillary lymph nodes

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Invasive Breast Cancer

Breast conservation alone

Breast conservationa with one of the following: Sentinel lymph node biopsy Axillary lymph node dissection

Total mastectomy alone

Total mastectomy with sentinel lymph node biopsy or Modified radical mastectomy

a

Breast conservation treatment includes lumpectomy, wide excision, partial or segmental mastectomy, and quadrantectomy. These are relatively synonymous terms that describe removal of varying amounts of breast tissue.

FIGURE 49-6. Lymphatic drainage of the breast.

amplification or overexpression of the HER-2/neu gene (Harbeck, Pegram, Ruschoff, et al., 2010).

Surgical Management The main goal of surgery is to gain local control of the disease. With breast cancer being diagnosed today at earlier stages, options for less invasive surgical procedures are available. Surgical treatment options for noninvasive and invasive breast cancer are summarized in Table 49-4.

Modified Radical Mastectomy Modified radical mastectomy is performed to treat invasive breast cancer. The procedure involves removal of the entire breast tissue, including the nipple–areola complex. In addition, a portion of the axillary lymph nodes are also removed in axillary lymph node dissection (ALND). If immediate breast reconstruction is desired, the patient is referred to a plastic surgeon prior to the mastectomy so that she has the opportunity to explore all available options. In modified radical mastectomy, the pectoralis major and pectoralis minor muscles are left intact, unlike in radical mastectomy, in which the muscles are removed. Radical mastectomy is rarely performed today. CHART 49-3

Pathologic Factors Associated With Favourable Prognosis for Breast Cancer • Noninvasive tumours or invasive tumours less than 1 cm • Negative axillary lymph nodes • Estrogen receptor (ER) and progesterone receptor (PR) proteins

• Well-differentiated tumours • Low expression of HER-2/neu oncogene (also known as ERBB2)

• No vascular or lymphatic invasion • Diploid tumours with low S-phase fraction

Total Mastectomy Like modified radical mastectomy, total mastectomy (i.e., simple mastectomy) also involves removal of the breast and nipple–areola complex but does not include ALND. Total mastectomy may be performed in patients with noninvasive breast cancer (e.g., DCIS), which does not have a tendency to spread to the lymph nodes. It may also be performed prophylactically in patients who are at high risk for breast cancer (e.g., LCIS, BRCA mutation). A total mastectomy may also be performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast cancer.

Breast Conservation Treatment The goal of breast conservation treatment (i.e., lumpectomy, wide excision, partial or segmental mastectomy, quadrantectomy) is to excise the tumour in the breast completely and obtain clear margins while achieving an acceptable cosmetic result. If the procedure is being performed to treat a noninvasive breast cancer, lymph node removal is not necessary. For an invasive breast cancer, lymph node removal (SLNB or ALND) is indicated. The lymph nodes are removed through a separate semicircular incision in the axilla. In 1990, the National Institutes of Health (NIH) issued a consensus statement that breast conservation along with radiation therapy in stage I and stage II breast cancer resulted in a survival rate equal to that of modified radical mastectomy.

Sentinel Lymph Node Biopsy As previously discussed, the status of the lymph nodes is the most important prognostic factor in breast cancer. Approximately two thirds of women with early-stage breast cancer who have an ALND have negative nodes. In the mid-1990s, SLNB emerged as a less invasive alternative to ALND and is now considered a standard of care for the treatment of early-stage breast cancer. ALND is associated with potential morbidity, including lymphedema, cellulitis, decreased arm mobility, and sensory changes. Studies have shown that SLNB is highly accurate and is associated with a local recurrence rate similar to

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Comparison of Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection

Sentinel Lymph Node Biopsy (SLNB)

Axillary Lymph Node Dissection (ALND)

Shorter operating room time (approximately 15–30 min) No surgical drain Local anesthesia with IV moderate sedation as outpatient surgery (unless being performed in conjunction with total mastectomy) Lymphedema incidence approximately 0–8% Presence of neuropathic sensations postoperatively (prevalence lower than after axillary lymph node dissection) Decreased range of motion in affected arm unlikely postoperatively but may occur Seroma (collection of serous fluid in the axilla) may occur postoperatively

Longer operating room time (approximately 60–90 min) Surgical drain General anesthesia; usually overnight admission (sometimes done as outpatient surgery) Lymphedema incidence approximately 10–30% Presence of neuropathic sensations postoperatively

Decreased range of motion likely postoperatively

should also be reassured that the radioisotope and blue dye are generally safe. The patient may notice a bluegreen discolouration in the urine or stool for the first 24 hours as the blue dye is excreted. The incidence of lymphedema, decreased arm mobility, and seroma formation (collection of serous fluid) in the axilla is generally low, but the patient should be prepared for this possibility. A recent study demonstrated that women who have SLNB alone have neuropathic sensations similar to those who undergo ALND, although the prevalence and severity of these sensations and the resulting distress are lower with SLNB (Krag et al., 2010). The nurse must not overlook the psychosocial needs of the patient who has undergone SLNB. Although SLNB is a less invasive procedure than ALND and results in a shorter recovery period, a patient who has undergone SLNB also has many difficult issues surrounding her breast cancer diagnosis and treatment. The nurse listens, provides emotional support, and refers the patient to appropriate specialists when indicated.

Seroma may occur postoperatively

that of ALND (Krag, Anderson, Julian, et al., 2010). Table 49-5 compares SLNB and ALND. The sentinel lymph node, which is the first node (or nodes) in the lymphatic basin that receives drainage from the primary tumour in the breast, is identified by injecting a radioisotope and/or blue dye into the breast; the radioisotope or dye then travels via the lymphatic pathways to the node. In SLNB, the surgeon uses a hand-held probe to locate the sentinel lymph node, excises it, and sends it for pathologic analysis, which is often performed immediately during the surgery using frozen section analysis. If the sentinel lymph node is positive, the surgeon can proceed with an immediate ALND, thus sparing the patient a return trip to the operating room and additional anesthesia. (The patient could also opt to return for additional surgery at a later time.) If the sentinel lymph node is negative, a standard ALND is not needed, thus sparing the patient the sequelae of the procedure. After the operation is complete, all the specimens are sent to pathology for more thorough analysis.

Nursing Management Patients who undergo SLNB in conjunction with breast conservation are generally discharged the same day. Patients who undergo SLNB with total mastectomy usually stay in the hospital overnight, possibly longer if breast reconstruction is being performed. The patient must be informed that although frozen section analysis is highly accurate, false-negative results can occur. A negative sentinel lymph node on frozen section analysis may show metastatic disease on subsequent analysis, indicating that ALND is still necessary. The patient

!!"##

Nursing Process

The Patient Undergoing Surgery for Breast Cancer Assessment The health history is a valuable tool to assess 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 her educational needs? • Is she experiencing any discomfort?

Diagnosis Preoperative Nursing Diagnoses Based on the health history and other assessment data, major preoperative nursing diagnoses may include the following: • Deficient knowledge about the planned surgical treatments • Anxiety related to the diagnosis of cancer • Fear related to specific treatments and body image changes • Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options • Decisional conflict related to treatment options

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Postoperative Nursing Diagnoses Based on the health history and other assessment data, major postoperative nursing diagnoses may include the following: • Pain and discomfort related to surgical procedure • Disturbed sensory perception related to nerve irritation in affected arm, breast, or chest wall • Disturbed body image related to loss or alteration of the breast • Risk for impaired adjustment related to the diagnosis of cancer and surgical treatment • Self-care deficit related to partial immobility of upper extremity on operative side • 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 ALND

Collaborative Problems/ Potential Complications Based on the assessment data, potential complications may include the following: • Lymphedema • Hematoma/seroma formation • Infection

Planning and Goals The major goals may include increased knowledge about the disease and its treatment; reduction of preoperative and postoperative fear, anxiety, and emotional stress; improvement of decision-making ability; pain management; improvement in coping abilities; improvement in sexual function; and the absence of complications.

Preoperative Nursing Interventions Providing Education and Preparation about Surgical Treatments Patients with newly diagnosed breast cancer are expected to absorb an abundance of new information during a very emotionally difficult time. The nurse plays a key role in reviewing treatment options by reinforcing information provided to the patient and answering any questions. The nurse fully prepares the patient for what to expect before, during, and after surgery. Patients undergoing breast conservation with ALND, or a total or modified radical mastectomy, generally remain in the hospital overnight (or longer if they have immediate reconstruction). Surgical drains will be inserted in the mastectomy incision and in the axilla if the patient undergoes an ALND. A surgical drain is generally not needed after an SLNB. The patient should be informed that she will go home with

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the drain(s) and that complete instructions about drain care will be provided prior to discharge. In addition, the patient is informed that she will often have decreased arm and shoulder mobility after an ALND and that she will be shown range-of-motion exercises prior to discharge. The patient is also reassured that appropriate analgesia and comfort measures will be provided to alleviate any postoperative discomfort.

Reducing Fear and Anxiety and Improving Coping Ability The nurse must help the patient cope with the physical as well as the emotional effects of surgery. Many fears may emerge during the preoperative phase. These can include fear of pain, mutilation (after mastectomy), and loss of sexual attractiveness; concern about inability to care for oneself and one’s family; concern about taking time off from work; and coping with an uncertain future. Providing the patient with realistic expectations about the healing process and expected recovery can help alleviate fears. Maintaining open communication and assuring the patient that she can contact the nurse at any time with questions or concerns can be a source of comfort. The patient should also be made aware of available resources at the treatment facility as well as in the breast cancer community such as social workers, psychiatrists, and support groups. Some women find it helpful and reassuring to talk to a breast cancer survivor who has undergone similar treatments.

Promoting Decision-Making Ability The patient may be eligible for more than one therapeutic approach; she may be presented with treatment options and then asked to make a choice. This can be very frightening for some patients, and they may prefer to have someone else make the decision for them (e.g., surgeon, family member). The nurse can be instrumental in ensuring that the patient and family members truly understand their options. The nurse can then help the patient weigh the risks and benefits of each option. The patient may be presented with the option of having breast conservation treatment followed by radiation or a mastectomy. The nurse can explore the issues with the individual patient by asking questions such as the following: • How would you feel about losing your breast? • Are you considering breast reconstruction? • If you choose to retain your breast, would you consider undergoing radiation treatments 5 days a week for 5 to 6 weeks? Questions such as these can help the patient focus. Once the patient’s decision is made, it is very important to support it.

Postoperative Nursing Interventions Relieving Pain and Discomfort Many patients tolerate the breast surgery quite well and have minimal pain during the postoperative

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NURSING RESEARCH PROFILE

Chart 49-4. Breast Cancer Associated With Long-Term Shift Work in Canada Grundy, A., Richardson, H., Burstyn, I., et al. (2012). Increased risk of breast cancer associated with long-term shift work in Canada. Occupational & Environmental Medicine, 70 (12), 831–838. Purpose Shift work is a risk factor for breast cancer. The study examined the association between women who work night shift for 30 years or more and breast cancer. Design A case-control study was initiated in Vancouver, British Columbia and Kingston, Ontario from 2005 to 2010. Women living in four urban centres, aged 20–80 years, with in situ or invasive breast cancer but no previous cancer history except for nonmelanoma skin cancer were recruited from the British Columbia Cancer Registry. Potential controls were cancer-free women recruited from screening clinics linked with the Screening Mammography Program of British Columbia. Controls were matched to the cases by 5-year age group. Potential participants received study information including a study description, consent form, and questionnaire. Participants either completed the questionnaire or information was collected by telephone interviews in English, Cantonese, Mandarin, or Punjabi. Blood samples were collected and permission was obtained to access medical records related to breast health. Women representing cases and controls were recruited from the Hotel Dieu Breast Assessment Program in Kings-

period. This is particularly true of the less invasive procedures such as breast conservation treatment with SLNB. However, all patients must be carefully assessed, because individual patients can have varying degrees of pain. Patients who have had more invasive procedures such as a modified radical mastectomy with immediate reconstruction may have considerably more pain. All patients are discharged home with analgesic medication (e.g., oxycodone and acetaminophen [Percocet] and are encouraged to take it if needed. An over-the-counter analgesic such as acetaminophen may provide sufficient relief. Sometimes patients report a slight increase in pain after the first few days of surgery; this may occur as patients regain sensation around the surgical site and become more active. However, patients who report excruciating pain must be evaluated to rule out any potential complications such as infection or a hematoma. Alternative methods of pain management such as taking warm showers and using distraction methods (e.g., guided imagery) may also be helpful.

Managing Postoperative Sensations Because nerves in the skin and axilla are often cut or injured during breast surgery, patients experience a variety of sensations. Common sensations include tenderness, soreness, numbness, tightness, pulling, and twinges. These sensations may occur along the chest wall, in the axilla, and along the inside aspect

ton, Ontario. The study coordinator contacted the women to confirm eligibility and sent a study package. All the women self-administered the questionnaire. The questionnaire focused on education, ethnicity, health, medical and reproductive history, family history of cancer, lifestyle characteristics including tobacco and alcohol consumption, lifetime physical activity, and lifetime occupational and residential descriptions. The night shift work exposure assessment was obtained from the occupational account. The total number of years employed on night shift work was calculated for each participant. Findings One third of cases and controls worked night shift. There was an increased breast cancer risk for women employed in night shift for 30 or more years. Night shift work may be a “probably carcinogen.” The largest proportion of long-term night shift workers were health care workers. The results are consistent with other studies about nurses. Nursing Implications Nurses need to be aware that long-term night shift work can have a negative effect on their health. Educators need to include the information about shift work in nursing courses so that nursing students and other health care workers can plan their work hours.

of the upper arm. After mastectomy, some patients experience phantom sensations and report a feeling that the breast or nipple is still present. Chart 49-4 presents specific information from this study. Sensations usually persist for several months and then begin to diminish, although some may persist for as long as 5 years and possibly longer. Patients should be reassured that this is a usual part of healing and that these sensations are not indicative of a problem.

Promoting Positive Body Image Patients who have undergone mastectomy often find it very difficult to view the surgical site for the first time. No matter how prepared the patient may think she is, the appearance of an absent breast can be very emotionally distressing. Ideally, the patient sees the incision for the first time when she is with the nurse or another health care provider who is available for support. The nurse first assesses the patient’s readiness and provides gentle encouragement. It is important to maintain the patient’s privacy while assisting her as she views the incision; this allows her to express 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. Reassuring the patient that her feelings are a usual response to breast cancer surgery

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may be comforting. If the patient has not had immediate reconstruction, providing her with a temporary breast form to place in her bra on discharge can help alleviate feelings of embarrassment or selfconsciousness.

issues because many patients are reluctant or embarrassed to bring it up themselves.

Promoting Positive Adjustment and Coping

LYMPHEDEMA. Lymphedema occurs in patients who undergo ALND and SLNB. Risk factors for lymphedema include increasing age, obesity, presence of extensive axillary disease, chemotherapy, and injury or infection to the extremity (Paskett, Dean, Oliveri, et al., 2012). Lymphedema results if functioning lymphatic channels are inadequate to ensure a return flow of lymph fluid to the general circulation. After axillary lymph nodes are removed, collateral circulation must assume this function. Transient edema in the postoperative period occurs until collateral circulation has completely taken over this function, which generally occurs within a month. Performing prescribed exercises, elevating the arm above the heart several times a day, and gentle muscle pumping (making a fist and releasing) can help reduce the transient edema. The patient needs reassurance that this transient swelling is not lymphedema. Once lymphedema develops, it tends to be chronic, so preventive strategies are vital. After ALND, the patient is taught hand and arm care to prevent injury or trauma to the affected extremity, thus decreasing the likelihood for lymphedema development (Chart 49-5). The patient is instructed to follow these guidelines for the rest of her life. She is also instructed to contact the physician or a nurse immediately if she suspects that she has lymphedema, because early intervention provides the best chance for control. If allowed to progress without treatment, the swelling can become more difficult to manage. Treatment may consist of a course of antibiotics if an infection is present. A referral to a rehabilitation specialist (e.g., occupational or physical therapist) may be necessary for a compression sleeve

Monitoring and Managing Potential Complications

Providing ongoing assessment of how the patient is coping with her diagnosis of breast cancer and her surgical treatment is important in determining her overall adjustment. Assisting the patient in identifying and mobilizing her support systems can be beneficial to her well-being. The patient’s spouse or partner may also need guidance, support, and education. The patient and partner may benefit from a wide network of available community resources, including the Reach to Recovery program of the CCS 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. The patient may also have considerable anxiety about the treatments that will follow surgery (i.e., chemotherapy and radiation) and their implications. Providing her with information about the plan of care and referring her to the appropriate members of the health care team also promote coping during recovery. Some women require additional support to adjust to their diagnosis and the changes that it brings. If a woman displays ineffective coping, consultation with a mental health practitioner may be indicated.

Improving Sexual Function Once discharged from the hospital, most patients are physically allowed to engage in sexual activity. However, any change in the patient’s body image, self-esteem, or the response of her partner may increase her anxiety level and affect sexual function. Some partners may have difficulty looking at the incision, whereas others may be completely unaffected. Encouraging the patient to openly discuss how she feels about herself and about possible reasons for a decrease in libido (e.g., fatigue, anxiety, self-consciousness) may help clarify issues for her. Helpful suggestions for the patient may include varying the time of day for sexual activity (when the patient is less tired), assuming positions that are more comfortable, and expressing affection using alternative measures (e.g., hugging, kissing, manual stimulation). Most patients and their partners adjust with minimal difficulty if they openly discuss their concerns. However, if issues cannot be resolved, a referral for counselling (e.g., psychologist, psychiatrist, psychiatric clinical nurse specialist, social worker, sex therapist) may be helpful. The ambulatory care nurse in the outpatient clinic or hospital should inquire whether the patient is having difficulty with sexuality

CHART 49-5

Patient Education: Hand and Arm Care After Axillary Lymph Node 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 insect 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 2.5–5.0 kg. 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.

• • • • • • •

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or glove, exercises, manual lymph drainage, and a discussion of ways to modify daily activities to avoid worsening lymphedema. HEMATOMA OR SEROMA FORMATION. Hematoma formation (collection of blood inside a cavity) may occur after either mastectomy or breast conservation and usually develops within the first 12 hours after surgery. The nurse assesses for signs and symptoms of a hematoma at the surgical site, which may include swelling, tightness, pain, and bruising of the skin. The surgeon should be notified immediately if there is gross swelling or increased bloody output from the drain. Depending on the surgeon’s assessment, a compression wrap may be applied to the incision for approximately 12 hours, or the patient may be returned to the operating room so that the incision may be reopened to identify the source of bleeding. Some hematomas are small, and the body absorbs the blood naturally. The patient may take warm showers or apply warm compresses to help increase the absorption. A hematoma usually resolves in 4 to 5 weeks. A seroma, a collection of serous fluid, may accumulate under the breast incision after mastectomy or breast conservation or in the axilla. Signs and symptoms may include swelling, heaviness, discomfort, and a sloshing of fluid. Seromas may develop temporarily after the drain is removed or if the drain is in place and becomes obstructed. Seromas rarely pose a threat and may be treated by unclogging the drain or manually aspirating the fluid with a needle and syringe. Large, long-standing seromas that have not been aspirated could lead to infection. Small seromas that are not bothersome to the patient usually resolve on their own. INFECTION. Although infection is rare, it is a risk after any surgical procedure. This risk may be higher in patients with conditions such as diabetes, immune disorders, and advanced age, as well as in those with poor hygiene. Patients are taught to monitor for signs and symptoms of infection (redness, warmth around incision, tenderness, foul-smelling drainage, temperature greater than 40°C, chills) and to contact the surgeon or nurse for evaluation. Treatment consists of

oral or IV antibiotics (for more severe infections) for 1 or 2 weeks. Cultures are taken of any foul-smelling discharge.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients who undergo breast cancer surgery receive a tremendous amount of information preoperatively and postoperatively. It is often difficult for the patient to absorb all of the information, partly because of the emotional distress that often accompanies the diagnosis and treatment. Prior to discharge, the nurse assesses the patient’s readiness to assume self-care responsibilities and identify any gaps in knowledge. A review of teaching, with reinforcement, may be required to ensure that the patient and family are prepared to manage the necessary care at home. The nurse reiterates symptoms the patient should report, such as infection, seroma, hematoma, or arm swelling. All teaching is reinforced during office visits and by telephone. Most patients are discharged 1 or 2 days after ALND or mastectomy (possibly later if they have had immediate reconstruction) with surgical drains in place. Initially, the drainage fluid appears bloody, but it gradually changes to a serosanguineous and then a serous fluid over the next several days. The patient is given instructions about drainage management at home (Chart 49-6). If the patient lives alone and drainage management is difficult, a referral for a home care nurse should be made. The drains are usually removed when the output is less than 30 mL in a 24-hour period (approximately 7 to 10 days). The home care nurse also reviews pain management and incision care. Generally, the patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed. A dry dressing may be applied to the incision each day for 7 days. The patient should realize that sensation may be decreased in the operative

CHART 49-6

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:

Patient

Caregiver

• Demonstrate how to empty and measure fluid from the drainage device.

✔

✔

• Demonstrate how to milk clots through the tubing of the drainage device.

✔

✔

• State observations that require contacting the physician or nurse (e.g., sudden change in

✔

✔

• 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

✔

✔

colour of drainage, sudden cessation of drainage, signs or symptoms of an infection).

24-hour period).

CHAPTER 49

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Assessment and Management of Patients With Breast Disorders

area because the nerves were disrupted during surgery and should be informed that gentle care is needed to avoid injury. After the incision has completely healed (usually after 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity. The patient can begin to use deodorant on the affected side, although many women note that they no longer perspire as much as before the surgery. After ALND, patients are taught arm exercises on the affected side to restore range of motion (Chart 49-7). After SLNB, patients may also benefit from these exercises, although they are less likely to have decreased range of motion than those who have undergone ALND. Range-of-motion exercises are initiated on the second postoperative day, although instruction often 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 full range of motion. The patient is instructed to perform range-of-motion exercises at home three times a day for 20 minutes at a time until full range of motion is restored (generally 4 to 6 weeks). Most patients find that after the drain is removed, range of motion returns quickly if they have adhered to their exercise program. If the patient is having any discomfort, taking an analgesic 30 minutes before beginning the exercises can be helpful. Taking a warm shower before exercising can also loosen stiff muscles and provide comfort. When exercising, the patient is encouraged to use the muscles in both arms and to maintain proper posture. Specific exercises may need to be prescribed and introduced gradually if the patient has had skin grafts; has a tense, tight surgical incision; or has had immediate reconstruction. Self-care activities, such as brushing the teeth, washing the face, and brushing the hair, are physically and emotionally therapeutic because they aid in restoring arm function and provide a sense of normalcy for the patient. The patient is instructed about postoperative activity limitation. Generally, heavy lifting (more than 2 to 4 kg) is avoided for about 4 to 6 weeks, although normal household and work-related activities are promoted to maintain muscle tone. Brisk walking, use of stationary bikes and stepping machines, and stretching exercises may begin as soon as the patient feels comfortable. Once the drain is removed, the patient may begin to drive if she has full arm range of motion and is no longer taking opioid analgesics. General guidelines for activity focus on the gradual introduction of previous activities (e.g., bowling, weight training) once fully healed, although checking with the physician or nurse beforehand is recommended. CONTINUING CARE. Patients who have difficulty managing their postoperative care at home may benefit from a home health care referral. The home care nurse assesses the patient’s incision and surgical drain(s), adequacy of pain management, adherence to the exercise plan, and overall physical and psychological functioning. In addition, the home care nurse

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reinforces previous teaching and communicates important physiologic findings and psychosocial issues to the patient’s primary care provider, nurse, or surgeon. The frequency of follow-up visits after surgery may vary but generally should occur every 3 to 6 months for the first several years. The patient may alternate visits with the surgeon, medical oncologist, or radiation oncologist, depending on the treatment regimen. The home care nurse can also be a great source of comfort and security for the patient and family and should encourage them to telephone if they have any questions or concerns. It is common for people to ignore routine health care when a major health issue arises, so women who have been treated for breast cancer are reminded of the importance of participating in routine health screening.

Evaluation Expected Preoperative Patient Outcomes Expected preoperative patient outcomes may include: 1. Exhibits knowledge about diagnosis and surgical treatment options a. Asks relevant questions about diagnosis and available surgical treatments b. States rationale for surgery 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 self-image 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. Makes 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 2. Identifies postoperative sensations and recognizes that they are a normal part of healing 3. Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection 4. Lists the signs and symptoms of infection to be reported to the nurse or surgeon 5. Verbalizes feelings regarding change in body image 6. Discusses meaning of the diagnosis, surgical treatment, and fears appropriately 7. Participates actively in self-care measures a. Performs exercises as prescribed b. Participates in self-care measures as prescribed

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CHART 49-7

Patient Education: Exercise 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 ft apart. Keeping the arms straight, raise the rod over the head. Bend elbows to lower the rod behind the head. Reverse manoeuvre, 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.

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 (e.g., redness, heat, pain, edema) b. Explains how to contact appropriate health care professionals in case of complications

CHAPTER 49

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Assessment and Management of Patients With Breast Disorders

CHART 49-8

Contraindications to BreastConservation 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 tumour-to-breast ratio • Tumour beneath nipple

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more positive lymph nodes, tumours larger than 5 cm, positive surgical margins).

Side Effects Generally, radiation therapy is well tolerated. Acute side effects consist of mild to moderate erythema, breast edema, and fatigue. Occasionally, skin breakdown may occur in the inframammary fold or near the axilla toward the end of treatment. Fatigue can be depressing, as can the frequent trips to the radiation oncology site for treatment. The patient needs to be reassured that the fatigue is usual and not a sign of recurrence. Side effects usually resolve within a few weeks to a few months after treatment is completed. Rare long-term effects of radiation therapy include pneumonitis, rib fracture, and breast fibrosis.

Nursing Management

Radiation Therapy Radiation therapy is used to decrease the chance of a local recurrence in the breast by eradicating residual microscopic cancer cells. If radiation therapy, which is part of breast conservation treatment (Chart 49-8), is contraindicated, a mastectomy would then be indicated. External-beam radiation (the most common type) typically begins about 6 weeks after breast conservation to allow the surgical site to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after its completion. Before radiation begins, the patient undergoes a planning session called a simulation in which the anatomic areas to be treated are mapped out and then identified with small permanent ink markings. External-beam radiation, which delivers high-energy photons from a linear accelerator, is administered to the entire breast region (whole breast radiation). Each treatment lasts only a few minutes and is generally given 5 days a week for 5 to 6 weeks. After completion of radiation to the entire breast, many patients receive a “boost,” a dose of radiation to the lumpectomy site where the cancer cells were located. The boost consists of the same dose of radiation but is less penetrating and directed to a smaller area. The treatments are not painful. Because most breast cancer recurrences appear at or near the lumpectomy site, the need for whole breast radiation is now being questioned. Partial breast radiation (radiation to the lumpectomy site alone) is now being evaluated at some institutions in carefully selected patients. One approach is brachytherapy, which delivers partial breast radiation by placing a radioactive source within the lumpectomy site. This technique can lead to an improved quality of life because the treatments are administered over 4 to 5 days instead of 5 to 6 weeks. Another approach is intraoperative radiation therapy (IORT), in which a single intense dose of radiation is delivered to the surgical site in the operating room immediately following the lumpectomy. Many questions remain unanswered, and longer follow-up with larger studies is needed to document the long-term effectiveness and potential side effects of these techniques. In the meantime, whole breast radiation remains the standard treatment of choice. Although not widely used today after mastectomy, postoperative radiation is indicated for women at high risk for cancer recurrence (i.e., chest wall involvement, four or

Self-care instructions for patients receiving radiation are provided to assist in the maintenance of skin integrity during the treatments and for several weeks after completion. They pertain only to the area being treated and not to the rest of the body. • 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 pruritus occurs. • Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light. Follow-up care includes teaching the patient to minimize sun exposure to the treated area (i.e., using sunblock with sun protection factor [SPF] 15 or above) and reassuring the patient that minor twinges and shooting pain in the breast are usual after radiation treatment.

Systemic Treatments Chemotherapy Adjuvant chemotherapy involves the use of anticancer agents in addition to other treatments (i.e., surgery, radiation) to delay or prevent a recurrence of breast cancer. It is recommended for patients who have positive lymph nodes or who have invasive tumours greater than 1 cm in size, regardless of nodal status. It is considered in patients with tumours that are 0.6 cm to 1 cm, are moderately to poorly differentiated, or have unfavourable features (NCCN, 2014). Table 49-6 outlines general indications for adjuvant chemotherapy. A survival benefit has been shown in premenopausal and postmenopausal women who received chemotherapy, although data are limited in women older than 70 years of age. Chemotherapy is most commonly initiated after breast surgery and before radiation. Chemotherapy regimens for breast cancer combine several agents (polychemotherapy), generally administered over a period of 3 to 6 months. Decisions regarding the optimal regimen are based on a variety of factors, including tumour characteristics (i.e., tumour size, lymph node status, hormone receptor status, HER-2/neu status) and the patient’s age, physical status, and existing comorbid conditions. A

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TABLE 49-6

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General Indications for Adjuvant Chemotherapy for Breast Cancer

Nodal Status, Tumour Size

Adjuvant Chemotherapy

Node negative, 0.5 cm or less Node negative 0.6–1 cm (well differentiated) Node negative, 0.6–1 cm (moderately or poorly differentiated and/or unfavourable features) Node negative, greater than 1 cm Node positive, any tumour size

None None Consider chemotherapy

Chemotherapy Chemotherapy

• In addition to chemotherapy, patients with HER-2/neu positive tumours will receive trastuzumab if they have node positive disease; or node negative disease with a tumour greater than 1 cm. Trastuzumab is a monoclonal antibody that targets and inactivates the HER-2/neu protein. HER-2/neu is overproduced in 25–30% of tumours and is associated with rapid growth and poor prognosis. • Following chemotherapy, patients with hormone receptor positive (ER+/PR+) tumours will receive hormonal therapy (tamoxifen or aromatase inhibitor) if they have either node positive disease; node negative disease with a tumour >1 cm; or node negative with a tumour 0.6–1 cm and moderately or poorly differentiated and/or unfavourable features. Note: These are only general guidelines. Recommendations may vary depending on factors such as prognostic variables, patient age, and comorbid conditions.

regimen that includes cyclophosphamide (Cytoxan), methotrexate (Trexall), and fluorouracil (Fluoroplex) (CMF) has been the most widely used adjuvant therapy. It is usually well tolerated and may be considered for patients with a low risk of recurrence. CMF also may be considered for use in patients who have a high risk for cardiac toxicity (a potential side effect of anthracycline-based regimens) or who have other limiting comorbidities. The taxanes (paclitaxel [Taxol], docetaxel [Taxotere]) are generally incorporated into treatment regimens for patients with larger, node-negative cancers and for those with positive axillary lymph nodes. The addition of four cycles of paclitaxel after a standard course of AC (regimen known as ACT) has been found to increase the diseasefree period and improve overall survival in patients with operable breast cancer and positive lymph nodes (Shulman, Cirrincione, Berry, et al., 2012). Much attention has been focused on dose-dense chemotherapy, the administration of chemotherapeutic agents at standard doses with shorter time intervals between each cycle of treatment. Patients who received ACT every 2 weeks, compared with those who received it on the conventional schedule of every 3 weeks, had an improved disease-free and overall survival. Long-term follow-up of this study and other clinical trials are ongoing to determine optimal treatment regimens, doses, and timing. SIDE EFFECTS. Today, many of the side effects of adjuvant chemotherapy can be managed well, allowing patients to maintain their daily routines and work schedules. In large part, this has been a result 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. In addition, strides have been made in the effectiveness of antiemetic agents used to alleviate nausea and vomiting and the use of hematopoietic growth factors to treat neutropenia and anemia. Common physical side effects of chemotherapy for breast cancer may include nausea, vomiting, bone marrow

suppression, taste changes, alopecia (hair loss), mucositis, neuropathy, skin changes, and fatigue. A weight gain of more than 4 kg occurs in about half of all patients; the cause is unknown. Premenopausal women may also experience temporary or permanent amenorrhea. Specific side effects vary with the type of chemotherapeutic agent used. In general, CMF and the taxanes are better tolerated than the anthracyclines. However, the taxanes can cause peripheral neuropathy, arthralgias, and myalgias, particularly at high doses. During taxane administration, hypersensitivity reactions may occur; therefore, the patient must be premedicated. Alopecia is also common. The side effects of the anthracyclines may be severe and include cardiotoxicity in addition to nausea and vomiting, bone marrow suppression, and alopecia. Their vesicant properties can lead to tissue necrosis if infiltration of the medication infusion occurs. NURSING MANAGEMENT. Nurses play an important role in helping patients manage the physical and psychosocial sequelae of chemotherapy. (Chapter 17 provides an in-depth discussion of side-effect management.) Instructing the patient about the use of antiemetics and reviewing the optimal dosage schedule can help minimize nausea and vomiting. The different classes of antiemetic agents include serotonin (5-HT-3) receptor antagonists (palonosetron [Aloxi], granisetron [Kytril], ondansetron [Zofran]); neurokinin-1 receptor antagonists (aprepitant [Emend]); dopamine receptor antagonists (prochlorperazine [Compazine], metoclopramide [Reglan]); benzodiazepines (lorazepam [Ativan]); and corticosteroids (dexamethasone [Decadron]). Measures to ease the symptoms of mucositis may include rinsing with normal saline or sodium bicarbonate solution, avoiding hot and spicy foods, and using a soft toothbrush. Some patients may require hematopoietic growth factors to minimize the effects of chemotherapy-induced neutropenia and anemia. Granulocyte colony-stimulating factors (G-CSFs) boost the white blood cell count, helping reduce the incidence of neutropenic fever and infection. The short-acting form, filgrastim (Neupogen), is injected subcutaneously for 7 to 10 days after chemotherapy administration. The long-acting form, pegfilgrastim (Neulasta), is injected once, 24 hours after chemotherapy. Erythropoietin growth factor increases the production of red blood cells, thus decreasing the symptoms of anemia. The shortacting form, epoetin alfa (Epogen) is usually administered weekly. The long-acting form, darbepoetin alfa (Aranesp), can be administered every 2 to 3 weeks. The nurse instructs the patient and family on proper injection technique of hematopoietic growth factors and about symptoms that require follow-up with a physician (Chart 49-9). To prevent some of the emotional trauma associated with alopecia, it often helps to have a patient obtain a wig before hair loss begins to occur. The nurse may provide a list of wig suppliers in the patient’s geographic region. Familiarity with creative ways to use scarves and turbans may also help minimize the patient’s distress. The patient needs reassurance that new hair will grow back when treatment is completed, although the colour and texture may be different. The CCS offers a program called Look Good, Feel Better that provides useful tips for applying cosmetics during the period a patient is receiving chemotherapy.

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CHART 49-9

HOME CARE CHECKLIST •

Self-Administration of Hematopoietic Growth Factors

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• State the purpose for the injections.

✔

✔

• Identify the equipment necessary for self-injection.

✔

✔

• Identify appropriate body sites for self-injection.

✔

✔

• Demonstrate how to draw up the solution in a syringe if indicated (note: darbepoetin and

✔

✔

• Demonstrate how to give an injection properly.

✔

✔

• State possible side effects of medication.

✔

✔

• Demonstrate correct disposal of sharps.

✔

✔

• Describe proper storage of supplies.

✔

✔

• State reasons for contacting the physician or nurse (e.g., excessive pain, fever).

✔

✔

pegfilgrastim come in prefilled syringes).

Chemotherapy may negatively affect the patient’s selfesteem, sexuality, and sense of well-being. This, combined with the stress of a potentially life-threatening disease, can be overwhelming. Providing support and promoting open communication are important aspects of nursing care. Referring the patient to the dietitian, social worker, psychiatrist, or spiritual advisor can provide additional support. Numerous community support and advocacy groups are available for patients and their families. Complementary therapies, such as guided imagery, meditation, and relaxation exercises, can also be used in conjunction with conventional treatments.

Hormonal Therapy The use of adjuvant hormonal therapy, with or without the addition of chemotherapy, is considered in women who have hormone receptor–positive tumours. Its use can be determined by the results of an estrogen and progesterone receptor assay. About two thirds of breast cancers are dependent on estrogen for growth and express a nuclear receptor that binds to the estrogen; thus, they are estrogen receptor–positive (ER+). Similarly, tumours that express the progesterone receptor are progesterone receptor– positive (PR+). Hormonal therapy involves the use of medications that compete with estrogen by binding to the receptor sites (selective estrogen receptor modulators [SERMs]), or by blocking estrogen production (aromatase inhibitors). Generally, tumours that are ER+/PR+ have the greatest likelihood of responding to hormonal therapy and have a more favourable prognosis than those that are ER–/ PR–. Premenopausal and perimenopausal women are more likely to have non–hormone-dependent lesions, whereas postmenopausal women are more likely to have hormone-dependent lesions. Traditionally, the SERM tamoxifen has been the primary hormonal agent used in treatment of premenopausal and postmenopausal breast cancer and remains the mainstay in premenopausal women. As a SERM, tamoxifen has

estrogen antagonistic (estrogen-blocking) and agonistic (estrogen-like) effects on certain tissues. Its antagonistic effects in the breast prevent estrogen from binding to the receptor sites, thus preventing tumour growth. Tamoxifen has positive agonistic effects on blood lipid profiles and bone mineral density in postmenopausal women. It also has agonistic effects on endometrial tissue and blood coagulation processes, leading to an increased incidence of endometrial cancer and thromboembolic events (e.g., deep vein thrombosis, superficial phlebitis, pulmonary embolism). Nevertheless, the benefits of tamoxifen in most women with breast cancer outweigh the risks. The aromatase inhibitors anastrazole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are important components in the hormonal management of postmenopausal women. Most of the circulating estrogens in postmenopausal women are derived from the conversion of the adrenal androgen androstenedione to estrone and the conversion of testosterone to estradiol. Aromatase inhibitors work by blocking the enzyme aromatase from performing the conversion, thereby decreasing the level of circulating estrogen in peripheral tissues. Clinical trials have demonstrated that the aromatase inhibitors are superior to tamoxifen in terms of disease-free survival. Benefits were seen in postmenopausal patients who received an aromatase inhibitor as cognitive function was not adversely impacted in comparison with tamoxifen, but the risk of decline in bone mineral density and bone fractures increased (Montagna, Cancello, & Colleoni, 2013). Table 49-7 outlines the adverse effects of adjuvant hormonal therapy. Chart 49-10 outlines appropriate patient education to manage the adverse effects.

Targeted Therapy One of the most exciting areas of research in the systemic treatment of breast cancer involves the use of targeted therapies. Trastuzumab (Herceptin) is a monoclonal antibody that binds specifically to the HER-2/neu protein.

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TABLE 49-7

UNIT 10

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Reproductive Function

Adverse Reactions Associated With Adjuvant Hormonal Therapy Used to Treat Breast Cancer

Therapeutic Agent

Patient Education: Managing Side Effects of Adjuvant Hormonal Therapy in Breast Cancer

Adverse Reactions/Side Effects

Selective Estrogen Receptor Modulator Tamoxifen (Nolvadex) Hot flashes, vaginal dryness/discharge/ bleeding, irregular menses, nausea, mood disturbances; increased risk for endometrial cancer; increased risk for thromboembolic events (deep vein thrombosis, pulmonary embolism, superficial phlebitis) Aromatase Inhibitors Anastrozole (Arimidex)

CHART 49-10

Musculoskeletal symptoms (arthritis, arthralgia, myalgia), increased risk of osteoporosis/fractures, nausea/ vomiting, hot flashes, fatigue, mood disturbances

Letrozole (Femara) Exemestane (Aromasin) Patients with breast cancer who are younger, have poor physical performance and who are treated with chemotherapy will experience more intense gastrointestinal and psychoneurological symptoms during treatment (Kim, Barsevick, & Tulman, 2009).

This protein, which regulates cell growth, is present in small amounts on the surface of normal breast cells and in most breast cancers. Approximately 25% to 30% of tumours overexpress (overproduce) the HER-2/neu protein and are associated with rapid growth and poor prognosis. Trastuzumab targets and inactivates the HER-2/neu protein, thus slowing tumour growth. Unlike chemotherapy, trastuzumab spares the normal cells and has limited adverse reactions, which may include fever, chills, nausea, vomiting, diarrhea, and headache. However, when trastuzumab is administered to patients who have previously been treated with an anthracycline, the risk of cardiac toxicity is increased. The medication has been shown to improve survival rates in women with HER-2/ neu–positive metastatic breast cancer and is now regarded as standard therapy. It may be administered as a single agent or in combination with chemotherapy. More recently, trastuzumab has been shown to be effective in treating early-stage breast cancer that is HER-2/neu positive. However, up to a quarter of the women relapse within 3 years, indicating the need for more clinical research (Dueck, Reinholz, Geiger, et al., 2013).

Treatment of Recurrent and Metastatic Breast Cancer Despite the advances made in the treatment of breast cancer, it may recur locally (on the chest wall or in the conserved breast), regionally (in the remaining lymph nodes), or systemically (in distant organs). In metastatic disease, the bone, usually the hips, spine, ribs, skull, or pelvis, is the most common site of spread. Other sites of metastasis include the lungs, liver, pleura, and brain. The overall prognosis and optimal treatment are determined by a variety of factors such as the site and extent of recurrence, the time to recurrence from the original diagnosis, history of prior treatments, the patient’s performance

Hot Flashes • • • •

Wear breathable, layered clothing (e.g., cotton). Avoid caffeine and spicy foods. Perform breathing exercises (paced respirations). Consider medications (vitamin E, antidepressants) or acupuncture.

Vaginal Dryness • Use vaginal moisturizers for everyday dryness (e.g., Replens, Vitamin E suppository).

• Apply vaginal lubrication during intercourse (e.g., Astroglide, K-Y jelly).

Nausea and Vomiting • Consume a bland diet. • Try to take medication in the evening.

Musculoskeletal Symptoms • Take nonsteroidal analgesics as recommended. • Take warm baths.

Risk of Endometrial Cancer • Report any irregular bleeding to a gynecologist for evaluation.

Risk for Thromboembolic Events • Report any redness, swelling, or tenderness in the lower extremities, or any unexplained shortness of breath.

Risk for Osteoporosis or Fractures • • • •

Undergo a baseline bone density scan. Perform regular weight-bearing exercises. Take calcium supplements with vitamin D. Take bisphosphonates (e.g., alendronate) or calcitonin as prescribed.

status, and any existing comorbid conditions. Patients with bone metastases generally have a longer overall survival compared with metastases in visceral organs. Local recurrence in the absence of systemic disease is treated aggressively with surgery, radiation, and hormonal therapy. Chemotherapy may also be used for tumours that are not hormonally sensitive. Local recurrence may be an indicator that systemic disease will develop in the future, particularly if it occurs within 2 years of the original diagnosis. Metastatic breast cancer involves control of the disease rather than cure. Treatment includes hormonal therapy, chemotherapy, and targeted therapy. Surgery or radiation may be indicated in select situations. Premenopausal women who have hormonally dependent tumours may eliminate the production of estrogen by the ovaries through oophorectomy (removal of the ovaries) or suppression of estrogen production by medications such as leuprolide (Lupron) or goserelin (Zoladex). Patients with advanced breast cancer are monitored closely for signs of disease progression. Baseline studies are obtained at the time of recurrence. These may include complete blood count; comprehensive metabolic panel;

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tumour markers (i.e., carcinoembryonic antigen, cancer antigen 15-3); bone scan; CT of the chest, abdomen, and pelvis; and MRI of symptomatic areas. Additional x-rays may be performed to evaluate areas of pain or abnormal areas seen on bone scan (e.g., long bones, pelvis). These studies are repeated at regular intervals to assess for effectiveness of treatment and to monitor progression of disease.

Nursing Management Nurses play an important role in not only educating patients and managing their symptoms but also in providing emotional support. Many patients find that recurrence of the disease is more distressing than the initial cancer diagnosis. They not only have to contend with another round of treatments but are faced with a greater uncertainty about their future and long-term survival. The nurse can help the patient identify coping strategies and set priorities to optimize quality of life. Family members and significant others should be included in the treatment plan and follow-up care. Referrals to support groups, psychiatry or psychiatric clinical nurse specialist, social work, and complementary medicine programs (e.g., guided imagery, meditation, yoga) should be made as indicated. Nurses also play important roles in providing palliative care, if indicated. The highest priorities should include alleviating pain and providing comfort measures. A frank discussion with the patient and family regarding their preferences for end-of-life care should occur before the need arises to ensure a smooth transition without disruption of care. Referrals to hospice and home health care should be initiated as necessary. Chapter 17 provides more information on the general care of the patient with advanced cancer. Chapter 18 discusses end-of-life care.

Reconstructive Procedures After Mastectomy Breast reconstruction can provide a significant psychological benefit for women who are already struggling with the emotional distress of losing a breast. A consultation with a plastic surgeon can help the patient understand procedures for which she is a candidate and the pros and cons of each. Factors to consider include body size and shape, comorbid conditions (e.g., hypertension, diabetes mellitus, obesity), personal habits such as smoking, and patient preference. The patient must be informed that although breast reconstruction can provide a good cosmetic result, it will never precisely duplicate the natural breast. Realistic preparation can help the patient avoid unrealistic expectations. Once reconstruction is complete, the opposite breast may require augmentation, reduction, or mastopexy to achieve symmetry on both sides. The patient must also be informed that breast reconstruction neither will interfere with breast cancer treatments nor affect the risk of cancer recurrence. Reconstruction is considered an integral component in the surgical treatment of breast cancer and is usually covered by provincial and territorial health plans. Many women elect immediate reconstruction at the time of the mastectomy operation. This can be beneficial in that it saves the woman from undergoing general

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anesthesia a second time and it saves the cost and stress of future hospitalizations. However, it does increase the length of the surgical procedure. Delayed reconstruction is preferable in women who are having a difficult time deciding on the type of reconstruction they desire. It may also be preferable in patients with advanced disease such as inflammatory breast cancer, where the breast cancer treatments should begin without delay. Any delays in healing after immediate reconstruction may interfere with the initiation of treatment.

Tissue Expander Followed by Permanent Implant Breast reconstruction using a tissue expander followed by a permanent implant is the simplest and most common method used today (Fig. 49-7). To accommodate an implant, the skin remaining after a mastectomy and the underlying muscle must gradually be stretched by a process called tissue expansion. The surgeon places a balloonlike device called a tissue expander through the mastectomy incision underneath the pectoralis muscle. A small amount of saline is injected through a metal port intraoperatively to partially inflate the expander. Then, for about 6 to 8 weeks, at weekly intervals, the patient receives additional saline injections through the port until the expander is fully inflated. It remains fully expanded for about 6 weeks to allow the skin to loosen. The expander is then exchanged for a permanent implant. This is usually performed as an outpatient surgical procedure. Advantages of this expansion procedure are a shorter operating time and a shorter recuperation period than for autologous reconstruction (see Tissue Transfer Procedures below). A disadvantage is a tendency for the implant to feel firm and round, with little natural ptosis (sag). Women with a small to medium opposite breast with little ptosis are good candidates for this procedure. Women who have had radiation or who have connective tissue disease are not good candidates because of the decreased elasticity of the skin.

!

NURSING ALERT

The patient must be cautioned not to have an MRI while the tissue expander is in place because the port contains metal. This is not an issue once the permanent implant is in place because it does not contain any metal.

The patient should be informed that for the rest of her life she should not engage in any exercises that will develop the pectoralis muscle because this can result in distortion of the reconstructed breast.

Tissue Transfer Procedures Autologous reconstruction is the use of the patient’s own tissue to create a breast mound. A flap of skin, fat, and muscle with its attached blood supply is rotated to the mastectomy site to create a mound that simulates the breast. Donor sites may include the transverse rectus abdominis myocutaneous (TRAM) flap (abdominal muscle) (Fig. 49-8), gluteal flap (buttock muscle), or the latissimus dorsi flap (back muscle) (Fig. 49-9). The results

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A

B

C

more closely resemble a real breast because the skin and fat from the donor sites are similar in consistency to a natural breast. These procedures avoid the use of synthetic material. However, they are far more complex and involve longer operative time (ranging from about 5 to 10 hours total time for the mastectomy and reconstruction) and longer recuperation than a tissue expander procedure. The risk of potential complications (e.g., infection, bleeding, flap necrosis) is also greater. Therefore, patients must be in relatively good health, and those with medical conditions (e.g., atherosclerosis, pulmonary disease, heart failure) that affect circulation or compromise oxygen delivery are not good candidates. Other poor candidates include those with uncontrolled type 1 diabetes mellitus or morbid obesity and heavy smokers. The TRAM flap is the most commonly performed tissue transfer procedure. A free TRAM procedure may also be performed; in this case, the skin, fat, muscle, and blood supply are completely detached from the body and then transplanted to the mastectomy site using microvascular surgery (use of a microscope to reconnect the vessels). Postoperatively, patients who have undergone TRAM procedures often face a lengthy recovery (often 6 to 8 weeks)

A

B

tion with tissue expander. A, Mastectomy incision line prior to tissue expansion. B, The expander is placed under the pectoralis muscle and is gradually filled with saline solution through a port to stretch the skin enough to accept a permanent implant. C, The breast mound is restored. Although permanent, scars will fade with time. The nipple and areola are reconstructed later. (Adapted from Breast reconstruction. Arlington Heights, IL: American Society of Plastic and Reconstructive Surgeons.)

and have incisions both at the mastectomy site and at the donor site in the abdomen. The nurse must assess the newly constructed breast site for changes in colour, circulation, and temperature because flap loss is a potential complication. Mottling or an obvious decrease in skin temperature is reported to the surgeon immediately. Breathing and leg exercises are essential because the patient is more limited in her activity and is at greater risk for respiratory complications and deep vein thrombosis. Measures to help the patient reduce tension on the abdominal incision during the first postoperative week include elevating the head of the bed 45 degrees and flexing the patient’s knees. Once the patient is able to ambulate, she can protect the surgical incision by splinting it and will gradually achieve a more upright position. The patient is instructed to avoid high-impact activities and lifting (more than 2 to 4 kg for 6 to 8 weeks after surgery) to prevent stress on the incision.

Nipple–Areola Reconstruction After the breast mound has been created and the site has healed, some women choose to have nipple–areola

A

B

FIGURE 49-9. Breast reconstruction: Latissimus dorsi flap. A, The latFIGURE 49-8. Breast reconstruction: Transverse rectus abdominis

myocutaneous (TRAM) flap. A, A breast mound is created by tunneling abdominal skin, fat, and muscle to the mastectomy site. B, Final location of scars. (Adapted from Breast reconstruction. Arlington Heights, IL: American Society of Plastic and Reconstructive Surgeons.)

issimus muscle with an ellipse of skin is rotated from the back to the mastectomy site. B, Because the flap is usually not bulky enough to provide an adequate breast mound, an implant is often also required. (Adapted from Breast reconstruction. Arlington Heights, IL: American Society of Plastic and Reconstructive Surgeons.)

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reconstruction. This is a minor surgical procedure carried out either in the physician’s office or at an outpatient surgical facility. The most common method of creating a nipple is with the use of local flaps (skin and fat from the centre of the new breast mound), which are wrapped around each other to create a projecting nipple. The areola is created using a skin graft. The most common donor site is the upper inner thigh because this skin has darker pigmentation than the skin on the reconstructed breast. After the nipple graft has healed, micropigmentation (tattooing) can be performed to achieve a more natural colour. The surgeon can usually match the reconstructed nipple– areola complex with that of the contralateral breast for an acceptable cosmetic result.

Prosthetics Not all patients desire or are candidates for reconstructive surgery. A breast prosthesis, an external form that simulates the breast, is another option. Prostheses are available in different shapes, sizes, colours, and materials, although they are most often made of silicone. They can be placed inside a pocket in a bra or can adhere directly to the chest wall. The nurse can provide the patient with the names of stores where she can be fitted for a prosthesis, or the patient can call the Reach to Recovery program of the CCS for appropriate referrals. The patient should be encouraged to find a store with a comfortable, supportive atmosphere that employs a certified prosthetics consultant. Generally, medical supply shops are not recommended because often they do not have the appropriate resources to ensure the proper fitting of a prosthesis. Prior to discharge from the hospital, the nurse usually provides the patient with a temporary, lightweight, cottonfilled form that can be worn until the surgical incision is well healed (4 to 6 weeks). After that, the patient can be fitted for a prosthesis and the special bras that hold it in place. A breast prosthesis can provide a psychological benefit and assist the woman in resuming proper posture because it helps balance the weight of the remaining breast.

Special Issues in Breast Cancer Management Implications of Genetic Testing The rapid advancement in genetics has brought new knowledge about genetically inherited breast cancer, but it has also raised potential ethical and psychosocial issues. Although the actual testing for the BRCA1 and BRCA2 genes involves a simple blood test, it is these issues that must be addressed. Before undergoing genetic testing, a person should meet either with a clinician who has expertise in this area or with a certified genetics counsellor to discuss risk factors as well as the benefits, sequelae, and limitations of testing. People considering testing must be informed that there is no guarantee that test results will remain confidential. Once confidentiality is breached, it could unleash potential discrimination in employment and insurability. There are laws now, however, in many provinces to protect the individual if this should happen. People must be well informed of all of the issues and potential implications prior to undergoing genetics testing. Nurses

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play a role in educating and counselling patients and their family members about the implications of genetic testing. Nurses provide support and clarification and make referrals to appropriate specialists when indicated. How people react when they receive their actual test results is not always easy to predict. A negative test in a person who comes from a family with a known mutation may lead to enormous relief. However, a negative test in a family with no known mutation may be a source of undue reassurance; the possibility of existing genes that cannot yet be detected remains. A negative test may also lead to feelings of guilt in a person whose family members did not receive favourable test results (Crotser & Dickerson, 2010); this is known as survivor’s guilt. A positive test could act as a motivator in a person to pursue appropriate screening or treatment, or it could cause tremendous anxiety, depression, and worry. In addition, test results may be ambiguous, leading to feelings of confusion and uncertainty. People must be informed that not all gene carriers develop breast cancer (incomplete penetrance) and that not all noncarriers are protected. Difficult ethical questions arise concerning whether the person who is tested should disclose the test results. Is it ethical to withhold results from family members who may be at risk? If they are told, what effect will it have on them? The person giving the news of her positive genetic test for breast cancer found it “distressing when the recipient does not react emotionally of respond behaviourly as the informer desires or expects.” (Crotser & Dickerson, 2010, p. 368). Another issue is when and how to communicate genetic test results to their children (Clarke, Butler, & Esplan, 2008). Hamilton, Williams, Skirton, et al. (2009) interviewed women 4 years after genetic testing for breast or ovarian cancer. The women described their lives as an “ongoing process of balancing the risks with living a normal life” (p. 276).

Pregnancy and Breast Cancer Breast cancer during pregnancy is defined as breast cancer diagnosed during gestation and occurs in 1 in 3000 women (CCS, 2014). Because of increased levels of hormones produced during pregnancy and subsequent lactation, the breast tissue becomes tender and swollen, making it more difficult to detect a mass. If a mass is found during pregnancy, ultrasound is the preferred diagnostic method because it involves no exposure to radiation. If indicated, mammography with appropriate shielding, FNA, and biopsy can be performed. Modified radical mastectomy remains the most common form of surgical treatment. SLNB is typically not performed because of the unknown effects of the radioisotope and the blue dye on the fetus. Breast conservation treatment may be considered if the breast cancer is diagnosed during the third trimester. Radiation can then be delayed until after delivery because it is contraindicated during pregnancy. Chemotherapy should be avoided during the first trimester; the fetal organs are still developing, and it poses a great risk for fetal malformations. However, chemotherapy has been administered during the second and third trimesters with few reported abnormalities. Long-term effects on the fetus are still being studied. If a woman is close to term, a cesarean section may be performed as soon as maturation of the fetus allows,

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and then treatment is initiated. If aggressive disease is detected early in pregnancy and chemotherapy is advised, termination of the pregnancy may be considered. If a mass is found while a woman is breastfeeding, she is urged to stop to allow the breast to involute (return to its baseline state) before any type of surgery is performed. Fertility issues and the future desire for children are major concerns of young breast cancer survivors. Certain chemotherapeutic agents, particularly cyclophosphamide, can lead to amenorrhea. Even if the woman is still fertile, many physicians recommend postponing pregnancy for 2 to 3 years after primary treatment because recurrence rates are the highest during this time. Women taking tamoxifen for 5 years are cautioned to avoid pregnancy because of potential effects on the fetus. This waiting period may make it more difficult for the woman to later become pregnant as she advances in age. These issues are discussed with the patient prior to initiating treatment. Fertile Future, a national nonprofit organization, can also provide updated information on reproduction (see Resources at the end of the chapter).

determining factor. Many older women, regardless of their advancing chronological age, remain in excellent health. Therefore, the woman’s treatment preferences should play a strong role in the decision-making process. It should not be assumed that older women are less concerned about their appearance than their younger counterparts. Research on this topic is limited and it may be beneficial to offer breast reconstruction surgery to older patients (Walton, Ommen, & Audisio, 2011). Nurses can play an important role in conducting research on this older population, thus adding to the knowledge base. A thorough assessment is performed before any treatment is initiated, and careful monitoring must occur throughout the course of treatment to avoid complications. The physical and psychosocial assessment of the older woman includes general health, currently existing comorbidities, performance status, cognitive status, current medications, available resources, and support systems.

Quality of Life and Survivorship

Women with a variety of disabilities may be unable to detect changes in their own breasts. Those with decreased sensation in their fingers may be unable to palpate even large breast masses, and those with vision loss may be unable to detect changes in the appearance of their breasts. Women with disabilities tend to undergo mammography less often than recommended. They may lack transportation to the imaging facility, and they may be unable to undress without assistance, stand, or maintain positioning for a mammogram. Many imaging facilities do not have accessible mammography equipment, and staff members may be unfamiliar with modifications in positioning needed to obtain acceptable scans (Canadian Breast Cancer Network [CBCN], 2012). Furthermore, health care providers often neglect to recommend health screening for women with disabilities, despite the fact that they have the same risks for breast cancer as other women and generally have a normal or near-normal life expectancy. The more severe the disability, the less likely that a woman will undergo mammography. For those women who cannot be adequately positioned for a mammogram, ultrasound may be used as an alternative; however, these women may need more frequent clinical breast examinations. Women with disabilities who are diagnosed with breast cancer tend to be offered breast conservation surgery less often than other women. However, they have the same concerns about body image as other women. An essential role of the nurse is to assist women with disabilities to identify accessible health screening and to advocate for greater accessibility of imaging centres and other health care facilities. Reminding women of the need for recommended clinical breast examinations and mammograms is an important part of nursing care.

With increased early detection and improved treatment modalities, women with breast cancer have become the largest group of cancer survivors. However, the treatment or simply the diagnosis of breast cancer may have longterm effects that negatively affect the patient and her family. The patient should be prepared early on for the potential long-term effects of the disease so she has realistic expectations and can make informed decisions. Breast cancer survivors may experience a variety of issues as a result of their diagnosis and treatment. Estrogen withdrawal from chemotherapy-induced menopause and hormonal treatments can lead to a variety of symptoms, including hot flashes, vaginal dryness, urinary tract infections, weight gain, decreased sex drive, and increased risk of osteoporosis. HT to alleviate symptoms is contraindicated in women with breast cancer. Certain chemotherapeutic agents can cause long-term cardiac effects and neuropathy. In addition, patients may experience impaired cognitive functioning such as difficulty concentrating (often referred to as chemobrain). Rare long-term effects of radiation can include pneumonitis and rib fractures. Longterm sequelae after breast surgery may include lymphedema (mainly after ALND), pain, and sensory disturbances. Once lymphedema develops, it tends to be a chronic problem, so prevention strategies (discussed earlier) are vital. Patients have also reported chronic pain issues after their surgical procedure (Rawson & Miller, 2012). Some of these symptoms can also lead to fatigue and sleep disturbances. Long-term psychosocial sequelae may include anxiety, depression, uncertainty about the future, and fear of recurrence. In the workplace, the patient may suffer from fear of discrimination, concern over coworkers’ reactions, fear of losing insurance benefits, and lack of physical stamina.

Gerontologic Considerations When deciding on the optimal treatment modality for an older patient, age alone should not be the single

Breast Health of Women With Disabilities

Reconstructive Breast Surgery Breast reconstruction is elective surgery that can enhance a woman’s self-image and sense of well-being. Women desire reconstruction for a variety of physical and psychological reasons. Therefore, it is important that the health care team conduct a thorough assessment prior to

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reconstructive surgery to evaluate the woman’s underlying desire, motivation, and expectations. Preparing a woman realistically could help her to avoid potential disappointment. A variety of reconstructive options are available today for women who desire a correction in the size or the shape of the breast, including reduction mammoplasty (breast reduction), augmentation mammoplasty (breast enlargement), and mastopexy (breast lift). Several options are also available to reconstruct the breast after a mastectomy.

Reduction Mammoplasty

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Mastopexy Mastopexy is performed when the patient is happy with the size of her breasts but wishes to have the shape improved and a lift performed. This is also an outpatient surgical procedure, and postoperative instructions are the same as for reduction mammoplasty.

DISEASES OF THE MALE BREAST Gynecomastia

Reduction mammoplasty is usually performed on women who have breast hypertrophy (excessively large breasts). The weight of the enlarged breasts can cause discomfort, fatigue, embarrassment, and poor posture. Reduction mammoplasty is an outpatient procedure that is performed under general anesthesia. Most commonly, an anchor-shaped incision that circles the areola is made, extending downward and following the natural curve of the crease beneath the breast (inframammary fold). Depending on the size of the breast, the nipple may be moved up to a higher position while still attached to the breast tissue or it may be separated and transplanted to a new location. Drains are placed in the incision and remain for 2 to 5 days. During the preoperative consultation, the patient is informed that there is a possibility that sensory changes of the nipple (such as numbness) may occur. These sensations are expected and usually resolve after several months but can sometimes persist. The procedure may also make breastfeeding impossible, although some women have breastfed successfully. The patient must also be aware that if she gains weight (usually more than 4 kg), her breasts may also enlarge. After reduction mammoplasty, many women verbalize feelings of extreme satisfaction, possibly because of the relief they experience. The patient is instructed to wear a supportive bra 24 hours a day for 2 weeks to prevent tension on the swollen breast and incision line. Vigorous exercise (e.g., jumping, jogging) should be avoided for about 6 weeks after surgery.

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. This type of gynecomastia is virtually always benign and resolves spontaneously in 1 to 2 years. Gynecomastia can also occur in older men and usually presents as a firm, tender mass underneath the areola. In these patients, gynecomastia may be diffuse and related to use of certain medications (e.g., digitalis, ranitidine [Zantac]). It may also be associated with certain conditions, including feminizing testicular tumours, infection in the testes, and liver disease resulting from factors such as alcohol abuse or a parasitic infection. Patients in their late teens to late 40s presenting with idiopathic (unknown cause) gynecomastia should have a testicular examination and possibly a testicular ultrasound. Treatment of the enlarged breast tissue is based on patient preference and is usually reserved for those men who cannot tolerate the cosmetic appearance of the breast or who have severe pain associated with the condition. Observation is acceptable in most cases because gynecomastia may resolve on its own. Surgical removal of the tissue through a small incision around the areola is the best treatment option. Liposuction performed by a plastic surgeon is another possibility, although this does not allow for pathologic examination of the tissue.

Augmentation Mammoplasty

Cancer of the male breast accounted for less than 1% of all cases of breast cancer with 200 cases in 2013 (Canadian Cancer Society [CCS], 2014b). The average age at the time of diagnosis is 67 years, but the disease may occur in younger men, especially if there is a genetic link (Mattarella, 2010). There is a well-documented link to mutations in the BRCA2 gene in men with breast cancer. Risk factors for male breast cancer may include a history of hypogonadism, liver disease, testicular problems such as delayed puberty, testicular injury, or inflammation of the testicules, mumps orchitis, radiation exposure, obesity, and Klinefelter’s syndrome (a chromosomal condition reflecting decreased testosterone levels). Liver disease due to factors such as alcohol abuse or a parasitic infection, which compromises estrogen metabolism, may also lead to an increase in rates of male breast cancer. Symptoms include a painless lump beneath the areola, nipple retraction, bloody nipple discharge, or skin ulceration. Diagnostic tests and treatment modalities are similar to those used for women.

Augmentation mammoplasty is requested by women who desire larger or fuller breasts. The procedure is performed by placing a breast implant either under the pectoralis muscle (subpectoral) or under the breast tissue (subglandular). The subpectoral approach is preferred because it interferes less with clinical breast examinations and mammograms. The incision line can be placed in the inframammary fold, in the axilla, or around the areola. The procedure is performed as an outpatient procedure under general anesthesia. A drain is not necessary. Postoperative instructions are the same as for reduction mammoplasty. Saline implants are typically used for augmentation mammoplasty. At this time, Natrelle, a silicone-filled breast implant, has been licensed for use in Canada (Health Canada, 2012). Women with breast implants should be aware that mammograms may be more difficult to read, and they should seek experienced breast radiologists.

Male Breast Cancer

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Early detection is uncommon in male breast cancer because of the rare nature of the disease. Neither patient nor physician suspects male breast cancer early in its development. Treatment generally consists of a total mastectomy with either SLNB or ALND. As in women with breast cancer, prognosis depends on the stage of disease at presentation. Involvement of the axillary lymph nodes is the most important prognostic indicator. Male breast cancers are very likely to be ER+, and tamoxifen, although it has several side effects, is a mainstay of treatment. Because breast cancer is primarily a disease of women, men may feel that a certain stigma is attached to their diagnosis. Health care professionals must be sensitive to their needs and provide information and support.

Critical Thinking Exercises 1 You are reviewing early detection guidelines with a 65-year-old woman who has a BRCA1 mutation. She had an MRI 1 week ago that was normal. Because of this, she asks you if she can skip having her mammogram. What would you advise? What screening modalities would you recommend to her on a yearly basis? What is the evidence base for your recommendations? How would you determine the strength of that evidence? 2 A 45-year-old woman tells you that nobody in her family has breast cancer. She is relieved, she says, because now she does not have to worry about getting it either. How would you respond to this woman? What is the evidence related to the risk of breast cancer with and without a family history? What is the strength of that evidence? 3 A 50-year-old woman had a right lumpectomy and an axillary lymph node dissection for breast cancer 12 years ago. She calls you in a panic because she accidentally burned her right hand while cooking. What advice would you give her? 4 A 28-year-old woman was just diagnosed with breast cancer. She will need surgery and most likely chemotherapy. She desperately wants to have children. How would you address this issue? What resources would be appropriate to provide to the patient? 5 A 54-year-old woman with breast cancer has completed surgery, chemotherapy, and radiation treatment. She tolerated the treatments very well both physically and emotionally. She is now taking tamoxifen, which she started 6 months ago, and she feels very depressed and anxious. What would you recommend for this woman? What is the evidence base for the recommendations you would provide? How would you determine the strength of that evidence?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS American Cancer Society (ACS). (2013). Breast cancer facts and figures, 2013–2014. Atlanta, GA: Author.

*Bickley, L. S. (2012). Bates’ guide to physical examination and history taking (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Canadian Cancer Society (CCS). (2014). Screening for breast cancer. Toronto: Author. Retrieved from http://www.cancer.ca/en/cancer-information/cancer-type/breast/screening/?region=ab#Screeningmammog ram Canadian Cancer Society (2014b). Canadian Cancer Statistics. Ottawa: Public Health Agency of Canada, and Statistics Canada. Day, R. A. (2012). Breasts and axillae assessment. In T. C. Stephen, D. L. Skillen, Day, R. A., et al., (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach, (Canadian ed., revised reprint., pp. 57– 60). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Edge, S., Byrd, D. R., Compton, C. C., et al. (2011). AJCC cancer staging manual (7th ed.). New York, NY: Springer-Verlag. Love, S. M., & Lindsey, K. (2010). Dr. Susan Love’s breast book (5th ed.). Cambridge, MA: Da Capo Press. National Comprehensive Cancer Network (NCCN). (2011). Breast cancer treatment guidelines for patients. Version IX. Atlanta, GA: American Cancer Society. National Comprehensive Cancer Network (NCCN). (2013). NCCN practice guidelines in oncology. Breast cancer. Version 1.2014. Atlanta, GA: American Cancer Society. National Comprehensive Cancer Network (2014). Breast cancer treatment guidelines in oncology. Breast Cancer. Version 2. Atlanta, GA: American Cancer Society. Weber, J., & Kelley, J. (2011). Health assessment in nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Yarbro, C. H., Wujcik, D., & Gobel, B. H. (Eds.). (2010). Cancer nursing: Principles and practices (7th ed.). Sudbury, MA: Jones & Bartlett.

JOURNALS AND ELECTRONIC DOCUMENTS Benson, J. R., & Wishart, G. C. (2013). Predictors of recurrence for ductal carcinoma in situ after breast-conserving surgery. Lancet Oncology, 14(9), e348–e357. Canadian Breast Cancer Network (2012). Women with Disabilities & Breast Cancer Screening: An Environmental Scan. Identified Problems, Strategies and Recommended Next Steps. Ottawa: Author. Retrieved from http://www.cbcn.ca/index.php?pageaction=content.page&id= 7947&lang=en *Clarke, S., Butler, K., & Esplan, M. J. (2008). The phases of disclosing BRAC1/2 genetic information to offspring. Psychooncology, 17, 797–803. *Crotser, C. B., & Dickerson, S. S. (2010). Women receiving news of a family BRCA1/2 mutation: Messages of fear and empowerment. Journal of Nursing Scholarship, 42(4), 367–378. **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 the American Medical Association, 281(23), 2189–2197. Dueck, A. C., Reinholz, M. M., Geiger, X. J., et al. (2013). Impact of c-MYC protein expression on outcome of patients with early-stage HER2 breast cancer treated with adjuvant Trastuzumab NCCTG (Alliance) N9831. Clinical Cancer Research, 19(20), 5798–5807. **Fisher, B., Costantino, 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 the National Cancer Institute, 90(18), 1371–1388. *Friedenreich, C. M., Woolcott, C. G., McTiernana, A., et al. (2010). Alberta physical activity and breast cancer prevention trial: Sex hormone changes in a year-long exercise intervention among post menopausal women. Journal of Clinical Oncology, 28(9), 1458–1466. *Gomez, S., Tan, S., Keegan, T. H., et al. (2007). Disparities in mammographic screening for Asian women in California: A cross-sectional analysis to identifying meaningful groups for targeted intervention. BMC Cancer, 7, 201. doi:10.1186/1471-2407-7-201 Graf, C., & Wessely, N. (2010). Physical activity in the prevention and therapy of breast cancer. Breast Care, 5(6), 389–394. *Greco, K. E., Nail, L. M., Kendall, J., et al. (2010). Mammography decision making in older women with a breast cancer family history. Journal of Nursing Scholarship, 42(3), 348–356. Grulich, A. E., McCredie, M., & Coates, M. (1995). Cancer incidence in Asian migrants to New South Wales, Australia. British Journal of Cancer, 71(2), 400–408.

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Hamilton, R., Williams, J. K., Skirton, H., et al. (2009). Living with genetic test results for hereditary breast and ovarian cancer. Journal of Nursing Scholarship, 41(3), 276–283. Harbeck, N., Pegram, M. D., & Ruschoff, J. (2010). Targeted therapy in metastatic breast cancer: The HER2/neu oncogene. Breast Care, 5(suppl. 1), 3–7. Health Canada. (2012). Summary basis of decision (SBD) for NATRELLE™ silicone-filled breast implants-smooth shell with barrier layer and NATRELLE™ silicone-filled breast implants-textured with barrier layer. Retrieved from http://www.hc-sc.gc.ca/dhp-mps/prodpharma/ sbd-smd/md-im/sbd_smd_2011_natrelleround_61865_60524-eng.php Kim, H.-J., Barsevick, A. M., & Tulman, L. (2009). Predictors of the intensity of cluster symptoms in patients with breast cancer. Journal of Nursing Scholarship, 41(2), 158–165. Krag, D. N., Anderson, S. J., Julian, T. B., et al. (2010). Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncology, 11(10), 927–933. *Kwok, C., Fethney, J., & White, K. (2012). Mammographic screening practices among Chinese-Australian women. Journal of Nursing Scholarship, 44(1), 11–18. Lostumbo, L, Carbine, N. E., & Wallace, J. (2010). Prophylactic mastectomy for the prevention of breast cancer (review). Cochrane Database of Systematic Reviews, (11), 1–90. Mattarella, A. (2010). Breast cancer in men. Radiologic Technology, 35(23), 18–20. Maxwell, K. N., & Donchek, S. M. (2012). Cancer treatment according to BRCA1 and BRCA2 mutations. Nature Reviews Clinical Oncology, 9(9), 520–528. Montagna, E., Cancello, G., & Colleoni, M. (2013). The aromatase inhibitors (plus ovarian function suppression) in premenopausal breast cancer patients: Ready for prime time? Cancer Treatment Reviews, 39(8), 886–890. Paskett, E. D., Dean, J. A., Oliveri, J. M., et al. (2012). Cancer-related lymphedema risk factors, diagnosis, treatment, and impact: A review. Journal of Clinical Oncology, 30(30), 3726–3733. *Prinjha, S., Evans, J., Ziebland, S., et al. (2011). ‘A mastectomy for something that wasn’t even truly invasive cancer.’ Women’s understandings of having a mastectomy for screen-detected DCIS: A qualitative study. Journal of Medical Screening, 18(1), 34–40. Rawson, R., & Miller, M. (2012). Chronic pain in breast cancer survivors. Cancer Nursing Practice, 11(4), 14–18.

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*Roth, M. Y., Elmore, J. G., Yi-Frazier, J. P., et al. (2011). Self-detection remains a key method of breast cancer detection for U.S. women. Journal of Women’s Health, 20(8), 1135–1139. *Shiloh, S., Daga, E., Friedman, I., et al. (2013). A follow-up study on men tested for BRCA1/BRCA2 mutations: Impacts and coping processes. Psycho-Oncology, 22(2), 417–425. Shulman, L. N., Cirrincione, C. T., Berry, D. A., et al. (2012). Six cycles of Doxorubicin and Cyclophosphamide or Paclitaxel are not superior to four cycles as adjuvant chemotherapy for breast cancer in women with zero to three positive axillary nodes: Cancer and leukemia group B 40101. Journal of Clinical Oncology, 30(33), 4071–4076. Sun, Z., Xiong, H., Kearney, A., et al. (2010). Breast cancer screening among Asian immigrant women in Canada. Cancer Epidemiology, 34, 73–78. **Vogel, V. G., Costantino, J. P., Wickerham, D. L., et al. (2006). Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes. The NSABP study of tamoxifen and raloxifene (STAR) P-2 trial. Journal of the American Medical Association, 295(23), 2727–2741. Walton, L., Ommen, K., & Audisio, R. A. (2011). Breast reconstruction in elderly women breast cancer: A review. Cancer Treatment Reviews, 37(5), 353–7.

RESOURCES American Cancer Society, www.cancer.org Canadian Cancer Society, www.cancer.ca Canadian Cancer Survivor Network, http://survivornet.ca/en/ Canadian Society of Plastic Surgeons, www.plasticsurgery.ca/ Cancer Care, Inc. (provides free professional support services to anyone affected by cancer), www.cancercare.org Fertile Future, www.fertilefuture.ca National Breast Cancer Coalition (This activist group has raised funds and consciousness levels regarding breast cancer and was instrumental in obtaining funds for research on prevention), www.natlbcc.org. National Cancer Institute, www.cancer.gov/cancertopics/types/breast National Lymphedema Network, www.lymphnet.org Oncology Nursing Society, www.ons.org Reach to Recovery Program (Information available through local Canadian Cancer Society chapters). Susan G. Komen for the Cure, ww5.komen.org

CHAPTER

50 Assessment and Management of Concerns Related to Male Reproductive Processes Adapted by Melanie J. Hamilton

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe structures and function of the male reproductive system, including pathophysiology, clinical manifestations, and management. 2. Discuss nursing assessment of the male reproductive system, and identify diagnostic tests that complement assessment. 3. Discuss the causes and management of male sexual dysfunction. 4. Compare the advantages and disadvantages of types of prostatectomy. 5. Use the nursing process as a framework for care of the patient undergoing prostatectomy. 6. Describe the nursing management of patients with testicular cancer.

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Disorders 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 both an openness to discuss critical and sensitive issues with the patient and effective assessment, management, and communication on the part of the nurse.

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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

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 60 years. Bowen 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: 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: rare type of cancer that occurs in the skin or tissues; 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 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: uncontrolled, persistent erection of the penis occurring from either neural or vascular causes, including medications, sickle cell thrombosis, leukemic cell infiltration, spinal cord tumours, and tumour invasion of the penis or its vessels prostate cancer: the most common cancer in men; risk factors include increasing age African or Caribbean

descent, and possibly a low fibre and 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, which is 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 conditions (e.g., 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 29 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 (TURP, or TUR): 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: 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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Urinary bladder Ampulla Seminal vesicle Symphysis pubis Vas deferens

Ejaculatory duct 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 50-1. Structures of the male reproductive system. Adapted from Willis, M. C. (1996). Medical

terminology: The language of health care. Baltimore: Williams & Wilkins.

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. 50-1). 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, which is a hoodlike structure lying on the testes 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. 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 base of the bladder. It surrounds the urethra and is traversed by the ejaculatory duct, which is 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. The 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, a tube that carries urine, opens at the tip of the glans. The glans is naturally covered or protected by elongated 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

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urethra, which passes through the penis, extends from the bladder through the prostate to the distal end of the penis.

ASSESSMENT Health History and Clinical Manifestations 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 (benign prostatic hyperplasia [BPH]): decreased force of urine stream, straining to start stream, hesitancy, intermittent/disrupted stream, or “double” or “triple” voiding (urinates two or three times over a period of several minutes to completely empty his bladder). Bladder symptoms may also be present: frequency (every two or fewer hours), nocturia more than twice a night, urgency, or urge incontinence. The patient is also assessed for dysuria, hematuria, and hematospermia (blood in the ejaculate). Assessment of sexual function is an essential part of every health history. Discussing sexuality with patients with an illness or who have a disability can be uncomfortable for nurses and other health care providers. Health care professionals may unconsciously have stereotypes related to sexuality (e.g., ill or persons with a disability are asexual or should remain sexually inactive). Patients may be embarrassed to initiate a discussion about these issues with their health care providers, or they may feel as though the issue is not a serious medical issue and cannot be helped or is a normal part of the aging process (Quinn & Happell 2012). Because changes in sexual functioning are a common concern of patients, it is important to address these issues. By initiating a discussion about sexual concerns, the nurse demonstrates that changes in sexual functioning are valid

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topics for discussion and provides a safe environment for discussing these sensitive topics. There are three models for sexual intervention which can assist health care providers to have a structured approach when addressing sexual health issues. The PLISSIT (permission, limited information, specific suggestions, intensive therapy), the BETTER (bring up, explain, tell, time, educate, and record) model, and the ALARM (activity, libido, arousal, resolution, and medical information) are commonly identified in the literature. These models may be used to provide a framework for nursing interventions (Quinn & Harpell, 2012). The nurse should always begin by asking the patient’s permission to discuss sexual functioning. Limited information about sexual function is initially provided, and 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 (DRE) and the testicular examination.

Digital Rectal Examination DRE is recommended as part of the regular health checkup for every man older than 40 years. It enables the examiner to assess the size, shape, and consistency of the prostate gland (Fig. 50-2). Tenderness of the prostate gland on palpation and the presence and consistency of any nodules are noted. Although DRE 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 penis is inspected and palpated for ulcerations, nodules, inflammation, and discharge. The scrotum is palpated carefully for nodules, masses, or

Lateral lobes Median sulcus

Prostate gland

FIGURE 50-2. (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.

B Normal prostate gland

A

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TABLE 50-1

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Reproductive Function

Age-related Change in Male Reproductive System

Age-related Change

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

inflammation. Examining the scrotum can reveal such disorders as hydrocele, hernia, or tumour of the testis. The testicular examination provides an excellent opportunity to instruct the patient about techniques for testicular selfexamination (TSE) and its importance in early detection of testicular cancer (discussed later in this chapter). This self-examination 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 50-1). Other changes include decreasing sexual function, slower sexual responses, an increased incidence of genitourinary tract cancer, and risk of urinary incontinence for various reasons. Male reproductive capability is maintained with advancing age, and many men are sexually active their entire adult lives. Although degenerative changes occur in the seminiferous tubules, spermatogenesis (production of sperm) continues. Sexual function involving libido (desire) and potency typically decreases. Vascular conditions cause about half of the cases of impotence in men older than 50 years. Cancers of the kidney, bladder, prostate, and penis have increased incidence in men older than 50 years. DRE, prostate-specific antigen (PSA), and a urine test for hematuria may uncover a higher percentage of malignancies at earlier stages. Urinary incontinence in the older man may have many causes, including medications and age-related conditions such as neurologic diseases or BPH. Diagnostic tests are performed to exclude reversible causes of urinary incontinence. For more information on the treatment of urinary incontinence in men and women, refer to Chapter 45.

DIAGNOSTIC EVALUATION OF THE MALE Prostate-Specific Antigen Test The prostate gland produces the substance PSA. It can be measured in a blood specimen, and levels increase with

Erectile dysfunction Weakening of prostatic contractions Hyperplasia of prostate gland Signs and symptoms of obstruction of lower urinary tract (urgency, frequency, nocturia)

prostate cancer. PSA levels are measured in nanograms per millilitre (ng/mL). With consideration to age, the PSA test and DRE are used to detect prostate cancer (Canadian Cancer Society 2014a). The range of values considered normal increases with age (Table 50-2). An elevated PSA level is not a specific indicator of prostate cancer. A number of conditions (e.g., BPH, transurethral resection of the prostate [TURP, or TUR], acute urinary retention, urinary tract infection, or acute prostatitis) can also cause an elevated PSA level in the absence of prostate cancer. Despite these limitations, in combination with DRE, the PSA is useful in identifying men at risk and in monitoring patients following treatment for cancer of the prostate (Cirillo, Petrachhini, D’Urso, et al., 2008). Prostate Cancer Canada ([PCC], 2013a) has new recommendations for early screening and detection of prostate cancer. The PCC recommends that men get baseline testing done in their 40s instead of waiting until they are 50. PSA levels may vary between individuals, so a baseline test at 40 allows physicians to better tailor follow-up or treatment (Prostate Cancer Canada, 2013a). The PCC proposes that men should continue with PSA testing based on individual risk. Men at risk, such as men with Black African or Black Caribbean decent and those with a family history of prostate cancer, should consider PSA testing even earlier than the age of 40.

Ultrasonography Transrectal ultrasound (TRUS) studies may be performed in patients with abnormalities detected by DRE or those with elevated PSA levels. TRUS is used in conjunction

TABLE 50-2

Prostate-specific Antigen Levels by Age Range

Age Range (Years)

Normal Total PSA Range

40–49 50–59 60–69 70–79

0.0–2.5 0.0–3.5 0.0–4.5 0.0–6.5

PSA, prostate-specific antigen. Canadian Cancer Society. (2014). Tests for prostate cancer. Retrieved from http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/ tests-and-procedures/prostate-specific-antigen-psa/?region=on&acc=true

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with a prostate biopsy to locate hypoechogeneic areas. 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.

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.

DISORDERS OF MALE SEXUAL FUNCTION Erectile Dysfunction Erectile dysfunction (ED), 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). A Canadian study indicates that approximately 49.4% of men over 40 are affected by some degree of ED (Canadian Society for the Study of the Aging Male [CSSAM], 2010). 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. Erective dysfunction has both psychogenic and organic causes. Psychogenic causes include anxiety, fatigue, depression, and pressure to perform sexually. Organic causes include occlusive vascular disease, endocrine disease (diabetes, pituitary tumours, hypogonadism with testosterone deficiency, hyperthyroidism, and hypothyroidism),

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cirrhosis, chronic renal failure, genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin disease, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury, multiple sclerosis), trauma to the pelvic or genital area, alcohol, medications (Chart 50-1), and drug abuse.

Assessment and Diagnostic Findings The diagnosis of ED 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. 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 (e.g., diabetes, multiple sclerosis, stroke, cardiac disease), use of medications (e.g., many antihypertensive medications including thiazide diuretics, spironolactone, beta-blockers, methyldopa and clonidine, anticholinergic medications, psychotropic agents including selective serotonin-reuptake inhibitors and tricyclics) and laboratory tests (e.g., gonadotrophins, testosterone, sex-binding globulin levels, prolactin levels, fasting lipid profile, and thyroid function tests) (Grant, Jackson, Baig, et al., 2013), stress, and alcohol use. 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 sleep-related 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 50-3 describes the evaluation and treatment of men with ED.

Medical Management Treatment, which depends on the cause, can be medical, surgical, or both (Table 50-3). Nonsurgical therapy

CHART 50-1

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) Antiseizure 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)

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Reproductive Function

from psychogenic causes are referred to a health care provider or therapist specializing in sexual dysfunction.

History taking Physical examination Laboratory tests

Pharmacologic Therapy Assessment Clinically significant findings Patient and partner’s goals and preferences Education Sexual, physiologic and pathophysiologic Counselling Diagnostic and therapeutic options

Hypogonadism

Shared decision making

Complex problem Referral to specialist for evaluation and treatment

Androgen therapy

Modify lifestyle Change medications

Cardiac symptoms

Dissatisfaction with result

Cardiologic evaluation

Oral therapy Dissatisfaction with result

Patient’s preference or sildenafil contraindicated

Refer to urology department

Vacuum restriction device or Transurethral therapy or Intracavernous injection

Dissatisfaction with result

Penile vascular surgery or Penile implant FIGURE 50-3. 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.

includes treating associated conditions, such as alcoholism and diabetes, and readjusting hypertensive agents or other medications. Endocrine therapy may be instituted for ED secondary to hypothalamic–pituitary–gonadal dysfunction and may reverse the condition. Patients with ED

Phosphodiesterase-5 (PDE-5) inhibitors are oral medications that are used to treat ED. Sildenafil (Viagra), the first of these agents, was introduced in 1998 in the United States. Other PDE-5 inhibitors include vardenafil (Levitra) and tadalafil (Cialis). PDE-5 is an enzyme found in trabecular smooth muscle that inactivates cGMP, the nucleotide that causes the cavernosal relaxation necessary for erection to occur. By blocking the inhibition of PDE-5, these pharmacologic agents facilitate corporeal smooth muscle relaxation in response to sexual stimulation (Steggall, 2012). The short-acting PDE-5 inhibitor vardenafil (Levittra) takes approximately 30 minutes to work and sildenafil (Viagra) should be taken about 1 hour before sexual activity. Both should be effective in producing an erection with stimulation; the erection can last about 60 to 120 minutes (Steggall, 2012). Tadalafil (Cialsis) is taken as a daily dose or can also be used “on demand.” When taken “on demand” it takes about 30 minutes to 2 hours to be effective. Both the short-acting and long-acting versions have side effects, including headache, flushing, and dyspepsia. PDE-5 inhibitors are contraindicated in men who take organic nitrates, because together these drugs can cause side effects such as severe hypotension (Curran, 2012; Steggall, 2012). PDE-5 inhibitors should be used with caution in patients with retinopathy, especially in those with diabetic retinopathy. Patient teaching related to the use of Viagra is summarized in Chart 50-2. 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 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 TURP, is more difficult with a semirigid rod than with the inflatable prosthesis. Factors to consider in choosing a prosthesis are the patient’s physical and social activities as well as the expectations of the patient and his partner. Ongoing counselling 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

CHAPTER 50

TABLE 50-3

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Assessment and Management of Concerns Related to Male Reproductive Processes

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Treatments for Erectile Dysfunction

Method

Description

Advantages and Disadvantages

Duration

Penile implants • Semirigid rod • Inflatable

Surgically implanted into corpus cavernosum

Reliable Requires surgery Healing takes up to 3 weeks. is difficult. Subsequent cystoscopic surgery is difficult. Semirigid rod results in permanent semierection.

Indefinite Inflatable prosthesis: saline returns from penile receptacle

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

Injected 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

continued >

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TABLE 50-3

UNIT 10

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Reproductive Function

Treatments for Erectile Dysfunction (Continued)

Method

Description

Advantages and Disadvantages

Duration

•

Smooth muscle relaxant causing blood to flow into penis

May be used twice a day Not recommended with pregnant partners.

Inserted 10 minutes before intercourse Erection can last up to 1 hour.

Urethral suppository (alprostadil)

Penile suppository

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. ED can have a significant impact on a man, his partner(s), and their relationship(s). There may be a reduction of self-esteem or

CHART 50-2

Patient Education Questions and Answers about Viagra WHAT IS VIAGRA? It is a pill that is taken by mouth to restore erectile function in men with impotence. Viagra will not restore desire or sex drive. HOW DOES VIAGRA WORK? Viagra works by relaxing the penis, thus increasing the efficiency of the erection. The enzyme that the medication specifically works on is a type 5 phosphodiesterase (PDE-5), which is found almost exclusively in the penis. HOW DO I TAKE VIAGRA? Take 1 hour before intercourse. The peak action occurs between 30 and 120 minutes. You must have sexual stimulation to create the erection. If you fall asleep or need to go out in public, you will have no erection if you have no stimulation. WHAT HAPPENS IF I DON’T HAVE STIMULATION IN THE FIRST HOUR? The beneficial effect can be seen as late as 8 hours, but most of the effectiveness is within the first 4 hours. HOW OFTEN MAY I USE VIAGRA? The recommended frequency is once a day. If you take it more than once a day, you may experience back and leg aches as well as nausea and vomiting. Taking Viagra more than once a day will not improve its effects. You may take it 7 days a week if you desire, but it does not build up in your blood. Remember, only take it when you want to have intercourse. WHAT ARE THE SIDE EFFECTS OF VIAGRA? Mild headache—but not bad enough to prevent taking the drug or enjoying its effects Facial flushing—your face may get red

Indigestion—very mild upset stomach, which can be severe if you take more than one pill a day Runny nose Visual disturbance (“blue haze”)—a transient or temporary change in your vision that makes everything appear blue for about an hour; this will happen if you take more than the highest dose available (100 mg). ARE THERE ANY INTERACTIONS WITH OTHER MEDICATIONS? You should not take Viagra if you are taking any nitrate medications: Nitroglycerin Isordil Nitro-bid Ismo Any nitro medication Indur If you are unsure about your medications, it is important that you ask your doctor or pharmacist. You do not need to worry about blood pressure medications or antidiabetic medications. CAN I USE VIAGRA WITH MUSE OR PENILE INJECTIONS? The use of Viagra with other forms of therapy has not been tested and should be avoided. IS THERE MORE THAN ONE DOSE OF VIAGRA? The doses available are 25 mg, 50 mg, and 100 mg. Your first prescription will be for two tablets of each dose. Use the 25-mg dose first. If the 25-mg dose does not work, then try the 50-mg tablet. If this is not strong enough, then try the 100-mg tablet. Do not take more than one tablet per day of any one dose. When you find a dose that works for you, call your physician or provider, and a long-term prescription will be sent to you.

MUSE, medicated urethral suppository for erection. Used with permission of John Rieke, M.D., Virginia Mason Division of Radiation Oncology.

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poor quality of life in men who suffer from ED (Peate, 2012). The literature states that nurses must help men identify both the physical and psychological impact of ED (Peate, 2012; Steggall, 2012). Men with illnesses and disabilities may need the assistance of a sex therapist to find, implement, and integrate their sexual beliefs and behaviours into a healthy and satisfying lifestyle. The nurse can inform patients that support groups for men with ED and their partners have been established.

Ejaculation Concerns 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. Neurologic disorders (e.g., spinal cord injury, multiple sclerosis, neuropathy secondary to diabetes), surgery (prostatectomy), and medications are the most common causes of inhibited ejaculation (Steggall, 2010). Treatment modalities depend on the nature and severity of the ejaculation concern Behavioural 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. Pharmacologic therapies may include using selective serotonin reuptake inhibitors (SSRIs). Topical lidocaine or lidocaine-prilocaine creams may be used in cases in which men do not want to take oral therapies or when oral therapies are contraindicated (Steggall, 2012b). In some cases, pharmacologic and behavioural therapy together may be effective (Steggall, 2010). For 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 (Robbins-Cherry, Hayter, Wylie, et al., 2011). 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 46. The incidence of sexually transmitted infections (STIs) in Canada is increasing in men and women. It is unclear whether these increasing rates are a result of actual increase

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in the number of people with STIs or because of changes in diagnosing and reporting procedures (Public Health Agency of Canada [PHAC], 2013). The PHAC (2013) indicates that regardless, STIs remain a public health concern. In 2008, 70% of the 161,592 cases of notifiable diseases reported by the CNDSS were sexually transmitted and bloodborne infections. Several infections are classified as STIs: 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, genital Chlamydia, and acquired immunodeficiency syndrome (AIDS). In Canada, the most commonly reported STI is Chlamydia. In 2010, 94,690 cases of chlamydia infection were reported in Canada (PHAC, 2013). Gonorrhea is the second most commonly reported STI, with the gender ratio being reversed and males accounting for two-thirds of cases. Syphilis infections have been rising dramatically since the year 2000. In 2010, 1,757 cases of infectious syphilis were reported with an overall rate of 5.2 per 100,000 people. The PHAC (2013) reports that the rates for males, particularly those of ages 30 to 39 years were higher than rates for females. A dramatic increase in syphilis incidence has been most notable among men who have sex with men (MSM) (Public Health Agency of Canada, 2013). Trichomoniasis or STIs characterized by genital ulcers are thought to increase susceptibility to human immunodeficiency virus (HIV) infection. Trichomoniasis is associated with nonchlamydial, nongonococcal urethritis. Prevention of STIs includes identifying individual risk behaviours. Nurses can assist patients with risk reduction strategies which can include abstinence, limiting sexual relations to long-term and monogamous partners, condom use, and sharing information on sexual history with partners (PHAC, 2013). Nurses must also encourage patients to seek and follow through with testing and treatment (where necessary) for sexually transmitted and bloodborne infections. Treatment of STIs 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 STIs must also be examined, treated, and counselled 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 STIs (Public Health Agency of Canada, 2013). Using latex condoms for at least 6 months after completion of treatment is recommended to decrease transmission of HPV infections as well as other STIs. Because patients with one STI may also have another, it is important to examine and test for other STIs. The 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. Refer to Chapters 53 and 71 for more detailed discussions of HIV infection, AIDS, and other STIs. Immunizations can also be used to prevent and control the spread of infections, including STIs (HPV and hepatitis). Since 2008, all provinces and territories have introduced HPV vaccines for young females. In 2012, the National

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Advisory Committee on Immunization extended the recommended use of the HPV vaccine to include older females (up to 45 years old) and young males (9 to 26 years). Future evaluations will need to measure how the vaccine affects men, women, and various at-risk subpopulations as well as the long-term effectiveness in reducing incidence of related cancers (PHAC, 2013).

CONDITIONS OF THE PROSTATE Prostatitis Prostatitis is an inflammation of the prostate gland caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (e.g., 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 acute or chronic and 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 when compared with acute infections, including increased 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 then 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 broad-spectrum antibiotic agent (to which the causative organism is sensitive) is administered for 10 to 14 days, typically fluoroquinolones. Intravenous administration of the antibiotic may be necessary to achieve high serum and tissue levels. 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 Septra) or a fluoroquinolone. Continuous therapy with low-dose antibiotics to suppress the infection may also be indicated. The patient is advised that the 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 self-stimulation. Research indicates that physical therapy, acupuncture, trigger point injections, and home exercise therapy may also help patients obtain relief from chronic prostatitis (Ulbricht & Russie, 2012; Van Alstyne, Harrington, & Haskvitz, 2010).

Nursing Management Acute prostatitis (fever, severe pain and discomfort, inability to urinate, malaise) may require the patient to receive intravenous antibiotics. Nursing management includes administration of prescribed antibiotics and patient teaching about the medication and the possible side effects. As well, the nurse will describe the use of comfort measures. 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). The patient is encouraged to remain on bed rest to alleviate symptoms quickly.

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 often necessary

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for at least 6 months to 1 year because prostatitis caused by the same or different organisms can recur.

Benign Prostatic Hyperplasia (Enlarged Prostate) Benign prostatic hyperplasia (BPH) is a condition in which the prostate gland enlarges due to the increased number of cells and then gradually extends upward into the bladder and obstructs the outflow of urine. It is one of the most common pathologic conditions in men older than 50 years, because the prostate naturally gets larger as men age. According to the Canadian Cancer Society (2014b) almost all men by the age of 70 will have some prostate enlargement. It is important to note that BPH does not increase the risk of prostate cancer.

Clinical Manifestations In the literature, lower urinary tract symptoms (LUTS) are often used to describe clinical manifestations of BPH (Roehrborn, 2011). LUTS symptoms are thought to be caused by increased muscle tone and resistance and direct mechanical obstruction of the bladder (Cohen & Parsons, 2012). The hypertrophied lobes may obstruct the vesicle 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. Men with BPH often report frequent urination (nocturia, frequency, urgency), straining, feeling unable to empty bladder, urinary incontinence, dysuria, and hematuria (Canadian Urological Association, 2010).

Assessment and Diagnostic Findings Examination reveals a prostate gland that is large, rubbery, and nontender. The irritative and obstructive 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, 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 obstructive 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

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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. If surgery is planned, 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 assessed as well as medications, particularly medications affecting clotting.

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 of complete urinary retention, urethral catheterization is required. In cases of severe prostatic enlargement or stricture, a urologist may be the only professional skilled enough to pass the catheter to allow urine drainage. An 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. Sometimes, an incision is made into the bladder (a suprapubic cystostomy) to provide drainage.

Pharmacologic Therapy Pharmacologic treatment for BPH includes use of alphaadrenergic blockers and 5-alpha-reductase inhibitors, or a combination of both. Phosphodiesterase-5 (PDE-5) inhibitors such as tadalafil (Cialis) may also be used, whether or not the patient has erection problems (Cohen & Parsons, 2012). Alpha-adrenergic blockers (e.g., terazosin [Hytrin], doxazosin [Cardura], tamsulosin [Flomax]) relax the smooth muscle of the bladder neck and prostate. Alfuzosin (Uroxatral) is an extended-release alphaadrenergic antagonist that exerts its effects on the prostate, bladder neck, and posterior urethra. The smooth muscle blockade improves urine flow and relieves BPH symptoms (Cohen & Parsons, 2012). Because a hormonal component of BPH has been identified, one method of treatment involves hormonal manipulation with antiandrogen agents (e.g., finasteride [Proscar], dutasteride [Avodart]). 5-Alpha-reductase inhibitors such as finasteride prevent the conversion of testosterone to dihydrotestosterone (DHT). Decreased levels of DHT lead to decreased glandular cell activity and prostate size. Side effects include gynecomastia (breast enlargement), ED, and flushing. There is some evidence the 5-alpha-reductase inhibitors may decrease the risk of prostate cancer (Cohen & Parsons, 2012). Saw palmetto is a herbal product used to treat the symptoms associated with BPH. The active element comes from the fruit of the American dwarf palm tree. Research has shown that the efficacy of saw palmetto is similar to that of medications such as finasteride, and the herbal product may be better tolerated and less expensive (Cohen & Parsons, 2012). In theory, it functions by interfering with the conversion of testosterone to DHT. In addition, saw palmetto may directly block the ability of DHT to stimulate

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prostate cell growth. It should not be used with finasteride, dutasteride, or medications containing estrogen.

Surgical Procedures Several approaches can be used to remove a noncancerous hypertrophied portion of the prostate gland: TURP, transurethral incision of the prostate (TUIP and suprapubic prostatectomy (Table 50-4). 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; suprapubic prostatectomy is an open procedure (i.e., 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 in men with small- to moderate-sized prostates with BPH or LUTS (Bhojani & Lingeman, 2011). In Canada, the TURP is performed on 90% of men with BPH (Ben-Zvi, Hueber, Valdivieso, et al., 2014). This procedure is carried out through endoscopy. The surgical and optical instrument is introduced directly TABLE 50-4

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. 50-4A). 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. Over time, repeated procedures may be necessary because the residual prostatic tissue can grow back. TURP rarely causes ED, 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. TRANSURETHRAL INCISION OF THE PROSTATE. TUIP is another procedure used in treating BPH. An instrument is passed through the urethra (Fig. 50-4B). One or two incisions are made in the prostate and prostate capsule to reduce prostate pressure on the urethra and to reduce urethral constriction. TUIP is indicated when the prostate gland is small (30 g or less). It can be performed on an outpatient basis and has a lower complication rate than other invasive prostate procedures.

Comparing Surgical Approaches for Treatment of Prostate Disorders

The surgical approach of choice depends on (a) the size of the gland, (b) the severity of the obstruction, (c) the age of the patient, (d) the condition of the patient, and (e) the presence of associated diseases. Surgical Approach

Advantages

Disadvantages

Nursing Implications

Transurethral Resection (TUR or TURP) (removal of prostatic tissue by instrument introduced through urethra)

Avoids abdominal incision Safer for surgical-risk patient Shorter hospitalization and recovery periods Lower morbidity rate Causes less pain

Requires highly skilled surgeon Recurrent obstruction, urethral trauma, and stricture may develop. Delayed bleeding may occur.

Monitor for hemorrhage. Observe for symptoms of urethral stricture (dysuria, straining, weak urinary stream).

Technically simple Offers wide area of exploration Permits exploration for cancerous lymph nodes Allows more complete removal of obstructing gland Permits treatment of associated bladder lesions

Requires surgical approach through the bladder Control of hemorrhage difficult Urine may leak around the suprapubic tube. Recovery may be prolonged and uncomfortable.

Monitor for indications of hemorrhage and shock. Give meticulous aseptic care to the area around suprapubic tube.

Perineal approach

Offers direct anatomic approach Permits gravity drainage Particularly effective for radical cancer therapy Allows hemostasis under direct vision Low mortality rate Lower incidence of shock Ideal for very old, frail, and poorsurgical-risk patient with large prostate

Higher postoperative incidence of impotence and urinary incontinence Possible damage to rectum and external sphincter Restricted operative field Greater potential for infection

Avoid using rectal tubes or thermometers and enemas after perineal surgery. Use drainage pads to absorb excess urinary drainage. Provide foam rubber ring for patient comfort in sitting. Anticipate urinary leakage around the wound for several days after the catheter is removed.

Retropubic approach

Avoids incision into the bladder Permits surgeon to see and control bleeders Shorter recovery period Less bladder sphincter damage

Cannot treat associated bladder disease Increased incidence of hemorrhage from prostatic venous plexus; pubic osteitis

Monitor for hemorrhage. Anticipate posturinary leakage for several days after removing the catheter.

Transurethral Incision (TUIP)

Results comparable to TURP Lower incidence of erectile dysfunction No bladder neck contracture Lower incidence of retrograde ejaculation

Requires highly skilled surgeon Recurrent obstruction and urethral trauma Delayed bleeding

Monitor for hemorrhage.

Open Surgical Removal Suprapubic approach

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Urethra

Hypertrophied prostate being cut

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Urethra

Incision into prostate Bladder Prostate

A

Testis

Bladder

Bladder

B

C

Sound in urethra Urethra

Pubis

Prostate Bladder

Bladder

Rectum

Rectum

D

Prostate

Testis

E

FIGURE 50-4. 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) Transurethral incision of the prostate (TUIP) involves one or two incisions into the prostate to reduce pressure on the urethra. (C) Suprapubic prostatectomy. With an abdominal approach, the prostate is shelled out of its bed. (D) Perineal prostatectomy. Two retractors on the left spread the perineal incision to provide a view of the prostate. (E) Retropubic prostatectomy is performed through a low abdominal incision. Note two abdominal retractors and arrow pointing to the prostate gland.

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 (Fig. 50-4C). 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.

Other Therapies Resection of the prostate can be performed with ultrasound guidance. The treated tissue either vaporizes or becomes necrotic and sloughs. The procedure is performed in the outpatient setting and usually results in less postoperative bleeding than in a traditional surgical prostatectomy. Transurethral needle ablation uses low-level radio frequencies to produce localized heat that destroys prostate tissue while sparing the urethra, nerves, muscles, and membranes. The radio frequencies are delivered by thin

needles placed in the prostate gland through use of a catheter. The body then resorbs the dead tissue. Transuretral Microwave Thermotherapy (TUMT) involves the application of heat to the prostatic tissue. A transurethral probe is inserted into the urethra, and microwaves are carefully directed to the prostate tissue. A watercooling system helps to minimize damage to the urethra and decreases the discomfort from the procedure. The tissue becomes necrotic and sloughs. Finally, “watchful waiting,” in which patients are monitored periodically for severity of symptoms, physical findings, laboratory tests, and diagnostic urologic tests, is the appropriate treatment for many patients, because the likelihood of progression of the disease or the development of complications is unknown.

Cancer of the Prostate Prostate cancer is the most common form of cancer in Canadian men, about 25% of all new cancer cases (Prostate

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Cancer Canada, 2013b). Prostate Cancer Canada (PCC) estimates that 23,600 will be diagnosed with prostate cancer in 2013 and that 43,900 will die of the disease. Prostate cancer rates are twice as high in black Canadian men than in white men, and black Canadian men are more likely to die of prostate cancer than men in any other racial or ethnic group. Prostate Cancer Canada (2013a) conducted an online poll for men aged 18 years and older. The results showed that over half of men (55%) did not know or underestimated the risk of developing prostate cancer in their lifetime. Within the survey, only 16% of men knew that the lifetime risk of developing prostate cancer was 1 in 7. The PCC continues to explain that over 44% of men admitted to being reluctant to be tested for prostate cancer. 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 black Canadian men by teaching and counselling them about prostate cancer, screening, and treatment. The incidence of prostate cancer increases rapidly after the age of 50 years, and more than 75% of cases occur in men older than 65 year (Drudge-Coates & Turner, 2012a). Prostate cancer is common in Canada (see Box 50-1 for a discussion of this cancer among First Nations, Metis and Inuit Populations), the United States, and northwestern Europe but is rare in Asia, Africa, Central America, and South America. Family history can also increase the risk by two to three times for men with a first-degree relative who has had prostate cancer, and when the relative is over 60 years of age at diagnosis, the risk may be more than four times the average. Drudge-Coates and Turner (2012a) explain this risk may be compounded by a family history of breast cancer. A diet low in fibre and high in fat, may lead to higher rates of prostate cancer. Research suggests that saturated fat (commonly found in processed foods, whole-milk dairy products, and fatty cuts of meat) increases the production of the hormone testosterone, which may help prostate cancer cells grow (Prostate Cancer Canada, 2013c). Lifestyle risks that may make prostate

Box 50-1 Prostate Cancer in First Nations, Metis and Inuit Populations One of the most common cancers diagnosed in Alberta from 1997–2010 include prostate cancer, but the number of prostate cancers are lower rates than those of non-First Nation men (Health Canada, 2013). According to the same report, even though First Nation males are less likely to be diagnosed with prostate cancer, they are more likely to die of the disease. Some of the barriers related to prostate cancer, include inadequate access to cancer screening. Reason include: lack of transportation, fear of cancer and diagnosis, geographic location, lack of culturally relevant services and shyness/ discomfort in discussing sexual health related disorders/ diseases. Recommendations to encourage Frist Nation males to access prostate cancer screening include aligning culturally sensitive services with various first nation cultures.

cancer more likely include obesity or increased BMI, along with a sedentary lifestyle or lack of exercise.

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 The diagnosis of prostate cancer is usually made using a triage approach which uses patient history, physical examination, and investigations such as PSA and biopsies (Drudge-Coates & Turner, 2012a). When prostate cancer is detected early, the likelihood of cure is high. Every man older than 50 years should have a DRE as part of his regular health checkup. Routine annual DRE (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 lesions are “stony hard,” “woody,” and fixed. DRE also provides useful clinical information about the rectum, anal sphincter, and quality of stool. The combination of DRE and PSA testing appears to be a costeffective method of detecting prostate cancer. Prostate cancer is confirmed by a histologic examination of tissue removed by TRUS-guided needle biopsy. The most frequent scoring tool is the Gleason Score (Table 50-5), used to grade prostate cancer and to guide the physician in determining the most appropriate treatment (Prostate Cancer Canada, 2013d; Drudge-Coates & Turner, 2012a). Men with a Gleason Score of 2 to 4 are at low risk, those with a score of 5 to 7 are at moderate risk,

TABLE 50-5

Gleason Score

Grade

Gleason Score

1

2–4

2

5–7

3

8–10

Description Low grade—slow growing, less likely to spread Moderate grade—grows slightly faster than grade 1 and may spread High grade—tends to grow quickly, more likely to spread

Canadian Cancer Society. (2014). Gleason classification for prostate cancer. Retrieved from http://www.cancer.ca/en/cancer-information/cancer-type/ prostate/pathology-and-staging/grading/gleason-classification/?region=ab

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and a score of 8 to 10 indicates a high risk of the prostate cancer extending beyond the prostatic capsule. Other tests include bone scans or skeletal x-rays to detect metastatic bone disease, 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.

Sexual Complications Treatment for prostate cancer increases the risk of sexual dysfunction. 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. Men who experienced some sexual dysfunction prior to surgery must be counselled that they have a high risk of ED after surgery. Hormonal therapy also affects the central nervous system mechanisms that mediate sexual desire and arousability. The PDE-5 inhibitors have been found to be effective for treating ED in younger men after radiation therapy or after radical retropubic prostatectomy, especially if the neurovascular bundles were preserved (Miles, Candy, Jones, et al., 2007).

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Robotic Assisted Laparoscopic Radical Prostatectomy In the last few years, the minimally invasive surgical approaches called robotic assisted laparoscopic radical prostatectomy (RALP) have been used as a standard of treatment for prostate cancer. Some literature supports the idea that there is a decrease in morbidity with the use of RALP (Jung, Seo, Lim, et al., 2012). Laparoscopic radical prostatectomy 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, a shorter duration of indwelling catheterization, and more rapid return to normal activity when compared with open radical prostatectomy (Jung et al., 2012). Research is ongoing to assess longterm outcomes and cancer control.

Cryosurgery of the Prostate Cryosurgery of the prostate is used to ablate prostate cancer in patients who may not tolerate surgery or in those with recurrent prostate cancer. Transperineal probes are inserted into the prostate under ultrasound guidance to freeze the tissue directly.

Treatment Options

Complications

Watchful Waiting

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 penile nerve supply. In most instances, sexual activity may be resumed in 6 to 8 weeks, which is the time required for the prostatic fossa to heal. According to Prostate Cancer Canada (2013f), a nerve-sparing technique may be used to try to preserve the nerves that control erections, rather than removing them with the prostate. However, this may not be an option for all patients because there is a risk that cancer cells may remain if the nerves are left intact. With 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.)

Watchful waiting is one option after the diagnosis of prostate cancer. This includes monitoring the prostate cancer and using treatment only if symptoms exist. This options may be chosen in older men with comorbidities. It can also be considered as an option in men with localized prostate cancer, with a limited life-expectancy (DrudgeCoates & Turner, 2012a).

Active Surveillance Active surveillance is another way to monitor prostate cancer, when there are aims to avoid or delay treatment. Some factors that may be used when considering active surveillance include small, slow growing cells that are composed of relatively normal-looking cells (this is determined by the pathologist from the prostate biopsy); the likelihood of the patient dying from other causes (including old age); and the possible side effects or the treatments outweigh the benefits of treatment (Prostate Cancer Canada, 2013e).

Surgical Management Radical Prostatectomy 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 (Drudge-Coates & Turner, 2012a). It is done through an abdominal or perineal incision (Fig. 50-4D,E). More frequently, radical prostatectomy is performed laparoscopically or robotically. Sexual dysfunction may follow a radical prostatectomy, and some patients experience various degrees of urinary incontinence (Isbarn, Huland, & Graefen, 2013).

Medical Management Radiation Therapy If prostate cancer is detected in its early stage, the treatment may be curative radiation therapy. Two major forms of radiation therapy are used to treat cancer of the prostate: teletherapy (external) and brachytherapy (internal). Teletherapy (external beam radiation therapy) involves 6 to 7 weeks of daily (5 days/week) radiation treatments. Intensity-modulated radiation therapy (IMRT) has revolutionized the delivery of external beam radiation therapy. IMRT sets a dose for the target volume and restricts the dose to adjacent structures. It is thought to be accurate within 1 to 3 mm. Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. This therapy can be permanent or temporary. The surgeon uses ultrasound guidance to insert needles into the prostate which will deliver

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TABLE 50-6

UNIT 10

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Reproductive Function

Androgen Deprivation Therapy for Advanced-stage Prostate Cancer

Drug LH-RH Agonists leuprolide (Lupron, Eligard) goserelin (Zoladex) Extended-release leuprolide implant (Viadur)

Nonsteroidal Antiandrogens flutamide (Euflex) bicalutamide (Casodex) nilutamide (Anandron) Estrogens diethylstilbestrol Conjugated estrogens (Premarin or ethinyl estradiol) estrogens contained in PC-SPES

Steroids prednisone

Pharmacologic Action

Nursing Considerations

Act at hypothalamus to produce initial surge, then rapid decline in LH, FSH, and testosterone Implanted device uses osmotic releasing system to deliver low dose of leuprolide

Injected or implanted: Leuprolide: Intramuscular injection every 1to 4 months

Block androgen receptors in the cancer cells to prevent testosterone and dihydrotestosterone from stimulating further tumour growth

Administered orally 1 to 3 times daily. Monotherapy with these agents may avoid some of the long-term adverse events associated with LH-RH agonists, but the longterm efficacy of this approach is not yet established.

Given to men to stop the testicles from producing testosterone; precise mechanism of actions in men with hormone-resistant prostate cancer remains unclear Known to directly kill certain cancer cells and lower serum FSH, LH, and testosterone

Administered orally, usually once daily Serious side effects may occur, such as gynecomastia, breast tenderness, cardiovascular morbidity, thromboembolic disorders, weight gain, and edema.

Suppresses corticotropin-releasing hormone and ACTH, resulting in suppression of androgen production by adrenals

Administered orally; dosages must be carefully titrated, and adverse effects may occur if treatment is abruptly discontinued.

Goserlin: Subcutaneous injection every 1 to 3 months Viadur implant: Implanted in upper arm every 12 months Note: Adherence to therapy is critical to maintaining uninterrupted low androgen levels to mimic physical castration

LH-RH, luteinizing hormone-releasing hormone; FSH, follicle-stimulating hormone; PCSPES, herbal agents with multiple active estrogenic agents; ACTH, adrenocorticotropic hormone.

the radioactive strands., and the patient returns home after the procedure. Radiation safety guidelines include straining urine for seeds and using a condom during sexual intercourse for 2 weeks after implantation, to catch any seeds that pass through the urethra (Waring & Gosselin, 2010). Side effects of teletherapy and brachytherapy, 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 (Waring & Gosselin, 2010). Irritation of the bladder and urethra from radiation therapy can cause pain with urination and during ejaculation until the irritation subsides. However, there is a greater preservation of sexual potency with radiation therapy than with surgery. For patients with clinically localized but high-risk prostate cancer, multimodal treatment may result in improved cancer control. In patients with larger tumours, combination therapy (radiation therapy followed by hormonal therapy) may improve overall survival (Waring & Gosselin, 2010).

Hormonal Therapy Hormone therapy is considered a treatment option in older men with prostate cancer who are not suitable for the more radical treatments. Typically, these men still require treatments to control the cancer. The goal of hormone therapy is to shrink and control the growth of prostate cancer cells, wherever they may be in the body (Malik, 2014). 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 binding of DHT. As a result, the prostatic epithelium atro-

phies (decreases). Up until the 1980s the only option available to reduce the production of testosterone was through surgical castration. This effect is accomplished either by orchiectomy (surgical removal of the testes). Currently pharmacologic advances have provided hormonal therapy to include the administration of medications (Table 50-6). 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 in 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 tumour size, decreases pain from metastatic nodules, and promotes 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). See Chart 50-3 for the Plan of Nursing Care for a patient with prostate cancer. Newer hormonal therapies include the luteinizing hormone-releasing hormone (LH-RH) agonists (leuprolide [Lupron] and goserelin [Zoladex]) and antiandrogen (text continued on page 1621)

CHAPTER 50

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Plan of Nursing Care NURSING INTERVENTIONS

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Assessment and Management of Concerns Related to Male Reproductive Processes

Chart 50-3. The Patient With Prostate Cancer

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 concern 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, such as social services, support groups, and 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 ill-

ness and treatment when questioned

• Engages in open communication with others

2. Helping the patient to understand the diagnostic tests and treatment plan will help to 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 tumour 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 or do ultrasound to determine amount of residual urine. 4. Initiate measures to treat retention. a. Encourage normal position for voiding. b. Recommend using Valsalva manoeuvre. c. Administer prescribed cholinergic agent. d. Monitor effects of medication. 5. Consult with physician regarding intermittent or indwelling catheterization; assist with procedure as required.

1. Provides a baseline for comparison and a goal to work toward 2. Voiding 20 to 30 mL frequently and output less than intake suggests retention. 3. Determines the amount of urine remaining in the bladder after voiding 4. Promotes voiding a. Usual position provides relaxed conditions conducive to voiding. b. Valsalva manoeuvre exerts pressure to force urine out of the bladder. c. Stimulates bladder contraction

• Voids at normal intervals • Reports absence of frequency, urgency, or bladder fullness

• Displays no palpable suprapubic distention after voiding

• Maintains balanced intake and output

d. If unsuccessful, another measure may be required. 5. Catheterization will relieve urinary retention until the specific cause is determined; treatment with an alpha-blocker may be initiated with catheter in place. continued >

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UNIT 10

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Reproductive Function

Plan of Nursing Care

Chart 50-3. The Patient With Prostate Cancer, Continued

NURSING INTERVENTIONS

RATIONALE

6. Monitor catheter function; maintain sterility of closed system; irrigate as required. 7. Monitor voiding if catheter removed.

6. Adequate functioning of catheter is to be ensured to empty the bladder and to prevent infection. 7. Trial without catheter will assess effectiveness of medication and whether surgery is indicated. 8. Surgical removal of the obstruction may be necessary.

8. Prepare patient for surgery if indicated.

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 patient. 2. Review the anatomy of the involved area. 3. Be specific in selecting information that is relevant to 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, or 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; suggest an evening cutoff time for drinking fluids to minimize nocturia. c. Describe pelvic floor muscle exercises to be performed two to three times a day. 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 issues 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 to control frequency and dribbling and aid in preventing retention. a. By sitting or standing, the 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.

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 amount of food eaten. 2. Routinely weigh patient. 3. Elicit patient’s explanation of poor appetite.

1. This assessment will help to determine nutrient intake. 2. Weighing the patient on the same scale under similar conditions can help to monitor changes in weight. 3. His explanation may present easily corrected practices.

• Responds positively to his favourite foods

• Assumes responsibility for his oral hygiene

• Notes increase in weight after improved appetite

CHAPTER 50

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Plan of Nursing Care

Chart 50-3. The Patient With Prostate Cancer, Continued

NURSING INTERVENTIONS

RATIONALE

4. Cater to his individual food preferences (e.g., avoiding foods that are too spicy or too cold). 5. Recognize effect of medication or radiation therapy on appetite.

4. Food should be palatable and appealing.

6. Inform patient that alterations in taste can occur.

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.

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Assessment and Management of Concerns Related to Male Reproductive Processes

EXPECTED OUTCOMES

5. Many chemotherapeutic agents and radiation therapy promote anorexia. 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 by-products of cellular destruction (brought on by malignancy and its treatment). 7. Prevention of nausea and vomiting can stimulate appetite.

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 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. Decreased libido and erectile dysfunction may be experienced.

• Describes the reasons for changes in

2. Treatment modalities may alter sexual function, but each is evaluated separately with regard to its effect on a particular patient. 3. Bonds between a couple can be strengthened with new appreciation and support that had not been evident before the current illness.

care personnel alternative approaches and methods of sexual expression • Includes partner in discussions related to changes in sexual function

sexual functioning

• Discusses with appropriate health

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 patient from falls/injuries.

1. Determining the nature and causes of pain and its intensity helps to select proper relief modality and provide a 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.

• 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

continued >

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UNIT 10

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Reproductive Function

Plan of Nursing Care

Chart 50-3. The Patient With Prostate Cancer, Continued

NURSING INTERVENTIONS

RATIONALE

4. Provide support for affected extremities.

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 the perception of pain and provide comfort. Regularly scheduled analgesics around the clock rather than as needed provide more consistent pain relief. 7. Opioid analgesics and inactivity contribute to constipation.

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.

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 (e.g., 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, the cause is treated. 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 the partner or others encourages the patient to repeat activities and achieve goals. 5. Encouragement stimulates improvement of performance. 6. See Nursing Diagnosis: Imbalanced nutrition (less than body requirements)

• Achieves improved physical mobility • Relates that short-term goals are encouraging him because they are attainable

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 catheter c. Frequency of urination

d. Diminished urinary output e. Increasing loss of bladder control

1. Certain changes signal early complications, requiring 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.

• Experiences no bleeding or passage of blood clots

• Reports no pain around the catheter • Experiences normal frequency of urination

• Reports normal urinary output • Maintains bladder control

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Assessment and Management of Concerns Related to Male Reproductive Processes

agents (flutamide [Euflex]). LH-RH uppresses testicular androgen, whereas flutamide causes adrenal androgen suppression. Cyproterone acetate (Androcur) 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. Side effects experienced by men undergoing hormonal therapy can include hot flashes, mood swings, altered libido, fatigue, gynecomastia, osteoporosis, and loss of muscle mass (Malik, 2014).

Other Therapies 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, external beam radiation therapy can be delivered to skeletal lesions to relieve pain. Radiopharmaceuticals, such as strontium 89 and samarium 153, can also be intravenously injected to treat multiple sites of bone metastases (Gunawardana, Lichtenstein, Better, et al., 2004). If antiandrogen therapies are not effective, medications such as prednisone and mitoxantrone may reduce pain and improve quality of life. With advanced prostate cancer, blood transfusions are administered to maintain adequate hemoglobin levels when bone marrow is replaced by tumour.

Chemotherapy Prior to 2004 there were no treatments available to improve the survival rate for men with metastatic prostate cancer. Chemotherapy may be used in certain cases to treat metastatic prostate cancer (Turner & Drudge-Coates, 2012). The standard of care is to use docetaxel 75 mg/m plus prednisone 5 mg BID. Using this type of chemotherapy has improved quality of life, overall pain reduction, and overall survival for approximately 18 months (DrudgeCoates & Turner, 2012b). Several other medications are under development for men with advanced prostate cancer and are in trial phases. Naturopathic or nutritional supplements are used by many patients who have been diagnosed with cancer (Braun, Gupta, Birdsall, et al., 2013). Prostate Cancer Canada (2013f) explains that alternative therapies can sometimes be used in place of conventional treatment options. At this time alternative therapies are considered scientifically unproven treatments. Patients should be encouraged to speak with their physician if they want to choose this route (Braun et al., 2013). !!"##

Nursing Process

The Patient Undergoing Prostatectomy Prostate surgery may be indicated for the patient with BPH or prostate cancer. The objectives before

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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.

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 concern (described in his own words)? Has he experienced decreased force of urinary flow, decreased ability to initiate voiding, urgency, frequency, nocturia, dysuria, urinary retention, or hematuria? Does the patient report associated issues, 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 ED 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 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.

Diagnosis Preoperative Nursing Diagnoses Based on assessment data, the patient’s major preoperative nursing diagnoses may include the following: • Anxiety about surgery and its outcome • Acute pain related to bladder distention • Deficient knowledge about factors related to the disorder and the treatment protocol

Postoperative Nursing Diagnoses Based on assessment data, the patient’s major postoperative nursing diagnoses may include the following: • Acute pain related to surgical incision, catheter placement, and bladder spasms • Deficient knowledge about postoperative care and management

Collaborative Problems/ Potential Complications Based on assessment data, the potential complications may include the following: • • • • • •

Hemorrhage and shock Infection Deep vein thrombosis (DVT) Catheter obstruction Sexual dysfunction Urinary incontinence

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UNIT 10

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Reproductive Function

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.

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 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 issues and concerns related to the genitalia and sexuality, the nurse provides privacy and establishes a trusting and professional relationship. He is encouraged to verbalize his feelings and concerns.

Relieving Discomfort If discomfort is present before the day of surgery because of urinary obstruction, analgesic agents are administered and measures to relieve anxiety are initiated. If the patient is hospitalized, the nurse monitors the patient’s voiding patterns, evaluates 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. 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 Chapters 45 and 46).

Providing Instruction Before surgery, the nurse reviews with the patient the anatomy of 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. 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.

Preparing the Patient Preoperative preparation is described in Chapter 19. Elastic compression stockings are applied before surgery and are particularly important for prevention of DVT 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.

Postoperative Nursing Interventions Maintaining Fluid Balance During the postoperative period after TURP, the patient is at risk for imbalanced fluid volume because of the irrigation of the surgical site during and after surgery. With continuous bladder irrigation (CBI) 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 (called TURP syndrome). The urine output and the amount of fluid used for irrigation must be closely monitored. The patient is also monitored for electrolyte imbalances (i.e., hyponatremia), rising blood pressure, confusion, and respiratory distress. The risk for fluid and electrolyte imbalance is increased in older adult patients with preexisting cardiovascular or respiratory disease. These signs and symptoms are documented and reported to the surgeon immediately.

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 conditions, 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. Anticholinergic medications, such as oxybutynin, that relax the smooth muscles can help to ease the spasms, which can be intermittent and severe. Warm compresses to the pubis 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

CHAPTER 50

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Assessment and Management of Concerns Related to Male Reproductive Processes

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, as 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.

Monitoring and Managing Potential Complications After prostatectomy, the patient is monitored for major complications such as hemorrhage, infection, DVT, and catheter obstruction. 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 urine 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 (e.g., 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. 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 high. Dressings can be held in place by a double-tailed, T-binder bandage or a padded athletic supporter. The

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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. 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 on the 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 DVT and pulmonary embolism, the 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 32 and 24, respectively. The patient who is receiving heparin must be closely monitored for excessive bleeding. OBSTRUCTED CATHETER. After a TURP, 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 colour of the urine is noted and documented; a change in colour 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 used to irrigate the bladder and prevent clot formation (Fig. 50-5). Continuous or intermittent irrigation may be used. Gentle manual irrigation of the catheter may be prescribed to remove any obstructing clots. 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.

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Irrigation solution

Triplelumen catheter

Bulb inflation Irrigation solution Irrigation solution Bulb inflation

Catheter drainage bag FIGURE 50-5. A three-way system for bladder irrigation.

Over distention of the bladder is avoided because it can induce secondary hemorrhage by stretching the coagulated blood vessels in the prostatic capsule. The drainage tube or 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, as 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 ED, decreased libido, and fatigue. These issues may become a concern of the patient soon after surgery or in the weeks to months during rehabilitation. 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 (Chart 50-4).

Promoting Home and Community-Based Care TEACHING SELF-CARE. Men undergoing prostatectomy may be discharged within 3 to 4 days or less. 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 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 (e.g., 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 does not immediately regain bladder control. Moreover, urinary frequency and burning may occur after the catheter is removed. Teaching the following exercises, known as pelvic floor muscle exercises, may help the patient regain urinary control:

• Tighten the pelvic floor by tensing the muscles around the rectum as if trying to stop from passing gas. The buttocks, thighs, and stomach should stay relaxed. If the penis twitches and contracts inwards slightly, the patient is tightening the correct muscles. • Squeeze firmly for 5 to 10 seconds per contraction. • Try to perform 10 to 12 contractions two to three times a day, relaxing the muscle for 10 to 20 seconds between each contraction (Lin, Yang, Lin, et al., 2011). Pelvic floor muscle 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

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NURSING RESEARCH PROFILE

Chart 50-4. Impact of Prostate Cancer Osei, D. K., Lee, J.W., Modest, N. M., & Potheir, P. K. T. (2013). Effects of an online support group for prostate cancer survivors: A randomized trial. Urologic Nursing, 33(3), 123–133. Purpose The aim of this study was to explore the effects of an on-line support system on the quality of life among men diagnosed with prostate cancer. Study Sample and Design A longitudinal, randomized, experimental study using 40 participants. Inclusion criteria: diagnosis of prostate cancer in the past 5 year, literate in English, internet and email access, between 40–85 and married or living with their significant other. Based on responses from the participants, the 40 men were paired (based on age, ethnicity and educational status) and then split into two groups (intervention and control). Men were given r access to the online support group or to a resource kit and after eight weeks of the study, the men in the support group were given the resource kit and the men with the resource kit were given access to the study. The resource kits contained pamphlets for future treatment options, potential side effects, approaches to dealing with side effects and other information.

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 and thus decrease the risk 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 50-5). CONTINUING CARE. Referral for home care may be indicated if the patient is an older adult or has other health problems, if the patient and family can-

After the baseline data was completed, Cronbach’s alphas were calculated for 10 quality of life scales. This included SF-12 (physical health and mental health), EPIC-26 (urinary obstruction, urinary incontinence, bowels, sexual and hormonal). The Satisfaction with Life (life satisfaction and MIDUS (relationship satisfaction). Findings Overall, the intervention group experienced improvement in urinary retention and obstruction health, sexual health and hormonal health. In contrast, the control group reported quality of life had dropped on six quality of life measures: physical health, perceived sexual health, hormonal health, life satisfaction and spouse negative characteristics. Nursing Implications Although more research is needed, on-line support groups do have some positive impact on perceived quality of life and recovery process. In the future, nurses could consider studying the differences between face to face groups and internet support groups. Because the internet has become such a part of our day to day lives, potential is enormous.

not 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 pelvic floor muscle exercises as prescribed. The patient may need to be reminded that return of bladder control may take time.

CHART 50-5

HOME CARE CHECKLIST •

Postprostatectomy Care Patient

Caregiver

• 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 pelvic floor 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.

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

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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.

Evaluation Expected Preoperative Patient Outcomes Expected preoperative patient outcomes may include the following: 1. Demonstrates reduced anxiety 2. States that pain and discomfort are decreased 3. Relates understanding of surgical procedure and postoperative course and practices pelvic floor muscle exercises and other techniques useful in facilitating bladder control

Expected Postoperative Patient Outcomes Expected postoperative patient outcomes may include the following: 1. Relates relief of discomfort 2. Exhibits fluid and electrolyte balance a. Irrigation fluid and urinary output 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 pelvic floor muscle 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

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 inguinal 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 35 years, 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

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

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 improvement occurs within 2 weeks, an underlying testicular tumour 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.

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Nursing Management

Secondary Testicular Tumours

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 to ease the pain. Later, local heat or sitz baths may help to 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.

Secondary testicular tumours 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, as these cancers generally also spread to other organs. Treatment depends on the specific type of cancer.

Testicular Cancer Testicular cancer is the most common cancer in Canadian adolescents and men 15 to 29 years of age. In 2013, there were approximately 940 cases of testicular cancer diagnosed. Although testicular cancer occurs most often between age 15 and 40 years, it can occur in males of any age. It is one of the most curable forms of cancer in Canada. If found and treated early there is a 95% cure rate and a 96% longer term survival rate (Movember Canada, 2014). The testicles contain several types of cells, each of which may develop into one or more types of cancer. It typically presents as a small hard lump, which may produce swelling or a change in the consistency of the testicle (Movember Canada, 2014). 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 Tumours Over 90% of all cancers of the testicle are germinal; germinal tumours may be further classified as seminomas or nonseminomas. About half of all germinal tumours are seminomas, or tumours that develop from the sperm-producing cells of the testes. Nonseminoma germinal cell tumours 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 tumours grow quickly.

Nongerminal Tumours Testicular cancer may also develop in the supportive and hormone-producing tissues, or stroma, of the testicles. These tumours account for about 4% of testicular tumours in adults and 20% of testicular tumours in children. The two main types of stromal tumours are Leydig cell tumours and Sertoli cell tumours. Although these tumours infrequently spread beyond the testicle, a small number of these tumours metastasize and tend to be resistant to chemotherapy and radiation therapy.

Risk Factors Risk factors for testicular cancer include undescended testicles (cryptorchidism), a family history of testicular cancer, and cancer of one testicle, which increases the risk in the other testicle. Race and ethnicity have been identified as risk factors. For example, white Canadian men have a five times greater risk than that of black Canadian men and more than double the risk of Asian Canadian men. Occupational hazards, including exposure to chemicals encountered in mining, oil and gas production, and leather processing, have been suggested as possible risk factors.

Clinical Manifestations Men with testicular cancer may experience few or no symptoms. The symptoms of testicular cancer appear gradually, with a mass or lump on the testicle and generally painless enlargement of the testis (Movember Canada, 2014). The patient may complain of heaviness in the scrotum, inguinal area, or lower abdomen. Back ache (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 tumours tend to metastasize early, spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs. Sexual function and fertility are quality of life-issues that are also associated with testicular cancer (Kim, McGlynn, McCorkle, et al., 2012).

Assessment and Diagnostic Findings Monthly TSEs are effective in detecting testicular cancer (Chart 50-6). 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, TSE should begin during adolescence. Human chorionic gonadotropin and alpha-fetoprotein are tumour markers that may be elevated in patients with testicular cancer. (Tumour markers are substances synthesized by the tumour cells and released into the circulation in abnormal amounts.) Tumour 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 tumour mass; lymphangiography to assess the extent of tumour 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

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CHART 50-6

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

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).

pelvis. Microscopic analysis of tissue is the only definitive way to determine if 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.

Medical Management Testicular cancer is one of the most curable solid tumours. 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. Some patients, however, have decreased hormonal levels, suggesting that the unaffected testis is not functioning at normal levels. Retroperitoneal lymph node

Spermatic cord

5. Locate and palpate the epididymis (C), a cordlike 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, pealike lump or if the testis is swollen (possibly from an infection or tumour), consult your physician.

dissection (RPLND) may be performed after orchiectomy to prevent lymphatic spread of the cancer. Laparoscopic RPLND (L-RPLND) has become a preferred alternative to the more invasive open RPLND for early-stage nonseminomatous germ cell testicular cancer (Ziaee et al., 2012). Patients who underwent L-RPLND had decreases morbidity, hospital stay, and time to return to normal activity. Althogh libido and orgasm are usually unimpaired after RPLND, the patient may develop ejaculatory dysfunction with resultant infertility. Thus, before surgery may be considered (Bradford, 2012). As stated previously, testicular cancers are classified as either seminomas or nonseminomas for determining treatment; seminomatous types are more sensitive to radiation therapy. Research has demonstrated that for stage IIA/B seminomas, radiation therapy alone provides excellent results for the majority of patients. Postoperative irradiation of the lymph nodes from the diaphragm to the iliac region is used to treat seminomas. Radiation is delivered

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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 and those for whom lymph node surgery is not recommended. Lymphangiography and CT are used to determine spread of the disease to the lymph nodes (Bohnenkamp & Yoder, 2009). Chemotherapy is reserved for the treatment of stage IIC testicular cancer as well as more advanced stages (Chung, Gospodarowicz, Panzarella, et al., 2004). The standard treatment for testicular germ cell cancer includes bleomycin, etoposide and cisplatin (Bradford, 2012). This regimen 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 favourable, and the disease is probably curable because of advances in diagnosis and treatment. Patients who undergo chemotherapy should discuss fertility options with their physician. Sperm cryopreservation is the only choice available at this time for conserving fertility in men with cancer (Bradford, 2012). A patient with a history of one testicular tumour has a greater chance of developing subsequent tumours. The most common site of recurrence is the retroperitoneum (Bohnenkamp & Yoder, 2009). 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 chemotherapy or radiation treatment for testicular cancer include kidney damage, hearing issues, gonadal damage, neurologic changes, and rarely secondary cancers (Bohnenkamp & Yoder, 2009). Chemotherapy has improved survival rates among patients with testicular cancer, giving it the highest cure rate of any solid tumour cancer.

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 Chapter 17). Preand postoperative care is described in Chapters 19 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

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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.

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 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. 50-6). 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 STIs. 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

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deferens. Many men have sperm in their ejaculate after a reversal, and 40% to 75% can impregnate a partner.

Banking Sperm

B

C A FIGURE 50-6. A vasectomy is a resection of the vas deferens to pre-

vent 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.)

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. 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 epididymoorchitis, 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.

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, supportive briefs for added comfort and support. He may become greatly concerned about the discolouration 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.

Vasovasostomy (Sterilization Reversal) Microsurgical techniques are used to reverse a vasectomy (vasovasostomy), thus restoring patency to the vas

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 (e.g., 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 self-stimulation and collected in a sterile container for storage.

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 older adult 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 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 Penile cancer predominantly occurs in men over 60 years of age; however, 22% of patients are younger than the age of 40 (Bullen, Edwards, Marke, et al., 2013; Turner, Drudge-Coates, & Henderson, 2013). The most recent statistics from the Canadian Cancer Society show that in 2007, 139 Canadian men were diagnosed with the disease

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(Canadian Cancer Society, 2014a). In some countries such as Asia, Africa, and South America, penile cancer is more prevalent. A publication by Turner, Drudge-Coates, and Henderson (2013) states that human papillomavirus appears to have a role in this type of cancer. 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 (Bullen et al., 2013). Cancer of the penis is a rare type of cancer that 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 (Turner et al. 2013). Bowen 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.

Prevention Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumours (Bullen et al., 2013; Canadian Cancer Society, 2014b; Turner et al., 2013)). In uncircumcised men, personal hygiene is an important preventive measure.

Medical Management The aim in managing penile cancer is to cure the client with minimal disfigurement. Treatment modalities include surgery (circumcision, glans resurfacing, glansectomy, or partial penectomy), chemotherapy, radiotherapy, or a combination of these approaches (Turner et al., 2013). Smaller lesions involving only the skin may be controlled by excision (Bullen, et al., 2010; Turner, et al., 2013). 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 tumours 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 tumour 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 remain engorged and painful. It occurs from either neural or vascular causes, including sickle cell thrombosis, leukemic cell infiltration, spinal cord tumours or injury, and tumour 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 ED. This condition may

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result in gangrene and often results in impotence, whether treated or not. Priapism is a urologic emergency, but men often delay seeking treatment because of embarrassment. By the time they arrive in the emergency department, several hours may have passed and permanent penile damage has occurred. The goal of therapy is to improve venous drainage of the corpora cavernosa to prevent ischemia, 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 Disease Peyronie 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 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 (e.g., from instrumentation, pelvic fractures, or STIs) 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 black Canadian 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

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Reproductive Function

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 PDE-5 inhibitors. What information would you give him about this class of medications and what teaching approach would you use? How would your approach differ if your patient were a 56-yearold 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 a radical prostatectomy to treat malignant 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? 4 A 34-year-old man is seeking treatment for an STI. When you are obtaining the health history, he reports that this is his fifth or sixth episode of STI. 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 STIs and the risk of transmitting an STI to his sexual partner? How would your teaching differ if the patient revealed that he had sex with men only? 5

A college athlete who describes his health as excellent comes to the student health clinic because he noticed a walnut-size mass in his testicle when showering. Describe the specific components of the history and physical examination that would be appropriate. What would be your concerns, and what referrals would be warranted for him? What is the evidence base for the effectiveness of testicular self-examination in detection of testicular cancer? How strong is that evidence, and what criteria did you use to determine the strength of the evidence?

REFERENCES AND SELECTED READINGS BOOKS Canadian Society for the Study of the Aging Male. (2010). The Hard Facts: One important aspect of sexual health and what you need to know about it. Canada: Author. Moore, K., & Vandall-Walker, V. (2008). Before and after your radical prostatectomy (3rd ed.). Montreal, QC: Canadian Continence Foundation. Vandall-Walker, V., Moore, K., & Pyne, D. (2008). Before and after radical prostate surgery: Information and resource guide. Edmonton, AB: AU Press, Athabasca University. Wein, A. J., Kavoussi, L. R., Novick, A. C., et al. (Eds.). (2007). Campbell-Walsh urology (9th ed.). Philadelphia, PA: Saunders.

JOURNALS AND ELECTRONIC DOCUMENTS Ben-Zvi, T., Hueber, P. A., Valdivieso, R., et al. (2014). Urological resident exposure to transurethral options for BPH management in 2012– 2013: A pan-Canadian survery. Canadian Urological Association Journal, 8(12), 54–60. Bhojani, N., & Lingeman, J. E. (2011). Surgery for BPH/LUTS: Is TURP still the gold standard? Urology Times, 38–39. Bohnenkamp, S., & Yoder, L. H. (2009). The medical-surgical nurse’s guide to testicular cancer. MEDSURG Nursing, 18(2), 116–122. Bradford, B. R. (2012). Chemotherapy-induced infertility in patients with testicular cancer. Onoclogy Nursing Forum, 39(1), 27–30.

Braun, D. P., Gupta, D., Birdsall, T. C., et al. (2013). Effect of naturopathic and nutritional supplement treatment on tumor response, control, and recurrence in patients with prostate cancer treated with radiation therapy. Journal of Alternative and Complementary Medicine, 19(3), 198–203. Bullen, K., Edwards, S., Marke, V., et al. (2013). Looking past the obvious: Experiences of altered masculinity in penile cancer. Psycho-Oncology, 19, 933–940. Dio: 10.1002/pon.1642 Canadian Cancer Society. (2008). Early detection for prostate cancer. Toronto, ON: Author. Retrieved from http://www.cancer.ca/Canadawide/Prevention/Get%20screened/Early%20 detection%20for%20 prostate%20cancer.aspx?sc_lang=en Canadian Cancer Society. (2014a). Penile Cancer Statistics. Toronto, ON: Author. Retrieved from http://www.cancer.ca/en/cancer-information/ cancer-type/penile/statistics/?region=ab Canadian Cancer Society. (2014b). Early Detection of Penile Cancer. Toronto, ON: Author. Retrieved Feb 18, 2014, from http://www.cancer. ca/en/cancer-information/cancer-type/penile/early-detection/?region=ab Canadian Cancer Society’s Advisory Committee on Cancer Statistics. (2013). Canadian Cancer Statitics 2013. Toronto, ON: Canadian Cancer Society. Retrieved from, http://www.cancer.ca/∼/media/cancer.ca/ CW/cancer%20information/cancer%20101/Canadian%20cancer%20 statistics/canadian-cancer-statistics-2013-EN.pdf Canadian Urological Association. (2010). Benign Prostatic Hyperplasia (BPH). [Brochure]. Retrieved from http://www.cua.org/patient_ information_e.asp Chung, P. W., Gospodarowicz, M. K., Panzarella, T., et al. (2004). Stage II testicular seminoma: Patterns of recurrence and outcome of treatment. European Urology, 45(6), 754–759. Cirillo, S., Petracchini, M., D’Urso, L., et al. (2008). Endorectal magnetic resonance imaging and magnetic resonance spectroscopy to monitor the prostate for residual disease or local cancer recurrence after transrectal high-intensity focused ultrasound. BJU International, 102(4), 452–458. Cohen, S. A., & Parsons, J. K. (2012). Combination pharmacological therapies for the management of benign prostatic hyperplasia. Drugs and Aging, 29(4), 275–284. Curran, M. P. (2012). Tadalafil: In the treatment of signs and symptoms of benign prostatic hyperplasia with or without erectile dysfunction. Drugs and Aging, 29, 771–781. Drudge-Coates, L., & Turner, B. (2012a-Urology Supplement). Prostate cancer overview. Part 1: Non-metastatic prostate cancer. British Journal of Nursing, 21(18), S23–S28. Drudge-Coates, L., & Turner, B. (2012b-Urology Supplement). Prostate cancer overview. Part 2: Metastatic prostate disase. British Journal of Nursing, 21(18), S23–S28. Garner, M., Turner, M. C., Ghadirian, P., et al. (2008). Testicular cancer and hormonally active agents. Journal of Toxicology and Environmental Health, Part B: Critical Reviews, 11(3–4), 260–275. Grant, P., Jackson, G., Baig, I., et al. (2013). Erectile dysfunction in general medicine. Clinical Medicine, 13(2), 136–140. Gunawardana, D., Lichtenstein, M., Better, N., et al. (2004). Results of strontium-89 therapy in patients with prostate cancer resistant to chemotherapy. Clinical Nuclear Medicine, 29(2), 81–85. Health Canada. (2013). First Nations Health Status Report: Alberta Region 2011–2012. Ottawa, ON: Author. http://publications.gc.ca/collections/ collection_2013/sc-hc/H26-4-2012-eng.pdf Isbarn, H., Huland, H., & Graefen, M. (2013). Results of radical prostatectomy in newly diagnosed prostate cancer. Deuches Arzteblatt International, 110(29–30), 497–503. Jacobsen, N. E., Moore, K. N., Estey, E., et al. (2007). Open versus laparoscopic radical prostatectomy: A prospective comparison of postoperative urinary incontinence rates. Journal of Urology, 177(2), 615–619. Jung, J. H., Seo, J. W., Lim, M. S., et al. (2012). Extended pelvic lymph node dissection include internal iliac packet should be performed during robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer. Journal of Laparoendoscopic and advanced surgical techniques, 22(8), 785–790. Kim, C., McGlynn, K. A., McCorkle, R., et al. (2012). Sexual functioning among testicular cancer survivors: A case-control study in the U.S. Journal of Psychosomatic Research, 73(1), 68–73. Lin, Y. H., Yang, M. S., Lin, U. C., et al. (2011). The effectiveness of pelvic floor exercises on urinary incontinence in radical prostatectomy patients. International Journal or Urological Nursing, 5(3), 115–122. Malik, S. (2014). Using hormone therapy for the management for prostate cancer. Nursing and Residential Care, 16(2), 75–77.

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Miles, C. L., Candy, B., Jones, L., et al. (2007). Interventions for sexual dysfunction following treatments for cancer. Cochrane Database of Systematic Reviews, 17(4), CD005540. Movember Canada (2014). Men’s Health: Testicular Cancer. Retrieved from: http://ca.movember.com/mens-health/testicular-cancer Osei, D. K., Lee, J. W., Modest, N. N., et al. (2013). Effects of an online support group for prostate cancer survivors: A randomized trial. Urologic Nursing, 33(3), 123–133. Peate, I. (2012). Breaking the silence: helping men with erectile dysfunction. British Journal of Community Health Nursing, 17(7), 310, 312, 314–317. Prostate Cancer Canada. (2013a). Prostate cancer Canada releases new recommendations. Retrieved from: http://prostatecancer.ca/In-TheNews/Foundation-News-Releases/Prostate-Cancer-Canada-ReleasesNew-Recommendation#.UzRlyGBOW70 Prostate Cancer Canada. (2013b). Statistics. Retrieved from: http://prostatecancer.ca/Prostate-Cancer/About-Prostate-Cancer/Statistics#. UzRl9GBOW70 Prostate Cancer Canada. (2013c). Risk Factors. Retrieved. http://prostatecancer.ca/Prostate-Cancer/About-Prostate-Cancer/Risk-Factors#. UzRnO2BOW70 Prostate Cancer Canada. (2013d). Grading. Retrieved from http://prostatecancer.ca/Prostate-Cancer/Testing-and-Diagnosis/Grading#. UzRoGGBOW70 Prostate Cancer Canada. (2013e). Active Surveillance. Retrieved from: http://prostatecancer.ca/Prostate-Cancer/Treatment/Active-Surveillance#.UzRnu2BOW70 Prostate Cancer Canada. (2013f). Radical Prostatectomy. Retrieved from: http://prostatecancer.ca/Prostate-Cancer/Treatment/Radical-Prostatectomy#.UzRoWWBOW70 Public Health Agency of Canada. (2013). The chief public health officer’s report on the sate of public health in Canada, 2013 infectious disease— The never-ending threat. Ottawa, ON: Author. Quinn, C., & Happell, B. (2012). Getting BETTER: Breaking the ice and warming to the inclusion of sexuality in mental health nursing care. International Journal of Mental Health Nursing, 21, 154–162. Robbins-Cherry, S. A., Hayter, M., Wylie, K. R., et al. (2011). The experiences of men living with inhibited ejaculation. Sexual and Relationship Therapy, 26(3), 242–253.

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Roehrborn, C. G. (2011). Male lower urinary tract symptoms (LUTS) and benign prostatic hyperthrophy (BPH). Medical Clinics of North America, 95(1), 87–100. Steggall, M. (2010). Premature ejaculation: definition, assessment and clinical management. International Journal of Urological Nursing, 4(3), 106–110. Steggall, M. (2012). Pharmacological management of premature ejaculation. Nurse Prescribing, 10(11), 545–550. Turner, B., & Drudge-Coates, L. (2012). New pharmacological treatments for prostate cancer. Nurse Prescribing, 10(10), 498–502. Turner, B., Drudge-Coates, L., & Henderson, S. (2013). Penile cancer: Diagnosis, clinical features and management. Nursing Standard, 27(29), 50–57. Ulbricht, C., & Rusie, E. (2012). Clinical Roundup: Evidenced-based systematic review results. Alternative and Complementary Therapies, 18(1), 51–55. Van Alstyne, L. S., Harrington, K. L., & Haskvitz, E. M. (2010). Physical therapists management of chronic prostatitis/chronic pelvic pain syndrome. Physical Therapy, 90(12), 1795–1806. Waring, J., & Gosselin, T. (2010). Developing a high-dose rate prostate brachytherapy program. Clinical Journal of Oncology Nursing, 14(2), 199–205. Wei, J. T., Calhoun, E., & Jacobsen, S. J. (2008). Urologic diseases in America project: Benign prostatic hyperplasia. Journal of Urology, 179(5), S75–S80. Ziaee, S. A. M., Tabibi, A., Sharifiaghdas, F., et al. (2011). Laparoscopic retroperitoneal lymph node dissection for stage 1 nonseminomatous germ cell testis tumors: first care in Iran. Urology Journal, 8(1) 27–30.

RESOURCES AND WEB SITES Canadian Cancer Society,http://www.cancer.ca. Canadian Continence Foundation, http://www.continence-fdn.ca. Canadian Prostate Cancer Network, http://www.cpcn.org. Canadian Prostate Health Council, www.canadian-prostate.com. Canadian Urological Association, http://www.cua.org/ Prostate Cancer Information, Health Canada and the Department of Urology, Dalhousie University; http://www.caprostate.com.

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Immunologic Function

Case Study Applying Concepts From NANDA, NIC, and NOC An Immunosuppressed Patient With a History of Oral Infections Mrs. Baker is a 52-year-old mother of three with severe rheumatoid arthritis. She has been taking prednisone, 10 mg daily for 6 months, as part of a treatment plan that will also include nonsteroidal anti-inflammatory drugs (NSAIDs) and diseasemodifying antirheumatic drugs (DMARDs). Although her physician has tried to taper the prednisone, each time the dose is reduced Mrs. Baker experiences a painful flare-up of her rheumatoid arthritis and symptoms of steroid withdrawal. Mrs. Baker states that when her symptoms flare, she takes an extra dose of prednisone. She has had oral candidal disease twice in the preceding 3 months and has had frequent upper respiratory tract infections. Visit to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems.

An immunosuppressed patient with a history of oral infections receives the nursing diagnoses Risk for Infection

requires

requires

requires nursing interventions Infection Protection

outcomes should show improvement in improves

Infection Severity

and improves Infection Control

and

Impaired Oral Mucous Membrane

and requires

and leads to reduced risk or improved

Oral Health Maintenance

leads to reduced risk or improved

Tissue Integrity: Skin and Mucous Membranes

and

leads to reduced risk or improved

and

Teaching: Prescribed Medication

which improves

Knowledge: Medication

may benefit from and Risk for Ineffective Therapeutic Regimen Management

requires

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes

Risk for Infection—At risk for being invaded by pathogenic organisms

Infection Protection—Prevention and early detection of infection in a patient at risk

Infection Severity—Severity of infection and associated symptoms

Impaired Oral Mucous Membrane— Disruption of the lips and soft tissues of the oral cavity

Infection Control—Minimizing the acquisition and transmission of infectious agents

Tissue Integrity: Skin and Mucous Membranes—Structural intactness and normal physiologic function of skin and mucous membranes

Risk for Ineffective Therapeutic Regimen Management—Having the potential for developing a pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals

Oral Health Maintenance— Maintenance and promotion of oral hygiene and dental health for the patient at risk for developing oral or dental lesions

Knowledge: Treatment Regimen— Extent of understanding conveyed about the safe use of medication

Return to functional baseline status, stabilization of, or improvement in:

Teaching: Prescribed Medication— Preparing a patient to safely take prescribed medications and monitor their effects From Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2012). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby. Johnson, M., Bulechek, G., Butcher, H. K., et al. (2011). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical thinking and quality care (3rd ed.). St. Louis, MO: Mosby; Moorhead, S., Johnson, M., Mass, M. L., et al. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby; NANDA International. (2012). Nursing diagnoses: Definitions & classification 2012–2014 . Philadelphia, PA: North American Nursing Diagnosis Association.

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51 Assessment of Immune Function Adapted by Kari Krell

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 selected variables on function of the immune system. 5. Use assessment parameters for determining the status of patients’ immune function.

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The term immunity refers to the body’s specific protective response to a foreign agent or organism. The immune system functions as the body’s defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner. Genetic and cellular responses result. Any qualitative or quantitative change in the components of the immune system can produce profound effects on the integrity of the human organism. Immune function is affected by a variety of factors, such as central nervous system integrity, general physical and emotional status, medications, dietary patterns, and the stress of illness, trauma, or surgery. Dysfunctions involving the immune system occur across the lifespan. Many are genetically based; others are acquired. Immune memory is a property of the immune system that provides protection against harmful microbial agents despite the timing of re-exposure to the agent. Tolerance is the mechanism by which the immune system is programmed to eliminate foreign substances such as microbes, toxins,

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and cellular mutations but maintains the ability to accept self-antigens. Some credence is given to the concept of surveillance, in which the immune system is in a perpetual state of vigilance, screening and rejecting any invader that is recognized as foreign to the host. The term immunopathology refers to the study of diseases that result 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 selfantigens, or inappropriate or exaggerated responses to specific antigens (Table 51-1). A growing number of patients with immunologic disorders live to adulthood. Thus, nurses in many practice settings need to understand how the immune system functions as well as immunopathologic processes. In addition, knowledge about assessment and care of people with immunologic disorders enables nurses to make appropriate management decisions.

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 antigenic determinant: the specific area of an antigen that binds with an antibody combining site and determines the specificity of the antigen–antibody reaction apoptosis: programmed cell death that results from the digestion of deoxyribonucleic acid by endonucleases B cells: cells that are important for producing a humoral immune response 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 nonantibody 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 epitope: any component of an antigen molecule that functions as an antigenetic determinant by permitting the attachment of certain antibodies 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 immune response: the coordinated response of the components of the immune system to a foreign agent or organism

immune system: the collection of organs, cells, tissues, and molecules that mediate the immune response immunity: the body’s specific protective response to a foreign agent or organism; resistance to disease, specifically infectious diseases 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 come in contact with specific antigens memory cells: cells that are responsible for recognizing antigens from previous exposure and mounting an immune response natural killer (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 T cells: cells that are important for producing a cellular immune response

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TABLE 51-1

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Immunologic Function

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

Secondary

Deficiency results from improper development of immune cells or tissues; usually congenital or inherited Deficiency results from some interference with an already developed immune system; usually acquired later in life

Adenoids Tonsil Thymus

Bronchusassociated lymphoid tissue

Intestine

ANATOMIC AND PHYSIOLOGIC OVERVIEW Anatomy of the Immune System The immune system is composed of an integrated collection of various cell types, each with a designated function in defending against infection and invasion by other organisms. Supporting this system are molecules that are responsible for the interactions, modulations, and regulation of the system. These molecules and cells participate in specific interactions with immunogenic epitopes (antigenic determinants) present on foreign materials, initiating a series of actions in a host, including the inflammatory response, the lysis of microbial agents, and the disposal of foreign toxins. The major components of the immune system include central and peripheral organs, tissues, and cells (Fig. 51-1).

Bone Marrow The white blood cells (WBCs) involved in immunity are produced in the bone marrow (Fig. 51-2). Like other blood cells, lymphocytes are generated from stem cells, which are undifferentiated cells. There are two types of lymphocytes—B lymphocytes (B cells) and T lymphocytes (T cells) (Fig. 51-3). 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 with 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 (RBCs) are destroyed. The white pulp contains concentrations of lymphocytes. The lymph nodes, which are connected by lymph channels and capillaries, are distributed throughout the body. They remove foreign material from the lymph system before it enters the bloodstream. The lymph nodes also serve as centres for immune cell proliferation. The remaining lymphoid tissues contain immune cells that defend the body’s

Peyer’s patches

Axillary lymph nodes Spleen

Inguinal lymph nodes

Appendix Bone marrow

FIGURE 51-1. Central and peripheral lymphoid organs, tissues, and

cells. Adapted from Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed., p. 357). Philadelphia, PA: Wolters Kluwer HealthéLippincott Williams & Wilkins.

mucosal surfaces against microorganisms (Hendry, Farley, McLafferty, et al., 2013; Levinson, 2012).

Function of the Immune System The basic function of the immune system is to remove foreign antigens such as viruses and bacteria to maintain homeostasis. There are two general types of immunity: innate (also called natural or native immunity) and adaptive (also called specific or acquired immunity). Innate immunity is a nonspecific immunity present at birth. Adaptive immunity develops after birth. Innate 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, adaptive responses increase in speed and vigour with repeated exposure to the invading agent (Hannon, Pooler & Porth, 2010). Although each type of immunity has a distinct role in defending the body against harmful invaders, the various components usually act in an interdependent manner.

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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

Humoural response

Cellular (cell-mediated) response

FIGURE 51-2. Development of cells of the immune system.

Innate Immunity The innate (natural) immune system provides rapid nonspecific immunity and is present at birth. Because of its nonspecificity, it has a broad spectrum of defense against and resistance to infection. Innate (natural) immunity provides a nonspecific response to any foreign invader, regardless of the invader’s composition. The basis of innate defense mechanisms is the ability to distinguish between friend and foe or “self” and “nonself.” Innate (natural) immunity cocoordinates the initial response to pathogens through the production of cytokines and other effector molecules, which either activate cells for control of the pathogen (by elimination) or promote the development of the acquired immune response. The cells involved in this response include macrophages, dendritic cells, and natural killer (NK) cells, which have the ability to recognize and respond to a wide variety of pathogens long before the development of antigen-specific acquired immunity. The early events in this immune response are critical in determining the nature of the adaptive immune response. Innate immune mechanisms can be divided into two stages: immediate (generally occurring within 4 hours) and delayed (occurring between 4 and 96 hours after exposure).

White Blood Cell Action Cellular response is key to the effective initiation of the immune response. 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 (polymorphonuclear leukocytes [PMNs]) 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 do. 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 15% are B cells (Hannon et al., 2010).

Inflammatory Response The inflammatory response is a major function of the natural immune system that is 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

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UNIT 11 Bone marrow or fetal liver

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Immunologic Function

Immune Regulation Pluripotent stem cell

Thymus

Lymphocyte stem cell

T cell B cell

Lymphoid tissue (lymph nodes, spleen, blood and lymph) FIGURE 51-3. Lymphocytes originate from stem cells in the bone mar-

row. 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. Redrawn from Hannon, R.A., Pooler, C., & Porth, C.M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer HealthéLippincott Williams & Wilkins.

formation of fibrous scar tissue and regeneration of injured tissue. The inflammatory response (discussed further in Chapter 7) is facilitated by physical and chemical barriers that are part of the human organism.

Physical and Chemical Barriers Activation of the natural immunity response is enhanced by processes inherent in physical and chemical barriers. Physical surface barriers include intact skin, mucous membranes, and cilia of the respiratory tract, which prevent pathogens from gaining access to the body. The cilia of the respiratory tract, along with coughing and sneezing responses, filter and clear pathogens from the upper respiratory tract before they can invade the body further. Chemical barriers, such as mucus, acidic gastric secretions, 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.

Regulation of the immune response involves balance and counterbalance. 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. A successful immune response eliminates the responsible antigen. Immunodeficiencies are characterized by inactivation or impairment of immune components, and disorders with an inflammatory component (e.g., asthma, allergy, arthritis) are characterized by persistent inflammatory responses. The immune system’s recognition of one’s own tissues as “foreign” rather than as self is the basis of many autoimmune disorders. Despite the fact that the immune response is critical to the prevention of disease, it must be well controlled to curtail immunopathology. Most microbial infections induce an inflammatory response mediated by T cells and cytokines, which, in excess, can cause tissue damage. Therefore, regulatory mechanisms must be in place to suppress or halt the immune response. This is mainly achieved by the production of cytokines and transformation of growth factor that inhibits macrophage activation. In some cases, T-cell activation is so overwhelming that these mechanisms fail, and pathology develops. Ongoing research on immunoregulation holds the promise of preventing graft rejection and aiding the body in eliminating cancerous or infected cells (Viganó, Perreau, Pantaleo, et al., 2012). Although innate immunity can effectively combat infections, many pathogenic microbes have evolved that resist innate immunity. Adaptive immunity is necessary to defend against these resistant agents.

Adaptive Immunity Adaptive (acquired) immunity 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 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 on re-exposure. In contrast to the rapid but nonspecific innate immune response, this form of immunity relies on the recognition of specific foreign antigens. The adaptive immune response is broadly divided into two mechanisms: (1) the cell-mediated response, involving T-cell activation, and (2) effector mechanisms, involving B-cell maturation and production of antibodies. The two types of adaptive immunity are known as active and passive and are strongly interrelated. Active adaptive immunity refers to immunologic defenses developed by the person’s own body. This immunity typically lasts many years or even a lifetime. Passive adaptive immunity is temporary immunity transmitted from a source outside the body that has developed immunity through previous disease or immunization. Examples are immune globulin or immunity resulting from the transfer of antibodies from the mother to an infant in utero or through breast-feeding. Active and passive adaptive immunity involve humoral and cellular (cell-mediated) immunologic responses (described later in this chapter), (Blendell & Fehr, 2012; Sherwood & Kell, 2010).

CHAPTER 51

Response to Invasion When the body is invaded or attacked by bacteria, viruses, or other pathogens, it has three means of defense:

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Assessment of Immune Function

Physiology/Pathophysiology Epitopes (antigenic determinants)

• The phagocytic immune response • The humoral or antibody immune response • The cellular immune response The first line of defense, the phagocytic immune response, primarily involves the WBCs (granulocytes and macrophages), which have the ability to ingest foreign particles and destroy the invading agent; eosinophils are only weakly phagocytic. 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 worn-out cells such as blood or skin cells or cells that need to be renewed. Apoptosis involves the digestion of DNA by endonucleases, resulting in the cells being targeted for phagocytosis (Bennetts & Pierce, 2010). 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 (Abbas, Lichtman, Pillai, et al., 2014). 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 are highly specific proteins that are transported in the bloodstream and attempt to disable 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. The structural 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 a microorganism. Not all antigens are naturally immunogenic; some must be coupled to other molecules to stimulate the immune response. A single bacterium or large molecule, such as a diphtheria or tetanus toxin, may have several 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. 51-4). There are four well-defined stages in an immune response: recognition, proliferation, response, and effector (Fig. 51-5).

Recognition Stage Recognition of antigens as foreign, or nonself, by the immune system is the initiating event in any immune response. The body 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

1641

Antibody A

Antigenbinding sites Antigen

Antibody C Antibody B FIGURE 51-4. Complement-mediated immune responses. Redrawn

from Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer HealthéLippincott Williams & Wilkins.

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 never-ending 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 in helping the circulating lymphocytes process the antigens. Both macrophages and neutrophils have receptors for antibodies and complement; as a result, they coat microorganisms with antibodies, complement, or both, enhancing phagocytosis. The engulfed microorganisms are then subjected to a wide range of toxic intracellular molecules. When foreign materials enter the body, circulating lymphocytes come into physical contact with the surfaces of these materials. Upon contact with the foreign material, lymphocytes, with the help of macrophages, either remove the antigen from the surface or obtain an imprint of its structure, which becomes important in 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 throat comes in contact with the organism. The lymphocyte, familiar with the surface

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UNIT 11

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Immunologic Function

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

Neutrophil

Cytotoxic cells

II. Proliferation Stage

Release of lymphokines

IV. Effector Stage

Antibodies released into bloodstream

Cytotoxic T cells released into bloodstream III. Response Stage FIGURE 51-5. Stages of the immune response. I, In the recognition stage, antigens are recognized by circu-

lating 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.

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 lymphocytes containing the antigenic message return to the nearest lymph node. Once in the node, these sensitized lymphocytes stimulate some of the resident 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.

Response Stage In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. The production of antibodies by the B lymphocytes in response to a

CHAPTER 51

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Assessment of Immune Function

specific antigen begins the humoural response. Humoural 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 tests 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 transplant rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant protective role (Chart 51-1).

antigen. While B lymphocytes are responsible for the production of antibodies, both the macrophages of innate immunity and the special T lymphocytes of cellular immunity are involved in recognition.

Effector Stage

Role of Antibodies

In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader. This initiates activities involving interplay of antibodies (humoral immunity), complement, and action by the cytotoxic T cells (cellular immunity).

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 on the class of the antibody. Each antibody molecule consists of two subunits, each of which contains a light and a heavy peptide chain (Fig. 51-6). The subunits are held together by a chemical link composed of disulfide bonds. Each subunit has a portion, referred to as the Fab fragment that serves as a binding site for a specific

Humoral Immune Response The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific

Antigen Recognition Several theories explain the mechanisms by which B lymphocytes recognize the invading antigen and respond by producing antibodies. It is known that B lymphocytes recognize and respond to invading antigens in more than one way. The B lymphocytes respond to some antigens by directly triggering antibody formation; however, in response to other antigens, they need the assistance of T cells to trigger antibody formation. With the help 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. B lymphocytes stored in the lymph nodes are subdivided into thousands of clones, which 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.

CHART 51-1

Comparison of Cellular and Humoral Immune Responses

Antigen

Antigen

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 Tumour surveillance or destruction Intracellular infections Viral, fungal, and parasitic infections

Fab fragment LC

LC HC

Invading agent with antigen Antibody molecule

HC

Disulfide bonds

LC = Light chain HC = Heavy chain Fc fragment

FIGURE 51-6. An antibody molecule. The Fab fragment serves as bind-

ing site for a specific antigen. The Fc fragment initiates classic complement activation.

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UNIT 11

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Immunologic Function Antigen

Antigen

CHART 51-2

Major Characteristics of the Immunoglobulins IgG (75% of Total Immunoglobulin)

Antigen LC

LC

HC

HC

Antibody

Antibody Exact fit: highly specific

LC

LC = Light chain HC = Heavy chain

HC

Poor fit: low specificity, cross-reactivity

Antibody

No fit: antigenic determinant does not fit with antibody binding site FIGURE 51-7. Antigen–antibody binding. (Left) A highly specific

antigen–antibody complex. (Middle) No match and, therefore, no immune response. (Right) Poor fit or match with low specificity; antibody reacts to antigen with similar characteristics, producing crossreactivity. HC = heavy chain; LC = light chain.

• • • • •

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

antigen. The Fab fragment (antibody-binding site) binds to the antigenic determinant similar to a lock-and-key mechanism (Fig. 51-7). The Fab fragment 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 to clear the body of the invading 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, which are two of the chemical mediators of the inflammatory response. Antibodies do not function in isolation; rather, they mobilize other components of the immune system to defend against the invader. Their typical role is to focus components of the natural immune system on the invader. This includes activation of the complement system and activation of phagocytosis (Abbas et al., 2014). The body can produce five different types of immunoglobulins (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. Major

IgE (0.004% of Total Immunoglobulin) • Appears in serum • Takes part in allergic and some hypersensitivity reactions • Combats parasitic infections characteristics of the immunoglobulins are summarized in Chart 51-2. The normal laboratory values for the three major immunoglobulins (IgA, IgG and IgM) can be found in Table 55-1 and Appendix A.

Antigen–Antibody Binding The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. The most efficient immunologic responses occur when the antibody and antigen fit like a lock and key. 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.

Cellular Immune Response The B lymphocytes are responsible for humoural immunity and the T lymphocytes are primarily responsible for cellular immunity. Stem cells continuously migrate from the bone marrow to the thymus gland, where they develop into T cells. Despite the partial degeneration of the thymus gland that occurs at puberty, T cells continue to develop here. Several types of T cells exist, each with designated roles in the defense against bacteria, viruses, fungi,

CHAPTER 51

TABLE 51-2

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Assessment of Immune Function

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Cytokines and Their Biologic Activity

Cytokine*

Biologic Activity

Interleukin-1 (α and β) Interleukin-2

Promotes differentiation of T and B lymphocytes, natural killer (NK) cells, and null cells Stimulates growth of T lymphocytes 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 lymphocytes, mast cells, and macrophages Stimulates antibody responses Stimulates growth and function of B lymphocytes and antibodies Stimulates growth of pre-B, CD4 + and CD8 + T lymphocytes and activates mature T lymphocytes Promotes chemotaxis and activation of neutrophils Stimulates growth and proliferation of T lymphocytes Inhibits interferon-gamma and mononuclear cell inflammation Promotes induction of acute phase proteins Introduces helper T lymphocytes Inhibits mononuclear phagocyte inflammation and promotes differentiation of B cells Promotes chemotaxis CD4 + T lymphocytes and eosinophils Increases vascular permeability, allowing white cells into area Activates macrophages; increases expression of class I and II MHC antigen processing and presentation Exerts antiviral activity in body cells; induces class I antigen expression; activates NK cells 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-γ Interferon (type 1 α and type β) 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 Tumour necrosis factor-alpha Tumour necrosis factor-beta

*Cytokines are biologically active substances that are 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. MHC = major histocompatibility complex.

parasites, and malignant cells. T cells attack foreign invaders directly rather than by producing antibodies. Cellular reactions are initiated, with or without the assistance of macrophages, by the binding of an antigen to an antigen receptor located on the surface of a T cell. 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 (Ozdemir, 2011).

Types of T Lymphocytes T cells include effector T cells, suppressor T cells, and memory T cells. The two major categories of effector T cells—helper T cells and cytotoxic T cells—participate in the destruction of foreign organisms. 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 interact. Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system. When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells, NK 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 also produce lymphokines, one category of cytokines (Table 51-2). Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and WBCs. These cells then assist in destroying the invading organism. Delayed-type hypersensitivity is an example of an immune reaction that protects the body from antigens through the production and release of lymphokines (see later discussion). Suppressor T cells have the ability to decrease B-cell production, thereby keeping the immune response at a level that is compatible with health (e.g., 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 51-3).

Null Lymphocytes and Natural Killer Cells Null lymphocytes and NK cells are other lymphocytes that assist in combating organisms. These cells are distinct from B cells and T cells and lack the usual characteristics of those cells. Null lymphocytes, a subpopulation of lymphocytes, destroy antigens already coated with antibody. These cells have special receptor sites on their surface that allow

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TABLE 51-3

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Immunologic Function

Lymphocytes Involved in Immune Responses

Type of Immune Response

Cell Type

Function

Humoral

B lymphocyte

Produces antibodies or immunoglobulins (IgA, IgD, IgE, IgG, IgM)

Cellular

T lymphocyte Helper T

Helper T1 Helper T2 Suppressor T Memory T

Cytotoxic T (killer T) Nonspecific

Non-T or non-B lymphocyte Null cell Natural killer (NK) cell (granular lymphocyte)

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 Destroys antigens already coated with antibody Defends against microorganisms and some types of malignant cells; produces cytokines

them to connect with the end of antibodies; this is known as antibody-dependent, cell-mediated cytotoxicity. Natural killer cells are a class of lymphocytes that recognize infected and stressed cells and respond by killing these cells and by secreting macrophage-activating cytokine. The helper T cells contribute to the differentiation of null and NK cells.

Complement System Circulating plasma proteins, known as complement, are made in the liver and activated when an antibody connects with its antigen. Complement plays an important role in the defense against microbes. 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, bridging natural and acquired immunity, and disposing of immune complexes and the byproducts associated with inflammation (Hannon et al., 2010). The proteins that comprise complement interact sequentially with one another in a cascading effect. The complement cascade is important to modifying the effector arm of the immune system. Activation of complement allows important events, such as removal of infectious agents and initiation of the inflammatory response, to take place. These events involve active parts of the pathway

that enhance chemotaxis of macrophages and granulocytes, alter blood vessel permeability, change blood vessel diameters, cause cells to lyse, alter blood clotting, and cause other points of modification. These macrophages and granulocytes continue the body’s defense by devouring the antibody-coated microbes and by releasing bacterial products. The complement cascade may be activated by any of three pathways: classic, lectin, and alternative. The classic pathway is triggered after antibodies bind to microbes or other antigens and is part of the humoral type of adaptive immunity. The lectin pathway is activated when a plasma protein (mannose-binding lectin) binds to terminal mannose residue on the surface glycoproteins of microbes. The alternative pathway is triggered when complement proteins are activated on microbial surfaces. This pathway is part of innate immunity. 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 complement-coated microbes (Abbas et al., 2014). This response is usually therapeutic and can be lifesaving if the cell attacked by the complement system is a true foreign invader. However, if that cell is part of the human organism, the result can be devastating disease and even death. Many autoimmune diseases and disorders characterized by chronic infection are thought to be caused in part by continued or chronic activation of complement, which in turn results in chronic inflammation. The RBCs 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 (Abbas et al., 2014).

Immunomodulators While antimicrobial agents and vaccines have yielded considerable therapeutic success and the immune system usually works effectively, many infectious diseases remain difficult clinical challenges. Treatment success may be compromised by defects of the immune system; in this case, enhancement of the host immune response may be therapeutically beneficial. An immunomodulator (also known as a biologic response modifier) affects the host via direct or indirect effects on one or more components of the immunoregulatory network. Interferons and colonystimulating factors are two of the more commonly used immunomodulators (Liles, 2010).

Interferons Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. These substances continue to be investigated to determine their roles in the immune system and their potential therapeutic effects in disorders characterized by disturbed immune responses. Interferons have antiviral and antitumour properties. In addition to responding to viral infection, interferons are produced by

CHAPTER 51

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 used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis). Research continues to evaluate the effectiveness of interferons in treating tumours and acquired immunodeficiency syndrome (AIDS).

Colony-Stimulating Factors Colony-stimulating factors are a group of naturally occurring glycoprotein cytokines that regulate production, differentiation, survival, and activation of hematopoietic cells. Erythropoietin stimulates RBC production. Thrombopoietin plays a key regulatory role in the growth and differentiation of bone marrow cells. Interleukin-5 (IL-5) stimulates the growth and survival of eosinophils and basophils. Stem cell factor and IL-3 serve as stimuli for multiple hematopoietic cell lines. Granulocyte colonystimulating factor, granulocyte-macrophage colonystimulating factor, and macrophage colony-stimulating factor all serve as growth factors for specific cell lines. These cytokines have attracted considerable interest for their potential role in immunomodulation (McInnes, 2013).

ADVANCES IN IMMUNOLOGY Genetic Engineering One of the more remarkable evolving technologies is genetic engineering, which uses recombinant deoxyribonucleic acid (DNA) technology. Two facets of this technology exist. 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. If a particular gene is abnormal or missing, experimental recombinant DNA technology may be capable of restoring normal gene function. For example, a recombinant gene is inserted onto a virus particle. When the virus particle splices its genes, the virus automatically inserts the missing gene and theoretically corrects the genetic anomaly. Extensive research into recombinant DNA technology and gene therapy is ongoing (Abbas et al., 2014).

Stem Cells Stem cells are capable of self-renewal and differentiation; they continually replenish the body’s entire supply of both RBCs and WBCs. Some stem cells, described as totipotent cells, have tremendous capacity to self-renew and differentiate. Embryonic stem cells, described as pluripotent, give rise to numerous cell types that are able to form tissues. Research has shown that stem cells can restore an

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Assessment of Immune Function

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immune system that has been destroyed. Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency (SCID); clinical trials using stem cells are under way in patients with a variety of disorders having an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases. However, along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about safety, efficacy, resource allocation, and human cloning (Master & Crozier, 2012).

ASSESSMENT OF THE IMMUNE SYSTEM An assessment of immune function begins during the health history and physical examination. Areas to be assessed include nutritional status; infections and immunizations; allergies; disorders and disease states, such as autoimmune disorders, cancer, and chronic illnesses; surgeries; medications; and blood transfusions. In addition to inspection of general characteristics, palpation of the lymph nodes and examinations of the skin, mucous membranes, and respiratory, gastrointestinal, musculoskeletal, genitourinary, cardiovascular, and neurosensory systems are performed (Moorhead, Johnson, Mass, et al., 2012) (Chart 51-3).

Health History 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.

Gender There are differences in the immune system functions of men and women. For example, many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Sex hormones have long been recognized for their role in reproductive function, and in the past two decades research has revealed that these hormones are integral signaling modulators of the immune system. Sex hormones play definitive roles in lymphocyte maturation, activation, and synthesis of antibodies and cytokines. In autoimmune disease, expression of sex hormones is altered, and this change contributes to immune dysregulation (Nussinovitch & Shoenfeld, 2012).

Gerontologic Considerations Immunosenescence is a complex route in which the aging process stimulates changes in the immune system. The immune system undergoes age-associated

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CHART 51-3

Assessing for Immune Dysfunction Be alert for the following signs and symptoms:

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

Musculoskeletal System • Joint mobility, edema, and pain

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

alterations that lead to a progressive deterioration in the ability to respond to infections. The capacity for selfrenewal of hematopoietic stem cells diminishes. There is a notable decline in the total number of phagocytes, coupled with an intrinsic reduction in their activity. The cytotoxicity of NK cells decreases, contributing to a decline in humoral immunity (Corona, Fenn, & Godbout, 2012). The reduction in the number of circulating lymphocytes impedes the efficacy of vaccination in older adults. Age related changes to the number and function of innate immune cells impair the body’s ability to defend against viral and microbial pathogens (Solana, Tarazona, Gayoso, et al., 2012).

The incidence of autoimmune diseases also increases with age, possibly from a decreased ability of antibodies to differentiate between self and nonself. Failure of the surveillance system to recognize mutant or abnormal cells also may be responsible, in part, for the high incidence of cancer associated with increasing age. Age-related changes in many body systems also contribute to impaired immunity (Table 51-4). 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 the risk for urinary tract infections. Moreover, prostatic enlargement or a neurogenic bladder can impede urine passage and impair bacterial clearance through the urinary system. Urinary stasis, common in older 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 effectiveness of cilia, and the ability to cough effectively. These impairments hinder the removal of infectious organisms and toxins, increasing the older person’s susceptibility to pulmonary infections and cancers. The skin becomes thinner and less elastic. Impaired skin integrity predisposes older people to infection from organisms that are part of normal skin flora. Secondary changes, including malnutrition and poor circulation, as well as the breakdown of natural mechanical barriers such as the skin, place the aging immune system at even greater disadvantage against infection. In addition, the increased incidence of peripheral neuropathy and the accompanying decreased sensation and circulation may lead to stasis ulcers, pressure ulcers, abrasions, and burns. The effects of the aging process and psychological stress interact, with the potential to negatively influence immune integrity (Huifen, Manwani, & Leng, 2011; Hunt, Walsh, Voegeli, et al., 2010; Lavretsky, 2010). Consequently, continual assessment of the physical and emotional status of the older is imperative, because early recognition and management of factors influencing immune response may prevent or mitigate the high morbidity and mortality seen with illness in the older population (Goldstein, 2012; Hahn, 2012).

Nutrition The relationship of infection to nutritional status is a key determinant of human health. Traditionally, this relationship focused on the effect of nutrients on host defenses and the effect of infection on nutritional needs. This has expanded in scope to encompass the role of specific nutrients in acquired immune function—the modulation of inflammatory processes and the virulence of the infectious agent itself. Iron may have beneficial or deleterious effects on the immune system, and further research is needed (Wessling-Resnick, 2010). The list of nutrients affecting infection, immunity, inflammation, and cell injury has expanded from traditional proteins to several vitamins, multiple minerals, and more recently specific lipid components of the diet (Offord, Karagounis, Vidal, et al., 2013). Vitamin D deficiency has been associated with increased risk of common cancers, autoimmune diseases, and infectious diseases (Hughes, Kutner & Brown,

CHAPTER 51

TABLE 51-4

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Age-Related Changes in Immunologic Function

Body System

Changes

Consequences

Immune

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 “nonself ” Suppressed phagocytic immune response

Suppressed responses to pathogenic organisms with increased risk for infection Increased incidence of cancers Anergy (lack of response to antigens applied to the skin [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 (e.g., reactivation or spread of tuberculosis)

Gastrointestinal

Decreased gastric secretions and motility Decreased phagocytosis by the liver’s Kupffer cells Altered nutritional intake with inadequate protein intake

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

Decreased kidney function and changes in lower urinary tract function (enlargement of prostate gland, neurogenic bladder). Altered genitourinary tract flora

Urinary stasis and increased incidence of urinary tract infections

Pulmonary

Impaired ciliary action due to exposure to smoke and environmental toxins

Impaired clearance of pulmonary secretions; increased incidence of respiratory infections

Integumentary

Thinning of skin with less elasticity; loss of adipose tissue

Increased risk of skin injury, breakdown, and infection

Circulatory

Impaired microcirculation

Stasis and pressure ulcers

Neurologic function

Decreased sensation and slowing of reflexes

Increased risk of injury, skin ulcers, abrasions, and burns

2013). More recently, the role of micronutrients and fatty acids on the response of cells and tissues to hypoxic and toxic damage has been recognized, suggesting that there is another dimension to the relationship. Micronutrients such as zinc, copper, manganese, and selenium may have widespread negative effects on the immune response, which can be reversed by supplementation (CherryBukowiec, 2013). The effects exerted by polyunsaturated fatty acids on immune system functions are under investigation. Studies show that these elements play a role in diminishing the incidence and severity of inflammatory disorders and may serve as immunomodulators (Hardin-Fanning, Boissonneault, & Lennie, 2011). Recent studies show that diets high in olive oil are not as immunosuppressive as diets rich in fish oil. 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 or serious illness, nutritional requirements may be further altered, potentially contributing to depletion of protein, fatty acid, vitamin, and trace elements and causing even greater risk of impaired immune response and sepsis. Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; patients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the patient’s nutritional status, caloric intake, and quality of foods ingested. There is evidence that nutrition plays a role in the development of cancer and that

diet and lifestyle can alter the risk of cancer development as well as other chronic diseases (Milner & Beck, 2012; Prasad, Sung, & Aggarwal, 2012). The nurse is responsible for assuming a proactive role in ensuring the best possible nutritional intake for all patients as a vital step in preventing disease and poor outcomes (Tappenden, Quatrara, Parkhurst, et al., 2013).

Infection and Immunization The patient is asked about childhood and adult immunizations, including vaccinations, to provide protection against influenza, pneumococcal disease (Pneumovax), pertussis, herpes simplex, and the usual childhood diseases (e.g., measles, mumps). Herpes simplex virus (HSV) infections have a significant impact on health, causing a wide range of diseases (e.g., oral and genital herpes). Teaching about the importance of adhering to the recommended schedule for these vaccines should be initiated. 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 documented. Recent 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 infections (STIs) or bloodborne pathogens such as hepatitis A, B, C, D, and E viruses and human immunodeficiency virus (HIV). A history of STIs such as gonorrhea, syphilis, human papillomavirus (HPV) infection, and chlamydia can alert the nurse that the patient may have been exposed to HIV or hepatitis. A history of past and present infections and the dates and types of treatments, along with a history of any multiple persistent

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infections, fevers of unknown origin, lesions or sores, or any type of drainage, as well as the response to treatment are obtained.

Allergy The patient is asked about any allergies, including types of allergens (e.g., pollens, dust, plants, cosmetics, food, medications, vaccines, latex), the symptoms experienced, and seasonal variations in occurrence or severity in the symptoms. A history of testing and treatments, including prescribed and over-the-counter medications that the patient has taken or is currently taking 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. Continued assessment for potential allergic reactions in the patient is vital.

Disorders and Diseases Autoimmune Disorders Autoimmune disorders affect people of both genders of all ages, ethnicities, and social classes. 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 Canadian population. The occurrence of different autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease (Hemminki, Li, Sundquist et al., 2010; Wu, Nguyen, Poon, et al., 2012). 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 If there is a history of cancer in the family, the type of cancer, age at onset, and relationship (maternal or paternal) of the patient to the affected family members is noted. Dates and results of any cancer screening tests for the patient are documented. A history of cancer in the patient is also obtained, along with the type of cancer, date of diagnosis, and treatment modalities used. Immunosuppression contributes to the development of cancers; however, cancer itself is immunosuppressive, as is the treatment for cancer. Large tumours can release antigens into the blood, and these antigens combine with circulating antibodies and prevent them from attacking the

tumour cells. Furthermore, tumour cells may possess special blocking factors that coat tumour cells and prevent their destruction by killer T lymphocytes. During the early development of tumours, the body may fail to recognize the tumour 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 recorded in the health history. In addition, the nurse should elicit information related to complementary or alternative modalities that have been used and the response to these efforts. Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. The size and extent of the irradiated area determine the extent of immunosuppression. Whole-body irradiation may leave the patient totally immunosuppressed. Chemotherapy also affects bone marrow function, destroying cells that contribute to an effective immune response and resulting in immunosuppression (Zack, 2012).

Chronic Illness and Surgery The health assessment includes a history of chronic illness, such as diabetes mellitus, renal disease, chronic obstructive pulmonary disease (COPD), or fibromyalgia. 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 COPD as a result of altered inspiratory and expiratory function and ineffective airway clearance. Additionally, a history of organ transplantation or surgical removal of the spleen, lymph nodes, or thymus is noted, because these conditions may place the patient at risk for impaired immune function (McCaffery, 2011).

Special Problems Conditions such as burns and other forms of injury and infection may contribute to altered immune system function. Major burns cause impaired skin integrity and compromise the body’s first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. The physiologic and psychological stressors associated with surgery or injury stimulates 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,

CHAPTER 51

TABLE 51-5

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Selected Medications and Effects on the Immune System

Drug Classification (and Examples)

Effects on the Immune System

Antibiotics (in large doses) ceftriaxone (Rocefin) cefuroxime sodium (Ceftin) chloramphenicol (Chloromycetin) dactinomycin (Cosmogen) fluoroquinolones (Cipro, Levaquin, Tequin) gentamicin sulfate (Garamycin) macriolides (erythromycin, Zithromax, Biaxin) penicillins streptomycin vancomycin (Vancocin, Vancoled)

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 Agranulocytosis Leukopenia, neutropenia, pancytopenia Transient leukopenia

Antithyroid Drugs propylthiouracil (PTU)

Agranulocytosis, leukopenia

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) (in large doses) aspirin COX-2 inhibitors ibuprofen (Advil, Motrin) indomethacin (Indocid, Indocin) phenylbutazone

Inhibit Prostaglandin Synthesis or Release

Adrenal Corticosteroids prednisone

Immunosuppression

Antineoplastic Agents (cytotoxic agents) alkylating agents cyclophosphamide (Cytoxan) mechlorethamine HCl (Mustargen) cyclosporine

Immunosuppression Leukopenia, bone marrow suppression Leukopenia, neutropenia Agranulocytosis, neutropenia Leukopenia, inhibits T-lymphocyte function

Antimetabolites fluorouracil (pyrimidine antagonist) methotrexate (folic acid antagonist) mercaptopurine (6-MP) (purine antagonist)

Immunosuppression Leukopenia, eosinophilia Leukopenia, aplastic bone marrow Leukopenia, pancytopenia

Agranulocytosis Anemia, allergy, no major other adverse affects to the immune system Leukopenia, neutropenia Agranulocytosis, leukopenia Pancytopenia, agranulocytosis, aplastic anemia

salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), and anesthetic agents can cause immune suppression (Table 51-5). 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 HIV transmission through blood transfusion is extremely low in patients who received a transfusion after 1985 (when testing of blood for HIV was initiated in the United States), a small risk remains. The patient is also asked about use of herbal agents and over-the-counter medications. Because many of these products have not been subjected to rigorous testing, their effects have not been fully identified. It is important, therefore, to ask patients about their use of these substances, to document their use, and to educate patients about untoward effects that may alter immune responsiveness.

a detailed patient history. Although factors that are not consistent with a healthy lifestyle are predominately responsible for ineffective immune function, positive lifestyle factors can also negatively affect immune function and require assessment. For example, rigorous exercise or competitive exercise—usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response (Romeo, Warnberg, Pozo, et al., 2010). This outcome is compounded if the person also faces stressful environmental conditions while undergoing exercise. Given the cumulative impact of various environmental stressors on the immune system, every effort should be made to minimize the person’s exposure to stressors other than the exercise performed (Kippelan & Anderson, 2012). See the nursing research profile in Chart 51-4.

Lifestyle Factors

Patient assessment must also address psychoneuroimmunologic factors. The bidirectional pathway between the brain and immune system is referred to as psychoneuroimmunology, a field that has been the focus of research and discussion over the last several decades ( Jaremka, Lindgren, & Kiecolt-Glaser, 2013; Segerstrom, 2010). It is thought that the immune response is regulated and modulated in part by neuroendocrine influences. Lymphocytes

Like any other body system, the functions of the immune system depend on other body systems. Poor nutritional status, smoking, excessive consumption of alcohol, illicit drug use, STIs, and occupational or residential exposure to environmental radiation and pollutants have been associated with impaired immune function and are assessed in

Psychoneuroimmunologic Factors

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NURSING RESEARCH PROFILE

Chart 51-4. Dose Effects of Relaxation Practice on Immune Response in Women Newly Diagnosed With Breast Cancer: An Exploratory Study Kang, D., McArdle, T., Park, N., et al. (2011). Dose effects of relaxation practice on immune responses in women newly diagnosed with breast cancer: An exploratory study. Oncology Nursing Forum, 38 (3), E240–E252. doi:10.1188/11.ONF. E240-E252 doi:10.1188/11.ONF.E240-E252 Purpose Stress can adversely affect immune function. The purpose of this study was to investigate the effects of relaxation techniques on immune responses. Forty-nine women with newly diagnosed breast cancer participated in relaxation techniques and were assessed twice a month for 10 months with immune measurements

and macrophages have receptors that are capable of responding to neurotransmitters and endocrine hormones. Lymphocytes can produce and secrete adrenocorticotropic hormone and endorphinlike compounds. Cells 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 to maintain 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 behaviour. 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 biobehavioural strategies involving self-regulation. Examples of these strategies are relaxation and imagery techniques, biofeedback, humour, hypnosis, and conditioning. The assessment should address the patient’s general psychological status and the patient’s use of these strategies.

Physical Assessment On physical examination (see Chart 51-3), 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, their location, size, consistency, and reports of tenderness on palpation are noted. Joints are assessed for tenderness, swelling, increased warmth, and limited range of motion. The patient’s respiratory, cardiovascular, genitourinary, gastrointestinal, and neurosensory systems are evaluated for signs and symptoms indicative of immune dysfunction. Any functional limitations or disabilities the patient may have are also assessed.

at the beginning and end of a 10-month practice. Immune measurements were evaluated by natural killer cell activity, lymphocyte proliferation, interferon responses, and interleukin responses. Findings Persistent relaxation practice significantly contributed to positive natural killer cell activity, lymphocyte proliferation and some interleukin variance. The findings suggest that long term adherence to a regular relaxation program may have positive effects on multiple immune responses. This supports nurses offering patient choice in preferred relaxation techniques in practice.

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 individual disease processes in subsequent chapters in this unit. Selected laboratory and diagnostic tests used to evaluate immune competence are summarized in Chart 51-5.

CHART 51-5

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 human immunodeficiency virus (HIV) infection.

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 (electrophoresis, immunoelectrophoresis, single radial immunodiffusion, nephelometry, and 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

CHAPTER 51

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 also many psychological reactions. It is the nurse’s role to counsel, educate, and support patients throughout the diagnostic process. 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 ideal time for the nurse to provide counselling and education, should these interventions be warranted.

Critical Thinking Exercises 1 A 70-year-old woman is referred to the allergy and immunology clinic for evaluation of her immune status. In addition to the eight medications she routinely takes, she has received several courses of antibiotics in the previous months for recurrent infections. What diagnostic tests would you expect to be ordered? What is the rationale for these? What further assessment data would you want to obtain from this patient? 2

A 38-year-old woman is hospitalized for a heart transplant, and immunosuppressant medications are prescribed. Describe how her altered immune function would affect the care that you provide. Develop an evidence-based teaching plan for the patient and her family before hospital discharge. Discuss the criteria used to assess the strength of the evidence for your teaching plan.

3 A 24-year-old woman is diagnosed with systemic lupus erythematosus (SLE), and corticosteroids are prescribed. What nursing observations and assessments are indicated? Identify patient teaching that is appropriate for the new diagnosis and prescription of steroids.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Abbas, A., Lichtman, A., & Pillai, S. (2014). Basic immunology, functions and disorders of the immune system (4th ed.). Philadelphia, PA: W. B. Saunders. Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2012). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby. Brophy, K., Scarlett-Ferguson, H., Webber, K. S., et al. (2011). Clinical drug therapy for Canadian practice (2nd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer HealthéLippincott Williams & Wilkins. Johnson, M., Bulechek, G., Butcher, H. K., et al. (2011). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical thinking and quality care (3rd ed.). St. Louis, MO: Mosby. Lehne, R. (2013). Pharmacology for nursing care (8th ed.). St. Louis, MO: Elsevier/Saunders. Levinson, W. (2012). Review of medical microbiology and immunology (12th ed.). Columbus, OH: The McGraw-Hill Companies.

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Liles, W. C. (2010). Immunomodulators. In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds.), Principles and practices of infectious diseases (7th ed.). Philadelphia, PA: Elsevier/Churchill Livingstone. McInnes, I. B. (2013). Cytokines. In Harris, Kelley’s textbook of rheumatology (9th ed.). Philadelphia, PA: Saunders/Elsevier. Moorhead, S., Johnson, M., Mass, M. L., et al. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby. Sherwood, L., Kell, R., & Ward, C. (2013). Human physiology: From cells to systems (2nd Canadian Ed). Toronto, ON: Nelson Education. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (Eds.). (2010). Canadian Bates’ guide to health assessment for nurses (1st. ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

JOURNALS *Bennetts, P., & Pierce, J. (2010). Apoptosis: Understanding programmed cell death for the CRNA. Journal of the American Association of Nurse Anesthetists, 78 (3), 237–245. *Blendell, R. L., & Fehr, J. L. (2012). Discussing vaccination with concerned patients: An evidence-based resource for healthcare providers. Journal of Perinatal and Neonatal Nursing, 26(3), 230–241. doi: 10.1097/JPN.0b013e3182611b7b *Cherry-Bukowiec, J. (2013). Optimizing nutrition therapy to enhance mobility in critically ill patients. Critical Care Nursing Quarterly, 36(1), 28–36. doi:10.1097/CNQ.0b013e31827507d7 Corona, A. W., Fenn, A. M., & Godbout, J. P. (2012). Cognitive and behavioral consequences of impaired immunoregulation in aging. Journal of NeuroImmune Pharmacology, 7(1), 7–23. doi.10.1007/ s11481-011-9313-4 Goldstein, D. (2012). Role of aging on innate responses to viral infections. Journals Of Gerontology Series A: Biological Sciences and Medical Sciences, 67(3), 242–246. *Hahn, J. (2012). Minimizing health risks among older adults with intellectual and/or developmental disabilities: Clinical considerations to promote quality of life. Journal of Gerontological Nursing, 38 (6), 11–17. doi: 10.3928/00989134-20120510-01 *Hardin-Fanning, F., Boissonneault, G. A, & Lennie, T. A., (2011). Polyunsaturated fatty acids. Journal of Gerontological Nursing, 37(5), 20–28. doi:10.3928/00989134-20110201-01 Hemminki, K., Li, X., Sundquist, J., et al. (2010). Subsequent autoimmune or related disease in asthma patients: Clustering of diseases or medical care? Annals of Epidemiology, 20(3), 217–222. doi:10.1016/j. annepidem.2009.11.007 *Hendry, C., Farley, A., McLafferty, E., et al. (2013). Function of the immune system. Nursing Standard, 27(19), 35–42. *Hughes, P. J., Kutner, A., & Brown, G. (2013). The physiology and pharmacology of vitamin D. Nurse Prescribing, 11(7), 344–351. Huifen, L., Manwani, B., & Leng, S. X. (2011). Frailty, inflammation, and immunity. Aging and Disease, 2(6), 466–473. *Hunt, K., Walsh, B., Voegeli, D., et al. (2010). Inflammation in aging part 1: Physiology and immunological mechanisms. Biological Research for Nursing, 11(3), 245–252. doi:10.1177/1099800409352237 Jaremka, L., Lindgren, M., & Kiecolt-Glaser, J. (2013). Synergistic relationships among stress, depression, and troubled relationships: Insights from psychoneuroimmunology. Depression and Anxiety (10914269), 30(4), 288–296. doi:10.1002/da.22078 *Kang, D., McArdle, T., Park, N., et al. (2011). Dose effects of relaxation practice on immune responses in women newly diagnosed with breast cancer: An exploratory study. Oncology Nursing Forum, 38 (3), E240–E252. doi:10.1188/11.ONF.E240-E252 Kippelen, P., & Anderson, S. (2012). Airway injury during high-level exercise. British Journal of Sports Medicine, 46(6), 385–390. doi:10.1136/bjsports-2011-090819 Lavretsky, H. (2010). Resilience, stress, and the neurobiology of aging. Psychiatric Times, 27(9), 10–14. Master, Z., & Crozier, G. G. (2012). The ethics of moral compromise for stem cell research policy. Health Care Analysis, 20(1), 50–65. doi: 10.1007/s10728-011-01712 Milner, J. J., & Beck, M. A. (2012). The impact of obesity on the immune response to infection.The Proceedings of the Nutrition Society, 71(2), 298–306. doi: 10.1017/S0029665112000158 Nussinovitch, U., & Shoenfeld, Y. (2012). The role of gender and organ specific autoimmunity. Autoimmunity Reviews, 6–7(11), A377–A385. doi. 10.1016/j.autrev.2011.11.001 Offord, E. E., Karagounis, L. L., Vidal, K. K., et al. (2013). Nutrition and the biology of human ageing: Bone health & osteoporosis / sarcopenia /

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immune deficiency. Journal Of Nutrition, Health and Aging, 17(8), 712– 716. doi:10.1007/s12603-013-0374-3 Ozdemir, C. (2011). Specific immunotherapy and turning off the T-cell: How does it work. Annals of Allergy, Asthma, and Immunology, 107(5), 381–392. Prasad, S., Sung, B., & Aggarwal, B. (2012). Age-associated chronic diseases require age-old medicine: Role of chronic inflammation. Preventive Medicine, 54, S29–S37. Romeo, J., Wärnberg, J., Pozo, T., et al. (2010). Physical activity, immunity and infection. The Proceedings of the Nutrition Society, 69(3), 390– 399. doi: 10.1017/S0029665110001795 Segerstrom, S. (2010). Resources, stress, and immunity: An ecological perspective on human psychoneuroimmunology. Annals of Behavioral Medicine, 40(1), 114–125. doi:10.1007/s12160-010-9195-3 Solana, R., Tarazona, R., Gayoso, I., et al. (2012). Innate immunosenescence: Effect of aging on cells and receptors of the innate immune system in humans. Seminars in Immunology, 24(5), 331–341. doi:10.1016/j. smim.2012.04.008 *Tappenden, K. A., Quatrara, B., Parkhurst, M. L., et al. (2013). Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition. MEDSURG Nursing, 22(3), 147–165. Viganó, S. S., Perreau, M. M., Pantaleo, G. G., et al. (2012). Positive and negative regulation of cellular immune responses in physiologic con-

ditions and diseases. Clinical and Developmental Immunology, 1–11. doi:10.1155/2012/485781 Wessling-Resnick, M. (2010). Iron Homeostasis and the inflammatory response. Annual Review of Nutrition, 30, 105– 122. doi:10.1146/ annurev.nutr.012809.104804 Wu, J., Nguyen, T., Poon, K., et al. (2012). The association of psoriasis with autoimmune diseases. Journal of the American Academy of Dermatology, 67(5), 924–930. doi:10.1016/j.jaad.2012.04.039 Zack, E. (2012). Chemotherapy and biotherapeutic agents for autoimmune diseases. Clinical Journal of Oncology Nursing, 16(4), E125–E132.

RESOURCES Canadian Allergy, Asthma and Immunology Foundation: http://www. allergyfoundation.ca/ Canadian Institute for Health Information: http://www.cihi.ca/CIHI-extportal/internet/EN/Home/home/cihi000001 Canadian Society of Allergy and Clinical Immunology: http://www.csaci. ca/. Genetic Alliance: http://www.geneticalliance.org/ National Organization for Rare Disorders: https://www.rarediseases.org/ OMIM—Online Mendelian Inheritance in Man: http://www.ncbi.nlm. nih.gov/omim.

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52 Management of Patients With Immunodeficiency Adapted by Kari Krell

Learning Objectives On completion of this chapter, the learner will be able to: 1. Compare the different types of primary immunodeficiency disorders and their causes, clinical manifestations, potential complications, and treatment modalities. 2. Describe the nursing management of the patient with an immunodeficiency. 3. Identify the essential teaching needs for a patient with an immunodeficiency. 4. Describe the nursing management of the patients with an immunodeficiency.

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Immunodeficiency disorders may be caused by a defect in or a deficiency of phagocytic cells, B lymphocytes, T lymphocytes, or the complement system. The specific symptoms and their severity, age at 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 and severe infections, infections caused by unusual organisms or by organisms that are normal body flora, poor response to standard treatment for infections, and chronic diarrhea. In addition, the patient is susceptible to a variety of secondary disorders, including cancer (Hannon, Pooler, & Porth, 2010). Immunodeficiencies may be classified as either primary or secondary and by the affected components of the immune system. Primary immunodeficiency diseases are genetic in origin and are caused by intrinsic defects in the cells of the immune system. In contrast, secondary immunodeficiencies, such as acquired immunodeficiency syndrome (AIDS), are caused by triggers such as infection with human immunodeficiency virus (HIV). Essential elements of effective nursing care include knowledge of the immune system and potential secondary disorders, skillful assessment, symptom management, and sensitivity and responsiveness to the learning needs of the patient and caregiver.

PRIMARY IMMUNODEFICIENCIES Primary immunodeficiencies represent inborn errors of immune function and include a variety of syndromes that render patients more susceptible to infections. Primary immunodeficiencies can be fatal if not treated. They are seen primarily in infants and young children. Occasionally, adults present with clinical episodes of infectious diseases that are beyond the scope of normal immunocompetence. Examples include infections that are unusually persistent, recurrent, or resistant to treatment and those involving unexpected dissemination of disease or atypical pathogens. Although some immunodeficiencies have mild presentations and good outcomes, others result in severe infection and significant morbidity and mortality. To date, more than 150 immunodeficiencies of genetic

origin have been identified (Burton, Murphy, & Reily, 2010). Common primary immunodeficiencies include disorders of humoural immunity (affecting B-cell differentiation or antibody production), T-cell defects, and combined B- and T-cell defects; phagocytic disorders; and complement deficiencies. These disorders may involve one or more components of the immune system. Symptoms of immunodeficiency diseases are related to the role that the deficient component normally plays (Table 52-1). Major signs and symptoms include multiple infections despite aggressive treatment, infections with unusual or opportunistic organisms, failure to thrive or poor growth, and a positive family history (Costa-Carvalho, Grumach, Franco, et al., 2014).

PHAGOCYTIC DYSFUNCTION Pathophysiology A variety of primary defects of phagocytes may occur; almost all of them are genetic in origin and affect the natural (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 person cannot initiate a normal inflammatory response against pathogenic organisms. 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. Phagocytic cell disorders are characterized by disease-specific infections, such as chronic granulomatous disease (Abbas, Lichtman, & Pillai, 2014).

Clinical Manifestations In phagocytic cell disorders there is an increased incidence of bacterial and fungal infections caused by organisms that are normally nonpathogenic. People with these disorders may also develop fungal infections from Candida organisms and viral infections from herpes simplex or herpes zoster. These patients experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis. In one rare type of

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: loss of muscle coordination 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: 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 52

TABLE 52-1

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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

Antibiotic therapy and treatment for viral and fungal infections Granulocyte-macrophage colonystimulating factor (GM-CSF); granulocyte colony-stimulating factor (G-CSF)

B lymphocytes

Sex-linked agammaglobulinemia (Bruton’s disease) Common variable immunodeficiency (CVID)

Severe pyogenic infections soon after birth Bacterial infections, infection with Giardia lamblia

Passive pooled plasma or gammaglobulin Intravenous immunoglobulin (IVIG) 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

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)

Thymus graft

Ataxia with progressive neurologic deterioration, telangiectasia (vascular lesions), recurrent infections; malignancies Severe infections, malignancies

Antimicrobial therapy; management of presenting symptoms; fetal thymus transplant, IVIG

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)

Angioneurotic edema

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

Paroxysmal nocturnal hemoglobinuria (PNH)

Pooled immunoglobulin

phagocytic disorder, hyperimmunoglobulinemia E syndrome (formerly known as Job syndrome), white blood cells cannot initiate an inflammatory response to infectious organisms. This results in recurrent bacterial infections of the skin and lung; abnormalities of connective tissue, skeleton, and dentition; and extremely elevated levels of IgE (Cohen, Powderly, & Opal, 2010). Although patients with phagocytic cell disorders may be asymptomatic, severe neutropenia may present and 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

Antifungal agents: Topical: miconazole Oral: clotrimazole, ketoconazole IV: amphotericin B

Antimicrobial therapy; IVIG, bone marrow transplantation; thymus transplantation; thymus factors Antimicrobial therapy; splenectomy with continuous antibiotic prophylaxis; IVIG and bone marrow transplantation Antimicrobial therapy; IVIG and bone marrow transplantation Pooled plasma, androgen therapy

None

primary phagocytic disorder, produces recurrent or persistent infections of the soft tissues, lungs, and other organs; these are resistant to aggressive treatment with antibiotics (EunKyung, Jaishankar, Saleh, et al., 2011).

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

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tetrazolium reductase test. 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. Warning signs of primary immunodeficiency disorders are summarized in Chart 52-1.

Medical Management Patients with neutropenia continue to be at increased risk for development of severe infections despite substantial advances in supportive care. Epidemiologic shifts occur periodically and need to be detected early because they influence prophylactic, empiric, and specific strategies for medical management. Attention to infection control practices is important, especially with the emergence of multidrug-resistant organisms. Although it is effective in preventing some bacterial and some fungal infections, prophylactic drug treatment must be used with caution, because it has been implicated in the emergence of resistant organisms. The choices for empiric therapy include combination regimens and monotherapy. Specific choices depend on local factors (epidemiology, susceptibility/ resistance patterns, availability, cost). Home and inpatient

settings are also available and the selection of setting depends on the patient’s risk category. Early diagnosis and appropriate treatment of many fungal and viral infections remains suboptimal in many cases (Saria, 2011). While granulocyte transfusions are used as a medical treatment, they are seldom successful because of the short halflife of these cells. Treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF) or granulocyte colony-stimulating factor (G-CSF) may prove successful, because these proteins draw nonlymphoid stem cells from the bone marrow and hasten their maturation. Cell therapy, which refers to the provision of living cells to patients for the prevention of human disease, may be effective. (The infusion of blood and blood products is the best established and most widely practiced form of cell therapy.) Hematopoietic stem cell transplantation (HSCT), another form of cell therapy, has proven to be a successful curative modality. The stem cells may be from embryos or adults. However, toxicity and reduced efficacy are frequent limitations of HSCT (Barrell, Dietzen, Zhezhen, et al., 2012; Ernst, Sauerbrei, Krumbholz, et al., 2012). Another emerging therapy involves the use of cells as vehicles for the delivery of genes or gene products. However, gene therapy has many side effects and needs further improvement (Booth, Gaspar, & Thrasher, 2011).

CHART 52-1

The Ten Warning Signs of Primary Immunodeficiency Primary immunodeficiency 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 immunodeficiency 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 immunodeficiency. 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 year

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 immunodeficiency

10

Though the primary immunodeficiency diseases can be serious, they are rarely fatal and can generally be controlled. Primary immunodeficiency should not be confused with acquired immunodeficiency syndrome (AIDS). Primary immunodeficiency 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 immunodeficiency. Educational materials developed by the Jeffrey Modell Foundation Medical Advisory Board, New York, NY. Used with permission.

CHAPTER 52

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 absent, and the germinal centres from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens. This syndrome is called X-linked agammaglobulinemia (Bruton’s disease), because all antibodies disappear from the patient’s plasma. B cells in the peripheral blood and IgG, IgM, IgA, IgD, and IgE are low or absent. Infants born with this disorder suffer from severe infections starting soon after birth. Males are at a high risk for having X-linked agammaglobulinemia if they have an affected male relative. More than 10% of patients with X-linked agammaglobulinemia are hospitalized for infection when they are younger than 6 months of age; prognosis depends on prompt recognition and treatment (Hannon et al., 2010). The second type of B-cell deficiency results from a lack of differentiation of B cells into plasma cells. Only diminished antibody 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 CVID; this disorder encompasses a variety of defects ranging from IgA deficiency, in which only the plasma cells that produce IgA are absent, 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. Most patients are diagnosed as adults, and delay in recognition of the disease is common. CVID is characterized by recurrent bacterial infections, especially of the upper and lower respiratory airways, and is also associated with an increased incidence of autoimmune and neoplastic disorders. Several T- and B-cell defects have been described, although the underlying cause is still unknown. The etiology of this disorder is believed to be multifactorial (Christian, 2011). It is estimated that CVID affects 1 in 10,000 (Immunodeficiency Canada, 2014).

Clinical Manifestations Infants with X-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 that time. 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. Young adults who develop

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the disease also have an increased incidence of chronic lung disease, hepatitis, gastric cancer, and malabsorption that results in chronic diarrhea (Hannon et al., 2010). 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 jiroveci pneumonia (PCP), 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 repeated 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. Measuring only the total serum globulin level is inadequate, because a compensatory overproduction of one globulin may mask the loss of another globulin or the deficiency of a globulin that is 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. Biopsies of the small intestine, spleen, and stomach may also be obtained to assess for lymphoid hyperplasia.

Medical Management Patients with primary phagocytic disorders may be treated with intravenous immunoglobulin (IVIG) (Chart 52-2). Its administration is an essential part of the prevention and treatment of complications of CVID (Younger, Aro, Blouin, et al., 2013). Antibody replacement therapy is recommended for severe, recurrent infections. Other interventions aimed at overcoming the immunologic defects in CVID, such as interleukin-2 therapy, are being studied (Brophy, Scarlett-Ferguson, Webber, et al., 2011; Rizzieri, Crout, Storms, et al., 2011).

T-CELL DEFICIENCIES Pathophysiology Defects in T cells lead to opportunistic infections. Most primary T-cell immunodeficiencies are genetic in origin. Although an increased susceptibility to infection is

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CHART 52-2

Pharmacology: Managing an Intravenous Immunoglobulin (IVIG) Infusion IVIG has become an important treatment for a variety of disease states that are characterized by deficient production of antibodies. It may have other indications but is commonly used for the treatment of DiGeorge syndrome, common variable immunodeficiency disease (CVID), severe combined immunodeficiency disease (SCID), Wiskott-Aldrich syndrome, and idiopathic thrombocytopenic purpura. 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, and it can safely be given in outpatient as well as inpatient settings. Variables affecting the risk and intensity of adverse events associated with the administration of IVIG include patient age, underlying condition, history of migraine, and cardiovascular and/or renal disease; dose, concentration, and rate of infusion; and specific data related to the precise lot of the product. The nurse must assess all of these variables before starting the IVIG infusion and during the infusion process. He or she must anticipate adverse effects if any of these variables are present (Shelton, Giffin, & Goldman, et al., 2006).

Guidelines for Nursing Management

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 U.S. Food and Drug Administration.

•

Dosage The optimal dose is 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 levels of immunoglobulin G.

• Pretreatment assessments should be performed before each infusion.

• Obtain height and weight before treatment to verify accurate dosing.

• Assess baseline vital signs before, during, and after treat-

• •

• •

•

•

Adverse Effects • Complaints of flank and back pain, shaking chills, dyspnea,

and tightness in the chest; headache, fever, and local reaction at the infusion site. • Serious conditions, including aseptic meningitis, renal failure, thromboembolic events, and anaphylaxis. Anaphylactic reactions typically occur 30 to 60 minutes after the start of the infusion. The potential increases as the dose of IVIG increases. • Hypotension (possible with severe reactions).

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’s syndrome, or thymic hypoplasia, is one example of a primary T-cell immunodeficiency. This rare, complex, multisystem genetic abnormality is caused by the absence of several genes on chromosome 22 (Karl, Heling, Sarut Lopez, et al., 2012). The variation in symptoms is a result of differences in the amount of genetic material affected. T-cell deficiency occurs when the thy-

•

•

ment. An elevated temperature at the beginning of treatment may be an indication to delay the infusion to avoid misinterpretation as a reaction to the infusion. Premedicate with acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. Understand that long-term tolerance of an older IVIG product does not necessarily imply tolerance to a newer product, even if it is technically superior. Caution should be exercised when changing IVIG products because they are not biologically equivalent. Be aware that corticosteroids may be used to prevent possible severe reactions in patients who are perceived to be at risk. Administer the IV infusion at a slow rate, not to exceed 3 mL/min. Continually assess the patient for adverse reactions; be especially aware of complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchoconstriction. Stop the infusions at the first sign of reaction and initiate the institutional protocol to be followed in this emergent situation. Be aware that patients with low gammaglobulin levels have more severe reactions than those with normal levels (e.g., 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. Recognize that the pharmacokinetics of IgG differ when smaller doses are given more frequently, as is commonly done with subcutaneous regimens. Differences include lower peaks and higher troughs, which may be preferable for some patients. Remember that the risk of transmission of hepatitis, HIV, or other known viruses is extremely low.

mus gland fails to develop normally during embryogenesis. It often manifests in the neonatal period as a cardiac anomaly. DiGeorge’s syndrome is one of the few immunodeficiency disorders with symptoms that present almost immediately following birth (McDonald-McGinn & Sullivan, 2011). Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought to be an autosomal recessive disorder that affects both males and females. It is considered an autoimmune disorder involving the thymus and other endocrine glands. The disease causes extensive morbidity resulting from endocrine dysfunction.

CHAPTER 52

Clinical Manifestations Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy, congenital heart disease, cleft palate and lip, dysmorphic facial features, and possibly renal abnormalities (Hannon et al., 2010). These infants are susceptible to yeast, fungal, protozoan, and viral infections and are particularly susceptible to childhood diseases (chickenpox, measles, rubella), which are usually severe and may be fatal. Infection with Candida albicans is almost universal in patients with severe deficiencies in T cell–mediated immunity. Many affected infants are also born with congenital heart defects, which can result in 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 (Molesky, 2011). The initial presentation of chronic mucocutaneous candidiasis may be a result of 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 Prompt diagnosis is necessary for appropriate management. A comprehensive immunologic laboratory analysis is necessary. Findings in children with DiGeorge syndrome include cardiac, nutritional, and developmental abnormalities (Slatter, Cant, Arkwright, et al., 2011).

Medical Management Patients with T-cell deficiency should receive prophylaxis for PCP. General care includes management of hypocalcemia and correction of cardiac abnormalities. Hypocalcemia is controlled by oral calcium supplementation in conjunction with administration of vitamin D or parathyroid hormone. Congenital heart disease frequently results in heart failure, and these patients may require immediate surgical intervention in a tertiary care centre. Transplantation of fetal thymus, postnatal thymus, or human leukocyte antigen (HLA)-matched bone marrow has been used for permanent reconstitution of T-cell immunity. In patients with DiGeorge syndrome, attention must be given to cardiac, nutritional, and developmental needs (Abbas et al., 2014). IVIG may be used if an antibody deficiency exists. This therapy may also be used to control recurrent infections. T-cell function improves with age and often is normal by 5 years of age. Prolonged survival has been reported after spontaneous remission of immunodeficiency, which occurs in some patients (McCusker & Warrington, 2011).

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COMBINED B-CELL AND T-CELL DEFICIENCIES Pathophysiology T-cell and B-cell immune deficiencies comprise a heterogeneous group of disorders, all characterized by profound impairment in the development or function of the cellular, the humoral, or both parts of the immune system. A variety of inherited (autosomal recessive and X-linked) conditions fit this description. These conditions are typified by disruption of the normal communication system of B cells and T cells and impairment of the immune response, and they appear early in life (Abbas et al., 2014). Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder that arises because of a defect on chromosome 11, which is the ataxia-telangiectasia mutation that affects both T- and B-cell immunity (Levinson, 2012). 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. Severe combined immunodeficiency disease is a disorder in which both B cells and T cells are missing. Consequently, both cell-mediated and humoral functions are affected. In addition, SCID is marked by susceptibility to serious fungal, bacterial, and viral infections. It refers to a wide variety of congenital and hereditary immunologic defects characterized by early onset of infections, defects in both B-cell and T-cell systems, lymphoid aplasia, and thymic dysplasia. It is one of the most common causes of primary immunodeficiencies. Inheritance of this disorder can be X linked, autosomal recessive, 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. Wiskott-Aldrich syndrome (WAS), a variation of SCID, is an inherited immunodeficiency caused by a variety of mutations in the gene encoding the WAS protein. It is characterized by frequent infections, thrombocytopenia with small platelets, eczema, and increased risk of autoimmune disorders and malignancies. Vasculitides and autoimmune hemolytic anemia are the two most common autoimmune manifestations and often cause considerable morbidity and mortality. The prognosis is poor, because most affected people develop overwhelming fatal infections (Atkinson, 2012).

Clinical Manifestations The onset of ataxia and telangiectasia occurs in the first 4 years of life. Many patients, however, remain symptomfree for 10 years or longer. As the patient approaches the second decade of life, chronic lung disease, cognitive impairment, neurologic symptoms, and physical disability become

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severe. Long-term survivors develop progressive deterioration of immunologic and neurologic functions. Some affected patients have lived until 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 most patients with SCID. Symptoms include respiratory infections and pneumonia (often secondary to PCP infection), 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 rash are also common manifestations (Maggina & Gennery, 2013).

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 (see Chart 52-2). Treatment options for SCID include stem cell and bone marrow transplantation. HSCT has been the definitive therapy for SCID since the first successful transplant in 1968. The ideal donor is an HLA-identical sibling. Improvements continue in the use of HSCT to treat patients with SCID as well as other primary immunodeficiencies. Evidence demonstrates that transplantation of allogeneic hematopoietic stem cells can cause an enhanced improvement over time (Dempster, 2013; Mehr, Kakakios, Shaw, et al., 2011). Other treatment regimens include administration of IVIG or 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 Many patients require immunosuppression to ensure engraftment of depleted bone marrow during certain transplantation procedures. For this reason, nursing care must be meticulous, with attention to preventing the transmission of infection. The use of routine practices related to infection control is essential in caring for these patients (Brown, 2010). Additional precautions, such as protective measures, where nurses protect the patient by donning gowns, gloves, and caps, is essential. The patient’s condition must be monitored at all times, as a certain number of patients experience complications that can be fatal.

DEFICIENCIES OF THE COMPLEMENT SYSTEM The complement system is an integral part of the immune system, and deficiencies in normal levels of C2 and C3

complement result in increased susceptibility to infectious diseases and immune-mediated disorders. 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. C2 and C3 component deficiencies result in diminished resistance to bacterial infections. Hereditary angioneurotic edema results from the deficiency of C1-esterase inhibitor, which opposes the release of inflammatory mediators. The clinical picture of this autosomal dominant disorder includes recurrent attacks of edema formation in the subcutaneous tissue, gastrointestinal tract, and upper airway (Abbas et al., 2014). Although the disease is mild in childhood and becomes more severe after puberty, first episodes have been reported later in life. Food allergy has often been linked to this disorder, although recent evidence has implicated a C1-esterase inhibitor deficiency. The fluctuations in hormone levels at the beginning of adolescence, in the perimenopausal period, during pregnancy, and during the use of oral contraceptives can precipitate edematous attacks that usually disappear after the onset of menopause. Fresh-frozen plasma has been used as a treatment option, with variable results (Johnston, 2011; Sardana & Craig, 2011). Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder resulting from a somatic mutation in the hematopoietic stem cell. An absent glycosylphosphatidylinositol (GPI)-anchored receptor prevents several proteins from binding to the erythrocyte membrane. These include the complement-regulatory proteins, CD55 and CD59, the absence of which results in enhanced complement-mediated lysis. Patients with this disorder present with anemia and hemoglobinuria. Laboratory diagnosis can include specialized tests, such as the sucrose hemolysis test, Ham acid hemolysis test, and fluorescentactivated cell analysis. Treatment is mainly supportive, consisting of transfusion therapy, anticoagulation therapy, and antibiotic therapy. HSCT may be curative (Varma, Varma, Reddy, et al., 2012).

SECONDARY IMMUNODEFICIENCIES Secondary immunodeficiencies are more common than primary immunodeficiencies and frequently occur as a result of underlying disease processes or the treatment of these disorders. The immune system can be affected by a variety of intrinsic factors, including immunosuppressive agents, harsh environmental conditions, hereditary disorders other than primary immunodeficiencies, and acquired metabolic disorders that cause secondary immunodeficiencies. Common causes of secondary immunodeficiencies include 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. Perhaps the best-known secondary immunodeficiency results from human immunodeficiency virus (HIV) infection, which causes acquired immunodeficiency syndrome (AIDS); however, the most

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Chart 52-3. Nurse-Driven Quality Improvement Interventions to Reduce Hospital-Acquired Infection in the NICU Ceballos, K., Waterman, K., Hulett, T., et al. (2013). Nurse-driven quality improvement interventions to reduce hospitalacquired infection in the NICU. Advances in Neonatal Care (Elsevier Science), 13(3), 154–165. doi: 10.1097/ anc.0b013e318285fe70 Purpose Most hospitalized patients are at high risk for infection. The study was undertaken to measure quality improvement (QI) methods through education and bundled interventions on practice. The objectives were to (1) reduce central line-associated blood stream infections (CLABSI) and ventilator-associated infections (VAP) in the NICU and (2) to examine the influence on patient outcomes. Design This was a unit-based QI project that followed National Healthcare Safetly Network inclusion criteria for CLABSI and VAP determination.. An interdescipniary QI team designed NICU specific prevention bundle was implemented in a systematic maner on inpatients in all 5 birth weight categories. A pre-post design was used to evaluate the effectiveness of the change in practice.

prevalent cause of immunodeficiency worldwide is severe malnutrition. AIDS, the most common secondary disorder, is discussed in detail in Chapter 53. In secondary immunodeficiencies, abnormalities of the immune system affect both natural and acquired immunity, may be subtle, and are usually heterogeneous in their clinical manifestations. Patients with secondary immunodeficiencies are known as immunocompromised hosts.

Findings Before implementation of the CLASBI bundle, infants had CLASBI rates above national benchmarks. During the year of bundle implementation, July 1, 2009 to June 30, 2010, CLASBI rates significantly decreased in all weight categories except infants < 750 g at birth. Rates in infants with a central venous catheter were 0 in all weight categories except 1,011–1,500 g. After July 2009, the NICU had and overall rate of 0.4 infections per 1,000 central line days. The incidence of VAP also decreased. Post VAP bundle implementation, January 1, 2010 to December 31, 2011, the NICU reported a VAP rate of 0 infections per 1,000 ventilated days in all weight categories except infants < 750 g (3.9) and infants 751–1,000 g (7.8). Nursing Implications Quality improvement nurse leaders created evidence–based system solutions to change practice resulting in improved patient outcomes. A culture of nurse empowerment and interdisciplinary teamwork fostered increased compliance of bundle implementation and led to other improvements in the NICU in bedside practice.

pose a high risk for infection, careful assessment of the patient’s immune status is essential. The assessment focuses on the history of past infections, particularly the type and frequency of infection; methods of and response to past treatments; signs and symptoms of any current skin, respiratory, oral, gastrointestinal, or genitourinary infection; and measures taken by the patient to prevent infection. The nurse assesses and monitors the patient for signs and symptoms of infection (Chart 52-4).

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. See the Nursing Research Profile in Chart 52-3.

NURSING MANAGEMENT FOR PATIENTS WITH IMMUNODEFICIENCIES Nursing management includes assessment, patient teaching, selected interventions, and supportive care. Assessment of the patient for infection and timely initiation of treatment are essential. 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

CHART 52-4

Assessing for Infection Be alert for the following signs and symptoms: • Fever with or without chills • Cough with or without sputum • Shortness of breath • Difficulty breathing • Difficulty swallowing • White patches in the oral cavity • Swollen lymph nodes • Nausea with or without vomiting • Persistent diarrhea • Frequency, urgency, or pain on urination • Change in the character of the urine • Lesions on the face, lips, or perianal area • Redness, swelling, or drainage from skin lesions • Persistent vaginal discharge with or without perianal itching • Persistent abdominal pain

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Advances in science have had the effect of expanding the spectrum of dysfunctional immune responses, leading to larger numbers of patients diagnosed with immunodeficiencies. Many patients develop oral manifestations and need education about their role in promoting good dental hygiene. Because the inflammatory response may be blunted, the patient is observed for subtle and unusual signs and changes in physical status. Vital signs and the development of pain, neurologic signs, cough, and skin and oral lesions are monitored and reported immediately. Pulse rate and respiratory rate should be counted for a full minute, because subtle changes can signal deterioration in the patient’s clinical status. Auscultation of the breath sounds is important to detect changes in respiratory status that signal an existing or impending infection. Any unusual response to treatment or a significant change in the patient’s clinical condition must be promptly reported to the physician. (Kolins, Zoylut, Mccollum, et al., 2011). The nurse continuously monitors laboratory values for changes indicative of 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 fail to 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 practices, all of which may affect immune function. Strategies the patient has used to reduce the risk of infection are identified and evaluated for their appropriateness and effectiveness (Brown, 2010; Stephen, Skillen, Day, et al., 2012). 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, achieving optimal nutritional status, and maintaining respiratory, bowel, and bladder function. The patient’s ability to demonstrate good hand hygiene must be assessed, and the patient is encouraged to cough and perform deep-breathing exercises at regular intervals. Teaching good dental hygiene measures reduces the potential for oral lesions, as do instructions on measures to protect the integrity of the skin. Attention to strict aseptic technique when performing invasive procedures, such as dressing changes, venipunctures, and bladder catheterizations, is essential. Other aspects of nursing care include assisting the patient to

CHART 52-5

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

Caregiver

• Identify signs and symptoms of infection to report to the health care provider, such as fever;

✔

✔

• Demonstrate correct handwashing procedure.

✔

✔

• State rationale for thorough handwashing before eating, after using the bathroom, and

✔

✔

• State rationale for use of cream and emollients to prevent or manage dry, chafed, or

✔

✔

• Demonstrate recommended personal hygiene in bathing and foot care to prevent bacterial

✔

✔

• State rationale for avoiding contact with people who have known illness or who have

✔

✔

• 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

✔

✔

• Identify the rationale for frequent cleaning of kitchen and bathroom surfaces with

✔

✔

• 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

✔

✔

chills; wet or dry cough; breathing problems; white patches in the mouth; swollen glands; nausea; vomiting; persistent abdominal pain; persistent diarrhea; problems with urination or changes in the character of the urine; red, swollen, or draining wounds; sores or lesions on the body; persistent vaginal discharge with or without itching; and severe fatigue.

before and after performing health care procedures. cracked skin.

and fungal diseases.

recently been vaccinated.

thoroughly, and immediately refrigerating all leftover food. disinfectant.

obtaining adequate rest.

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CHART 52-6

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:

Patient

Caregiver

• Identify the benefits and expected outcome of IVIG.

✔

✔

• Demonstrate how to check for patency of the 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 acetaminophen (Tylenol) and diphenhydramine

✔

✔

• Verbalize understanding of emergency measures for anaphylactic shock.

✔

✔

(Benadryl) before treatment begins.

manage stress, to incorporate lifelong patterns of physiologic safety, and to adopt behaviours that strengthen 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-γ), the patient and family must be informed about the potential risks and benefits of the treatment regimen. A major role of the nurse is to develop and maintain a knowledge base in these evolving treatment modalities, to help the patient and family understand the treatment options and cope with the uncertainties of treatment outcomes.

Promoting Home and Community-Based Care Teaching Patients Self-Care The patient and caregivers require instruction about the signs and symptoms that indicate infection and about the potential for occurrence of atypical symptoms secondary to underlying immunosuppression. They must be informed of the need for continuous monitoring for subtle changes in the patient’s physical health status and of the importance of seeking immediate health care if changes are detected. 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, who will determine and initiate appropriate therapy. Instruction needs to be provided about prophylactic medication regimens, including dosage, indications, times, actions, potential interactions, and side effects. Patients and their families are also instructed about the importance of continuing treatment regimens without interruption and incorporating these routines into their daily living patterns. The patient is instructed about the importance of avoiding others with infections

and avoiding crowds, and about other ways to prevent infection (Chart 52-5). 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 52-6). Patients who can perform self-infusion at home must be instructed in sterile technique, medication dosages, administration rate, and detection and management of adverse reactions (Cheng & Christmas, 2011; Saria, 2011).

Continuing Care Encouraging the patient and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favourable prognosis. The patient must be made aware that all health-related instructions are lifelong, that follow-up with all scheduled appointments is essential, and that it is the patient’s responsibility to notify the primary care provider of any early signs or symptoms of infection, however subtle they may be. If the patient’s treatment includes IVIG and the patient or family cannot administer treatment, a referral for home care or an infusion service is warranted.

Critical Thinking Exercises 1

You are the charge nurse on a medical critical care unit. A new nurse approaches you for advice on the best infection control practices to use with a patient with cancer who has just been admitted and is immunosuppressed. Identify the infection control measures that are indicated. Describe the evidence base for the infection control measures you identified and the criteria used to evaluate the strength of that evidence.

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2 The mother of your 7-year-old neighbour contacts you to discuss his frequent illnesses. She asks whether there may be something serious underlying the nine ear infections he has had in the previous year. Identify the 10 warning signs of primary immune deficiency that you would consider when responding to this mother’s dilemma. 3 You are caring for a 20-year-old man who has an immunodeficiency and has been hospitalized multiple times. Describe the assessment parameters and the nursing plan of care for this patient. Identify the laboratory values that are important to monitor and report. Describe the plan for continuing care for this patient.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Abbas, A., Lichtman, A., & Pillai, S. (2014). Basic immunology, functions and disorders of the immune system (4th ed.). Philadelphia, PA: W. B. Saunders. Brophy, K., Scarlett-Ferguson, H., Webber, K. S., et al. (2011). Clinical drug therapy for Canadian practice (2nd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Cohen, J., Powderly, W. G., & Opal, S. M. (2010). Infectious diseases (3rd ed.). St. Louis, MO: Mosby. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer HealthéLippincott Williams & Wilkins. Levinson, W. (2012). Review of medical microbiology and immunology (12th ed.). Columbus, OH: The McGraw-Hill Companies. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (Eds.). (2010). Canadian Bates’ guide to health assessment for nurses (1st. ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS Atkinson, T. (2012). Immune deficiency and autoimmunity. Current Opinion in Rheumatology, 24(5), 515–521. *Barrell, C., Dietzen, D., Zhezhen, J., et al. (2012). Reduced-intensity conditioning allogeneic stem cell transplantation in pediatric patients and subsequent supportive care. Oncology Nursing Forum, 39(6), E451–E458. doi: 10.1188/12.ONF.E451-E458 Booth, C., Gaspar, B., & Thrasher, A. (2011). Gene therapy for primary immunodeficiency. Current Opinion in Pediatrics, 23(6), 659–666. *Brown, M. (2010). Nursing care of patients undergoing allogeneic stem cell transplantation. Nursing Standard, 25(11), 47–56. *Burton, J., Murphy, E., & Riley, P. (2010). Primary immunodeficiency disease: A model for case management of chronic diseases. Professional Case Management, 15(1), 5–14. doi: 10.1097/NCM.0b013e3181b5dec4 Ceballos, K., Waterman, K., Hulett, T., et al. (2013). Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Advances in Neonatal Care (Elsevier Science), 13(3), 154– 165. doi: 10.1097/anc.0b013e318285fe70 Cheng, J., & Christmas, C. (2011). Special considerations with the use of intravenous immunoglobulin in older persons. Drugs and Aging, 28 (9), 729–736. doi: 10.2165/11592740-000000000-00000 Christian, C. (2011). Common variable immunodeficiency (CVID); a case study. New Zealand Journal of Medical Laboratory Science, 65(3), 86–88. *Clark, E., Giambra, B., Hingl, J., et al. (2013). Nursing guidelines for administration of immunoglobulin replacement therapy. Journal of Infusion Nursing, 36(1), 58–68. doi: 10.1097/NAN.0b013e3182798af8 Costa-Carvalho, B. T., Grumach, A. S., Franco, J. L., et al. (2014). Attending to warning signs of primary immunodeficiency diseases across the range of clinical practice. Journal of Clinical Immunology, 34(1), 10–22. doi: 10.1007/s10875-013-9954-6 *Dempster, J. (2013). Management of hereditary angioedema. Nursing Standard, 27 (37), 35–40.

EunKyung, S., Jaishankar, G., Saleh, H., et al. (2011). Chronic granulomatous disease: A review of the infectious and inflammatory complications. Clinical and Molecular Allergy, 9(1), 10–23. doi: 10.1186/1476-7961-9-10 Ernst, J. J., Sauerbrei, A. A., Krumbholz, A., et al. (2012). Multiple viral infections after haploidentical hematopoietic stem cell transplantation in a child with acute lymphoblastic leukemia. Transplant Infectious Disease, 14(5), E82–E88. doi: 10.1111/j.1399-3062.2012.00778.x Immunodeficiency Canada. (2014). Primary immunodeficiency (PI). Retrieved from: http://immunodeficiency.ca/primary-immunodeficiency/ primary-immunodeficiency-pi/ Johnston, D. (2011). Diagnosis and management of hereditary angioedema. JAOA: Journal of the American Osteopathic Association, 111(1), 28–36. Karl, K., Heling, K., Sarut Lopez, A., et al. (2012). Thymic-thoracic ratio in fetuses with trisomy 21, 18 or 13. Ultrasound in Obstetrics and Gynecology, 40 (4), 412–417. doi: 10.1002/uog.11068 Kolins, J., Zbylut, C., & McCollum, S. (2011). Hematopoietic stem cell transplantation in children. Critical Care Nursing Clinics of North America, 23(2), 349–376. doi: 10.1016/j.ccell.2011.02.004 Maggina, P., & Gennery, A. R. (2013). Severe combined immunodeficiency in the newborn. Infant, 9(2), 52–55. McCusker, C., & Warrington, R. (2011). Primary immunodeficiency. Allergy, Asthma and Clinical Immunology, 7 (Suppl 1), S11. doi: 10.1186/1710-1492-7-S1-S11 McDonald-McGinn, D., & Sullivan, K. (2011). Chromosome 22q11.2 deletion syndrome (DiGeorge Syndrome/Velocardiofacial Syndrome). Medicine, 90 (1), 1–18. doi: 10.1097/MD.0b013e3182060469 Mehr, S., Kakakios, A., Shaw, P., et al. (2011). Beware the lymphopenia: A case of severe combined immunodeficiency. Journal of Paediatrics and Child Health, 47 (8), 565–567. doi: 10.1111/j.1440-1754.2010.01870.x *Molesky, M. (2011). Chromosome 22q11.2 microdeletion syndrome. Neonatal Network, 30 (5), 304–311. doi: 10.1891/0730-0832.30.5.304 Rizzieri, D., Crout, C., Storms, R., et al. (2011). Feasibility of low-dose interleukin-2 therapy following T-cell-depleted nonmyeloablative allogeneic hematopoietic stem cell transplantation from HLA-matched or -mismatched family member donors. Cancer Investigation, 29(1), 56–61. doi: 10.3109/07357907.2010.535055 Sardana, N., & Craig, T. (2011). Recent advances in management and treatment of hereditary angioedema. Pediatrics, 128 (6), 1173–1180. doi: 10.1542/peds.2011-0546 *Saria, M. (2011). Preventing and managing infections in neutropenic stem cell transplantation recipients: Evidence-based review. Clinical Journal of Oncology Nursing, 15(2), 133–139. doi: 10.1188/11.CJON.133-139 Shelton, B., Griffin, J., & Goldman, F. (2006). Immune globulin IV therapy: Optimizing care of patients in the oncology setting. Oncology Nursing Forum, 33(5), 911–921. Slatter, M., Cant, A., Arkwright, P., et al. (2011). Clinical features that identify children with primary immunodeficiency. Pediatrics, 127 (810), doi: 10.1542/peds.2010-3680 Varma, S., Varma, N., Reddy, V. et al. (2012). Detection of paroxysmal nocturnal hemoglobinuriaphenotype in patients with chronic lymphocytic leukemia and multiple myeloma. Indian Journal of Pathology and Microbiology, 55(2), 206–210. Younger, M. A., Aro, L., Blouin, W., et al. (2013). Nursing guidelines for administration of immunoglobulin replacement therapy. Journal of Infusion Nursing, 36(1), 58–68.

RESOURCES Canadian Allergy, Asthma and Immunology Foundation, 774 Echo Drive, Ottawa, ON K1S 5N8, (613) 730-6272: http://www.allergy foundation.ca/. Canadian Immunodeficiencies Patient Organization, 362 Concession 12 East, RR #2, Hastings, Ontario, K0L 1Y0, (877) 262-CIPO: http:// www.cipo.ca. Canadian Institute for Health Information, 495 Richmond Road, Suite 600, Ottawa, ON K2A 4H6, (613) 241-7860: http://www.cihi.ca/CIHIext-portal/internet/EN/Home/home/cihi000001 Canadian Society of Allergy and Clinical Immunology, 774 Echo Drive, Ottawa, ON K1S 5N8, (613) 730-6272: http://www.csaci.org. Centers for Disease Control and Prevention: www.cdc.gov Genetic Alliance, 4301 Connecticut Avenue NW, Suite 404, Washington, DC 20008-2369, (202) 966-5557: http://www.geneticalliance.org. Immunodeficiency Canada, 3299 Bayview Avenue, Toronto, ON M2K 2Y5, (416) 964-3434: http://immunodeficiency.ca

CHAPTER

53 Management of Patients With HIV Illness and AIDS Adapted by Jean Harrowing, Ted Birse, and Vera Caine

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the modes of transmission of HIV infection and prevention strategies. 2. Describe the host/HIV interaction during primary infection. 3. Explain the pathophysiology associated with the clinical manifestations of HIV illness. 4. Describe the clinical management of patients with HIV illness and AIDS. 5. Discuss the nursing interventions appropriate for patients with HIV illness. 6. Use the nursing process as a framework for care of the patient with HIV illness.

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Although advances have been made in treating human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), the epidemic remains a critical public health issue in communities around the world. Prevention, early detection, and ongoing treatment remain important aspects of care for people with HIV illness and AIDS. Nurses in all settings encounter people with this infection; 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. To assist nursing students in their efforts to learn, the Canadian Association of Nurses in AIDS Care ([CANAC], 2013) has established the core competencies necessary to provide safe, ethical care to persons who live with HIV illness. 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

Glossary alpha-interferon: protein substance that the body produces in response to infection B-cell lymphoma: common malignancy in patients with AIDS candidiasis: yeast infection of skin or mucous membrane CCR5: along with the CD4+ receptor, this cell surface molecule is used by HIV to fuse with the host’s cell membranes cytomegalovirus: a species-specific herpes virus that may cause retinitis in people with AIDS EIA (enzyme immunoassay): a blood test that can determine 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: retrovirus identified in 1986 in AIDS patients in West Africa HIV-associated dementia (HAD): 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): viruses that cause various warts, including plantar and genital warts; some strains of HPV can also cause cervical cancer immune reconstitution inflammatory syndrome: a syndrome that results from rapid restoration of pathogen-specific immune responses to opportunistic infections; most often occurs after starting antiretroviral therapy Kaposi’s sarcoma: malignancy that involves the epithelial layer of blood and lymphatic vessels latent reservoir: the integrated HIV provirus within the CD4+ T cell during the resting memory state; does not express viral proteins and is invisible to the immune system and antiviral medications. macrophage: large immune cell that devours invading pathogens and other intruders; can harbour 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: opportunistic infection caused by mycobacterial organisms that commonly

causes a respiratory illness but can also infect other body systems opportunistic infection: illness caused by various organisms, some of which usually do not cause disease in people 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 pneumonia or Pneumocystis jiroveci pneumonia (PJP): common opportunistic lung infection caused by an organism, believed to be a fungus based on its structure polymerase chain reaction: 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 following infection; also known as acute HIV infection progressive multifocal leukoencephalopathy: 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 singlestranded RNA into a double-stranded 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 53

randomized controlled trial of primary prophylaxis of Pneumocystis jiroveci pneumonia (PJP; formerly Pneumocystis carinii pneumonia) appeared in the literature. In 1995, protease inhibitors (PIs) were added to the growing number of antiretroviral agents. Improved treatment of HIV and AIDS has resulted in declining death rates in Canada, from a peak of 1,500 reported deaths in 1995 to 25 reported deaths in 2009 (Public Health Agency of Canada [PHAC], 2010a). However, the annual number of positive HIV tests has been gradually increasing since 2001, with an estimated 26% of infected individuals unaware of their seropositive status (PHAC, 2010c). HIV illness remains a serious issue in this country. Canadian scientists continue to participate in research to develop a safe and effective HIV vaccine (Government of Canada, 2012). The government continues to support global efforts to reduce the impact of HIV illness on vulnerable populations around the world through financial contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Canadian International Development Agency, 2011). Now, HIV illness is a chronic condition that requires daily treatment and frequent monitoring. Although damage to the immune system is significant and long-term exposure to the drugs results in concerns about their toxic side effects, survival rates have increased dramatically. However, many people continue to face challenges that are associated with persistent emotional, social, and financial barriers, obstacles that must be addressed to enhance health and well-being. Furthermore, as people live longer with the illness, there is growing complacency among the general public and a greater need for prevention strategies.

HIV INFECTION AND AIDS Since AIDS was first identified 30 years ago, remarkable progress has been made in improving the quality and duration of life for people living with HIV illness. During the first decade, this progress was associated with the recognition and treatment of opportunistic diseases and introduction of prophylaxis against common opportunistic infections (OIs). The second decade witnessed progress in the development of highly active antiretroviral therapies (HAARTs) as well as continuing progress in the treatment of OIs. The third decade has focused on issues of adherence to antiretroviral therapy, development of second-generation medications that affect different stages of the viral life cycle, and continued need for an effective vaccine. The HIV antibody test, an enzyme immunoassay (EIA; formerly enzyme-linked immunosorbent assay [ELISA]), became available in 1984, allowing early diagnosis of the infection before the onset of symptoms. Since then, HIV infection has been best managed as a chronic disease, most appropriately in an outpatient care setting, whereas AIDS may involve acute conditions that require hospital treatment.

Epidemiology In the fall of 1982, after the first 100 cases were reported, the Centers for Disease Control and Prevention (CDC)

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issued a case definition of AIDS. Since then, the CDC has revised the case definition a number of times (in 1985, 1987, and 1993). In Canada, the most recent revision confirms a case of AIDS in the presence of a positive HIV test and a definitive diagnosis of one or more of the specified indicator diseases (Canadian AIDS Society & Health Canada, 2002). In May 2003, HIV disease became legally notifiable in all Canadian provinces and territories (PHAC, 2010c). All jurisdictions voluntarily report positive HIV tests to the Centre for Infectious Disease Prevention and Control (CIDPC). Three types of HIV tests may be available in Canada, depending on the province or territory where testing occurs: nominal, nonnominal, and anonymous (PHAC, 2010c). Nominal, or name-based testing, means that the test is ordered using the name of the person being tested. A nonnominal, or nonidentifying test, is requested using a code or the initials of the person being tested. An anonymous test uses a code known only to the person being tested. This process offers the highest degree of confidentiality and may encourage more people to come forward for testing (Jürgens, 2001). However, anonymous testing is available in only seven provinces and territories at this time (PHAC, 2010c). The PHAC (2010b) estimated that at the end of 2008, there were 65,000 people living with HIV in Canada. Between 1979 and December 31, 2010, there were 22,120 cases of AIDS reported to the CIDPC and 72,226 positive HIV tests were reported between 1985 and December 31, 2010 (PHAC, 2010a). In 2010, 2,358 HIV cases were reported, a 2.4% decrease since 2009 (2,416 cases). Unprotected sex and sharing of injection drug use equipment are the major means of transmission of HIV. A total of 210 AIDS cases were diagnosed in 2010 (PHAC, 2010a). Among reported cases of AIDS in adult males in 2010, 34.7% were in the exposure category of men who have sex with men; 35.3% from injection drug use; and 26.7% from heterosexual contact. Aboriginal women, women from countries where HIV is endemic, women who use injection drugs, and women in prison continue to be overrepresented and disproportionately affected by HIV infection (PHAC, 2010b). Aboriginal Canadians, who are overrepresented among reported AIDS cases, account for 33.3%, with injection drug use and from heterosexual exposure the leading risk categories (PHAC, 2010a). As of December 31, 2008, 12.4% of all reported AIDS cases occurred in people 50 years of age or older. The proportion of annual positive HIV tests reports among those in this age group increased from 10.6% in 1999 to 15.3% in 2008 (PHAC, 2010b). There are a number of factors that put older Canadians at risk for HIV infection such as limited knowledge about HIV acquisition, age-related physiological changes, and societal values about sexuality among older adults. AIDS has reached epidemic proportions in some other parts of the world. According to the Joint United Nations Programme on HIV/AIDS ([UNAIDS] 2011), 34 million people are infected with HIV. Annual new HIV infections are estimated to have fallen by 21% between 1997 and 2010. The number of people dying of AIDS-related causes decreased from a peak of 2.2 million in the mid-2000s to 1.8 million in 2010. This decrease has been attributed to the introduction of antiretroviral therapy in low-and middle income countries. Globally, two main patterns in the

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pandemic are apparent. In sub-Saharan Africa, the disease is generalized throughout the population. In the rest of the world, epidemics are concentrated within at-risk populations, such as men who have sex with men, injecting drug users, and sex trade workers (UNAIDS, 2011). The earliest confirmed case of HIV illness 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, one possibility includes 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 (Barnett & Whiteside, 2006).

HIV Transmission HIV-1 is transmitted in body fluids that contain free virions and infected CD4+ T lymphocytes. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Perinatal transmission of HIV-1 may occur in utero, at the time of delivery, or through breast-feeding, but transmission frequency during each period has been difficult to determine (Nduati, John, Mbori-Ngacha, et al., 2000). Any behaviour that results in breaks in the skin or mucosa results in the increased probability of exposure to HIV (Chart 53-1). Because HIV is harboured within lymphocytes, 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 selfdeferral, 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. In 2001, the Canadian Blood Services (2006) began using nucleic acid amplification testing to test directly for viral nucleic acids rather than using evidence of antibody production by the individual’s immune system. This test reduces the size of the window period, indicating the presence of HIV 11 to 13 days after infection as compared with the 16-day window period associated with antibody tests. However, blood donated during the

CHART 53-1

Risk Behaviours Associated With HIV Infection and AIDS • Sharing infected injection drug use equipment • Having sexual relations with infected individuals (both

male and female) Also at risk are people who received HIV-infected blood or blood products (especially before blood screening was instituted in 1985) and infants born to mothers with HIV infection.

window period will be infectious but will test negative for HIV antibodies. The window period is the period of time between exposure to the virus and seroconversion, during which screening tests will be falsely negative. Although antibodies will usually be detected within days or weeks of infection, the window period can last up to a year.

Gerontologic Considerations As of December 2008, 15.3% of HIV infections in Canada were among persons 50 years of age or older (PHAC, 2012b). HIV illness in middle-aged and older populations may be underreported and underdiagnosed because health care professionals erroneously believe that this group is not at risk for the infection. Many older adults are sexually active but do not use condoms, viewing them only as a means of unneeded birth control and not considering themselves at risk for HIV illness. Also, HIV-related dementia in the older adult may mimic Alzheimer’s disease and may be misdiagnosed. The characteristics of older people living with HIV infection reflect those of others in their country of origin who have HIV infection (Nokes, Rivero-Mendez, Valencia, et al., 2006). Several factors put older adults at risk for HIV infection: • Many older adults are sexually active but do not use condoms, viewing them only as a means of unneeded birth control. • Many older adults do not consider themselves at risk for HIV infection. • Older gay men, who grew up and lived in an era when disclosure of their sexual orientation was not acceptable and who have lost long-time partners, may begin new relationships with younger men. • Older adults may be intravenous (IV) / injection drug users. • Older adults may have received HIV-infected blood through transfusions before 1985. • Normal age-related changes include a reduction in immune system function, which puts the older adult at greater risk for infections, cancers, and autoimmune disorders. Many older adults also experience the loss of loved ones, resulting in depression and bereavement, factors that are associated with depressed immune function. Many older adults also experience the loss of loved ones, resulting in depression and bereavement—factors that are also associated with depressed immune function. HIVassociated dementia (HAD) in the older adult may mimic Alzheimer’s disease and may be misdiagnosed. There are at least three major differences between older (age 50 years and up) and younger persons with HIV illness: presence of comorbidities such as diabetes or high blood pressure, number of persons to whom HIV status was disclosed, and physical functioning ability (Nokes, Holzmer, Corless, et al., 2000). Limited research has demonstrated that the virologic efficacy of antiretroviral therapy in older patients is comparable to that in younger patients; however, the recovery of the immune system is slower and more blunted in older patients (Manfredi, 2004). There is an urgent need for research to document the efficacy of antiretroviral therapy,

CHAPTER 53

examine frequency and severity of side effects, and explore issues of adherence in the older population.

Prevention of HIV Infection Until an effective vaccine is developed, preventing HIV transmission by teaching patients how to reduce potential harm from risky behaviours is essential. Although HIV prevention strategies have focused on individual behaviours, political, economic, and social determinants of risk also need to be considered (Horton & Das, 2008). A combination of evidence-based prevention strategies that include behavioural, structural, and biomedical approaches tempered by the wisdom and ownership of communities offers the best hope for prevention (Merson, O’Malley, Serwadda, et al., 2008).

Preventive Education Effective evidence-based programs have been initiated to educate the public regarding safer sexual practices to decrease the risk of transmitting HIV infection to sexual partners (Chart 53-2). Other than abstinence, consistent and correct use of condoms (Chart 53-3) is the only

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effective method of decreasing the risk of sexual transmission of HIV infection. When male condoms are used consistently during vaginal or anal intercourse, their effectiveness can be as high as 95% (Padian, Buve, Balkus, et al., 2008). Nonlatex condoms made of natural materials such as lambskin are available for people with latex allergy but will not protect against HIV infection. A male condom should be used for oral contact with the penis, and a dental dam (a flat piece of latex used by dentists to isolate a tooth for treatment) should be used for oral contact with

CHART 53-3

Patient Education: The Right Way to Use a Male Condom 1. Put on a new condom before any kind of sex. 2. Hold the condom by the tip to squeeze out the air.

CHART 53-2

Health Promotion: Safer Sexual Behaviours • Advise patients to abstain from sharing sexual fluids. • Advise patients to reduce the number of sexual partners to one.

3. Unroll the condom all the way over the erect penis

• Advise patients to always use latex condoms. If the patient

is allergic to latex, use nonlatex male and female condoms.

• Advise patients to avoid reusing condoms. • Advise patients to avoid using cervical caps, intrauterine

devices, or diaphragms without using a condom as well.

• Advise patients to always use dental dams for oral–genital or anal stimulation.

• Advise patients to avoid anal intercourse because this practice may injure tissues.

• Advise patients to avoid manual–anal intercourse (“fisting”).

• Advise patients not to ingest urine or semen. • Educate patients about nonpenetrative sexual activities, • •

•

•

such as body massage, social kissing (dry), mutual masturbation, fantasy, and sex films. Advise patients to avoid sharing needles, razors, toothbrushes, sex toys, or blood-contaminated articles. Advise HIV-seropositive patients to inform previous, present, and prospective sexual and drug-using partners of their HIV-positive status. If the patient is concerned for his or her safety, advise the patient that there are established mechanisms through the public health department in which professionals are available to confidentially notify exposed people. Advise HIV-seropositive patients to avoid having unprotected sex with another HIV-seropositive person. Crossinfection with that person’s HIV can increase the severity of infection, and puts the person at risk for other sexually transmitted infections. Advise HIV-seropositive patients to avoid donating blood, plasma, body organs, or sperm.

4. 5. 6. 7.

Have sex. Hold the condom so it cannot come off the penis. Pull out. Use a new condom if you want to have sex again or if you want to have sex in a different place (e.g., in the anus and then in the vagina). Keep condoms cool and dry. Never use skin lotions, baby oil, petroleum jelly, or cold cream with condoms. The oil in these products will cause the condom to break. Products made with water or silicone (such as K-Y jelly) are safer to use.

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the vagina or rectum. The polyurethane female condom, which is an effective contraceptive, provides a physical barrier that also prevents exposure to genital secretions containing HIV such as semen and vaginal fluid (Padian et al., 2008). The female condom is the only barrier method that can be controlled by the woman (see Chapter 47). Microbicides are chemical products such as gels, creams, films, or suppositories that are inserted into the vagina or rectum before sexual intercourse to prevent HIV transmission (Padian et al., 2008). Nonoxynol-9 (N-9) was widely advocated to reduce the risk of HIV infection until a clinical trial conducted in almost 1,000 female commercial sex workers in African countries revealed that those who used N-9 intravaginally along with condoms were 50% more likely to be infected with HIV than those who did not use the N-9 gel. Microbicide research is moving in three directions: (1) new microbicides that contain antiretroviral agents such as tenofovir gel or dapivirine gel and ring (International Partnership for Microbicides, 2014); (2) long-acting dispersal methods such as vaginal rings that remain in place or do not require frequent applications; and (3) combination products with different mechanisms of action (Padian et al., 2008). In March 2007, based on the results of three clinical trials, the World Health Organization (WHO) and UNAIDS recommended that circumcision be recognized as an effective strategy to reduce the risk of HIV acquisition in men because the presence of the foreskin, which harbours HIV target cells, might facilitate survival and entry of the virus (Padian et al., 2008). 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 IV / injection drug users. In addition, people who are HIV positive or who use injection drugs should be instructed not to donate blood or share drug equipment with others. The Harm Reduction Model recognizes that total abstinence from addictive drugs might not be a realistic shortterm goal. This model recommends working with drug users to assist them to increase their healthy behaviours. Needle and crack pipe exchange programs and safe consumption sites are available in some locations so that drug users can obtain sterile drug equipment and nursing support at no cost. Extensive research has demonstrated that these programs do not promote increased drug use; on the contrary, they have been found to decrease the incidence of bloodborne infections in persons who use injection drugs (Gold, Gafni, Nelligan, et al., 2001; Pauly, Goldstone, McCall, et al., 2007; Trzcianowska & Mortensen, 2001; Wodak & Cooney, 2005; Wood, Tyndall, Montaner, et al., 2005). Nurses should refer clients to needle and crack pipe exchange programs and safe consumption facilities in their neighbourhood whenever available. In the absence of such programs, drug users should be instructed on methods to clean their equipment and advised to avoid sharing drug use equipment. Drug users interested in treatment programs should be referred to those programs.

Related Reproductive Education Because HIV infection in women often occurs during the childbearing years, family planning issues need to be

addressed. Attempts to achieve pregnancy by couples in which only one partner has HIV expose the unaffected partner to the virus. Artificial insemination using processed semen from a male HIV-infected partner has been shown to be the safest conception method to protect the uninfected female partner (de Ruiter, Mercey, Anderson, et al., 2008). However, the availability and cost of this process may be prohibitive to many couples. Women considering pregnancy need to have accurate information about the risks of transmitting HIV infection to themselves, their partner, and their future children, and about the benefits of taking antiretroviral agents to reduce perinatal HIV transmission. Women who are HIV positive should be instructed not to breast-feed their infants, because HIV is transmitted through breast milk. Certain contraceptive methods may pose additional health risks for women. Estrogen in oral contraceptives may increase a woman’s risk of HIV infection. In addition, women infected with HIV who use estrogen-containing oral contraceptives have shown increased shedding of HIV in vaginal and cervical secretions. The intrauterine contraceptive device (IUD) may also increase the risk of HIV transmission because the string of the IUD may serve as a means to transmit the virus. 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 HIV and other sexually transmitted infections (STIs). The female condom has the distinction of being the first barrier method that can be controlled by women (see Chapter 47).

Transmission to Health Care Providers Routine Practices In 1987, following the recommendations of the CDC, the Laboratory Centre for Disease Control endorsed and published recommendations to guide practice in Canada. By 1996, efforts to standardize procedures and reduce the risk for exposure resulted in the development of Standard Precautions. Standard Precautions incorporate the major features of Universal Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances). These standard sare applied to all patients receiving care in hospitals regardless of their diagnosis or presumed infectious status (Chart 53-4). 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. In 1999, Health Canada adopted the term Routine Practices to emphasize that the level of care should be applied to all patients, clients, and residents, regardless of perceived risk and care setting. The primary goal of Routine Practices is to protect the health of patients and caregivers by preventing the transmission of nosocomial infection. A second tier for infection control precautions for specified conditions, called Additional Precautions, was designed for use in addition to

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CHART 53-4

Elements of Routine Practices 1. Hand hygiene: Use after touching blood, body fluids, secretions, excretions, or contaminated items; immediately after removing gloves; and between patient contacts. 2. Screening for communicable diseases and risk assessment: • Assess clients for respiratory, GI, and other symptoms that may indicate disease. • Assess clients for exposure or conditions that may indicate or increase their susceptibility to infectious diseases. 3. Risk reduction strategies: • Minimize personal exposure by placing client in an area/ setting where risk of transmission is reduced. • Use personal protective equipment (PPE) to create barrier against body substances and mucous membranes.

Personal Protective Equipment (PPE) • Gloves: Use for touching blood, body fluids, secretions,

excretions, and contaminated items, and for touching mucous membranes and nonintact skin. • Gown: Use during procedures and patient care activities when contact of clothing/exposed skin with blood or body fluids, secretions, and excretions is anticipated. • Surgical mask, face protection (goggles), face shield*: Use during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, and secretions, especially suctioning or endotracheal intubation.

• N-95 respirators: Use a fit-tested respirator to protect

airway if the client has a known or suspected airborne infection or when performing an aerosolizing procedure with a client with a droplet infection. • Handle sharps safely. • Clean multiuse client care equipment and dispose off single-use equipment properly. • Ensure appropriate cleaning and disinfecting protocols and chemicals are employed to create a clean environment. • Ensure proper handling and washing of soiled patient care linens. • Handle general, biomedical, and pathologic waste is handled and disposed off in such a way that transmission of potential infections is avoided. • Maintain current personal immunization status and tuberculin testing. Follow up for punctures or mucous membrane exposures to bloodborne pathogens according to agency/facility protocol. 4. Education: • Participate in timely and appropriate education of health care professionals, clients, and families/visitors regarding infection prevention and control, hygiene, and health promotion principles and strategies.

*From the Public Health Agency of Canada, 2012b. http://www.phac-aspc.gc.ca/amr-ram/ipcbp-pepci/infection-eng.php

Routine Practices for patients with documented or suspected infections involving highly transmissible pathogens. The three types of Additional Precautions are referred to as Airborne Transmission Precautions, Droplet Transmission Precautions, and Contact Transmission Precautions. They can be used singularly or in combination, but they are always to be used in addition to Routine Practices (PHAC, 2012b).

Postexposure Prophylaxis for Health Care Providers Postexposure prophylaxis in response to the exposure of health care personnel to blood or other body fluids reduces the risk of HIV infection (Worthington, 2001) (Chart 53-5). Health care providers who have sustained a significant exposure to HIV are offered counselling and anti-HIV postexposure prophylaxis, if appropriate (PHAC, 2013b). Some clinicians will consider the using postexposure prophylaxis for patients exposed to HIV as a result of high-risk sexual behaviour or IV/injection drug use. This use of postexposure prophylaxis is controversial because of the concern that it may be substituted for safer sex practices and safer IV/injection drug use. Postexposure prophylaxis should not be considered an acceptable method of preventing HIV disease. The medications recommended for postexposure prophylaxis are those used to treat established HIV illness. Ideally, prophylaxis needs to start immediately after exposure; therapy started more than 72 hours after

exposure is thought to offer no benefit but may be offered in extenuating circumstances. The recommended course of therapy involves taking the prescribed medications for 4 weeks. Those who choose postexposure prophylaxis must be prepared for the side effects of the medications, as well as the unknown long-term risks, because HIV may become resistant to the medications used to treat it. If the person becomes infected despite prophylaxis, viral drug resistance may reduce future treatment options. In practice, the number of individuals offered postexposure prophylaxis who actually complete the full course of treatment is substantially reduced because of the side effects associated with the medication.

Pathophysiology Because HIV infection is an infectious disease, it is important to understand how HIV-1 integrates itself into a person’s immune system and how immunity plays a role in the course of HIV disease. This knowledge is also essential for understanding medication therapy and vaccine development. Viruses are intracellular parasites. HIV belongs to a group of viruses known as retroviruses, which carry their genetic material in the form of ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). As shown in Figure 53-1A, HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of

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CHART 53-5

Physiology/Pathophysiology

Postexposure Prophylaxis for Health Care Providers According to the Centers for Disease Control and Prevention (CDC; 2005), the average risk for HIV transmission to health care providers after a percutaneous exposure to HIV-infected blood is estimated to be approximately 0.3% and after a mucous membrane exposure, approximately 0.09%. If you sustain an occupational exposure to HIV, take the following actions immediately: • Alert your supervisor/nursing faculty 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 whether written informed consent must be obtained from the source patient before his or her testing. OraQuick rapid testing should be used if possible if the HIV status of the source patient is unknown, because results can be available within 20 minutes. • Report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. This visit should be documented in the health care worker’s confidential medical record. • Give consent for baseline testing for HIV, hepatitis B, and hepatitis C. Confidential HIV testing can be performed up to 72 hours after the exposure but should be performed as soon as the health care worker can give informed consent for baseline testing. • 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. Continue the HIV medications for the full 4 weeks after exposure. The majority of HIV exposures will warrant a combination of antiretroviral agents. Combinations that may be prescribed for postexposure prophylaxis include zidovudine (ZDV) and lamivudine (3TC) or emtricitabine (FTC); stavudine (d4T) and 3TC or FTC; and tenofovir (TDF) and 3TC or FTC. • Follow up with postexposure testing at 1 month, 3 months, and 6 months, and perhaps 1 year. • Document the exposure in detail for your own records as well as for the employer. Centers for Disease Control and Prevention. (2005). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR–Morbidity and Mortality Weekly Report, 54(RR-9), 1–17.

protruding glycoproteins. For HIV to enter the targeted cell, the membrane of the viral envelope must be fused with the plasma membrane of the cell, a process mediated by the envelope glycoproteins of HIV. All viruses target specific cells. HIV targets cells with CD4 receptors, which are expressed on the surface of T lymphocytes, monocytes, dendritic cells, and brain microglia. Mature T cells (T lymphocytes) are composed of two major subpopulations that are defined by cell surface receptors of CD4 or CD8. 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 a level as low as 500 cells/mm3 can be considered within normal limits. During acute/recent infection, most variet-

GP120 CD4+ binding site

1 Lipid membrane

GP120 GP41 3

2 RNA Viral polyprotein

Reverse transcriptase

4 5

6

Reverse transcriptase

A

7

P17 P24

8

B

FIGURE 53-1. A, Structure of HIV-1. A glycoprotein envelope sur-

rounds the virus, which carries its genetic material in RNA. Knobs, consisting of proteins GP120 and GP41, protrude from the envelope. These proteins are essential for binding the virus to the CD4+ T lymphocyte. B, Life cycle of HIV-1: (1) Attachment of the HIV virus to a 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. (Redrawn from Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.)

ies of HIV-1 use the chemokine receptor CCR5 (R5 virus) for entry to T cells in addition to the CD4+ receptor, which suggests that the R5 variant is preferred to a different variant (CXCR4). Over the course of infection, viruses in the majority of untreated patients eventually exhibit a shift in coreceptor from CCR5 to either CXCR4 or both CCR5 and CXCR4 (dual- or mixed-tropic) receptors (1st International Reference Panel for HIV-1 RNA Genotypes Panel, 2004). The glycoproteins of HIV (GP120 and GP41) must attach to both the CD4+ and the CCR5 binding sites in order to bind to the CD4+ cell membrane, which results in fusion of HIV with the T cell. Once HIV has attached to the host cell, the virus can replicate. The HIV life cycle is complex (Fig. 53-1B) and consists of the following steps (Hannon, Pooler, & Porth, 2010): 1. Attachment. In this first step, the GP120 and GP41 glycoproteins of HIV bind with the host’s uninfected CD4+ receptor and chemokine coreceptors, usually CCR5, which results in fusion of HIV with the CD4+ T-cell membrane. 2. Uncoating. The contents of HIV’s viral core (two single strands of viral RNA and three viral enzymes: reverse transcriptase, integrase, and protease) are emptied into the CD4+ T cell. 3. DNA synthesis. HIV changes its genetic material from RNA to DNA through action of reverse transcriptase,

CHAPTER 53

4.

5. 6. 7. 8.

resulting in double-stranded DNA that carries instruction for viral replication. Integration. New viral DNA enters the nucleus of the CD4+ T cell and through action of integrase is blended with the DNA of the CD4+ T cell, resulting in permanent, lifelong infection. Prior to this step, the uninfected person has been only exposed to, not infected with, HIV. With this step, HIV infection is permanent. Transcription. When the CD4+ T cell is activated, the double-stranded DNA forms single-stranded messenger RNA (mRNA), which builds new viruses. Translation. The mRNA creates chains of new proteins and enzymes (polyproteins) that contain the components needed in the construction of new viruses. Cleavage. The HIV enzyme protease cuts the polyprotein chain into the individual proteins that make up the new virus. Budding. New proteins and viral RNA migrate to the membrane of the infected CD4+ T cell, exit from the cell, and start the process all over.

In resting (nondividing) CD4+ cells, HIV can survive in a latent state as an integrated provirus that produces few or no viral particles. These resting CD4+ T cells can be stimulated to produce new particles if something activates them. When a T cell that harbours this integrated DNA (also known as provirus) becomes activated against HIV or other microbes, the cell begins to produce new copies of both RNA and viral proteins. Activation of the infected cell may be achieved by antigens, mitogens, certain cytokines (tumour necrosis factor-alpha [TNF-α] or interleukin-1 [IL-1]), or virus gene products of such viruses as cytomegalovirus (CMV), Epstein–Barr virus, herpes simplex virus, and hepatitis viruses. Consequently, whenever the infected CD4+ cell is activated, HIV replication and budding occur, which can destroy the host cell. Newly formed HIV released into the blood can infect other CD4+ cells (Fig. 53-1B). HIV-1 mutates quickly, at a relatively constant rate, with about 1% of the virus’s genetic material changing annually. HIV-1 exhibits substantial genetic diversity and several different genotypes of HIV-1 exist. There is a major group (group M), which consists of subtypes A through L, and a more diverse collection of outliers, which has been referred to as groups N and O. Many of the early nucleic acid–based tests had a fairly narrow band of specificity targeted mainly at subtype B viruses, because these predominated in the western world (1st International Reference Panel for HIV-1 RNA Genotypes, 2004). A mutation of CCR5 that is common in Caucasians, but not other ethnic groups, has been identified. 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.

Stages of HIV Illness The stage of HIV illness is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies.

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The Health Canada standard case definition of AIDS categorizes HIV disease and AIDS in adults and adolescents on the basis of clinical conditions associated with HIV disease and a positive HIV test. The classification system (Table 53-1) groups clinical conditions into one of three categories, denoted A, B, and C.

Primary Infection (Acute/Recent HIV Infection, Acute HIV Syndrome) The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. Initially, there is a window period during which an HIVinfected person tests negative on the HIV antibody blood test, although he or she is infected and highly infectious, because his or her viral load is very high. After 2 to 3 weeks, antibodies to the glycoproteins of the HIV envelope can be detected in the sera of HIV-infected people, but most of these antibodies lack the ability to totally control the virus. By the time neutralizing antibodies can be detected, HIV-1 is firmly established in the host. Primary infection is characterized by high levels of viral replication, widespread dissemination of HIV throughout the body, and destruction of CD4+ T cells. This leads to dramatic drops in CD4+ T-cell counts, which are normally 500 to 1,500 cells/mm3 of blood. The host is responding to the HIV infection through a CD4+ T-cell response that causes 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 free HIV particles (outside cells) and assist in their removal. The remaining amount of virus in the body after this initial immune response is referred to as the viral set point which results in a steady state of infection that lasts for years. 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. The primary infection stage is part of CDC category A and includes the acute symptomatic and early infection phases. During this stage, the virus is widely disseminated in lymphoid tissue, and a latent reservoir within resting memory CD4+ T cells is created (Zack & Park, 2008). An estimated 40% to 90% of patients who are acutely infected with HIV experience symptoms of acute retroviral syndrome characterized by fever, lymphadenopathy, pharyngitis, skin rash, myalgias/arthralgias, and other conditions (Panel on Antiretroviral Guidelines for Adults and Adolescents [Guidelines], 2008).

HIV Asymptomatic (CDC Category A: More Than 500 CD4+ T Lymphocytes/mm3) After the viral set point is reached, HIV-infected people enter into a chronic stage in which the immune system cannot eliminate the virus despite its best efforts. This set point varies greatly from patient to patient and dictates the subsequent rate of disease progression; on an average, 8 to 10 years pass before a major HIV-related complication develops. In this prolonged, chronic stage, patients feel

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TABLE 53-1

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Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults

Diagnostic Categories CD4+ T-Cell Category (1) ≥500/µL (2) 200–499/µL (3)

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TABLE 53-3

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Antiretroviral Agents (Continued)

Generic Name (Abbreviation) and Trade Names Indinavir (IDV) Crixivan

Lopinavir + ritonavir (LPV/RTV) Kaletra

Food Interactions

Adverse Events

For unboosted IDV: Should be taken 1 h before or 2 h after meals; may take with skim or low-fat meal For RTV-boosted IDV: Can be taken with or without food Should be taken with food

Nephrolithiasis; GI intolerance; nausea; indirect hyperbilirubinemia; hyperlipidemia; headache, asthenia; blurred vision; dizziness; rash; metallic taste; thrombocytopenia; alopecia; hemolytic anemia; hyperglycemia; fat maldistribution; possible increased bleeding episodes in patients with hemophilia

Nelfinavir (NFV) Viracept

Should be taken with a meal or snack

Ritonavir (RTV) Norvir

Should be taken with food if possible; may improve tolerability

Saquinavir (SQV) Invirase

Tipranavir (TPV) Aptivus

Take with food

Darunavir Prezista

Fusion Inhibitors Enfuvirtide (T-20) Fuzeon

Maraviroc Selzentry Integrase Strand Transfer Inhibitor Raltegravir Isentress

Injected subcutaneously, so meals are not an issue

GI intolerance; nausea; vomiting; diarrhea; asthenia; hyperlipidemia (especially hypertriglyceridemia); elevated serum transaminase; hyperglycemia; fat maldistribution; possible increased bleeding episodes in patients with hemophilia Diarrhea; hyperlipidemia; hyperglycemia; fat maldistribution; possible increased bleeding episodes in patients with hemophilia; serum transaminase elevation GI intolerance; nausea; vomiting; diarrhea; paresthesias—circumoral and extremities; hyperlipidemia, especially hypertriglyceridemia; hepatitis; asthenia; taste perversion; hyperglycemia; fat maldistribution; possible increased bleeding in patients with hemophilia. Lower doses used as a booster GI intolerance; nausea; diarrhea; abdominal pain and dyspepsia; headache; hyperlipidemia; elevated transaminase enzymes; hyperglycemia; fat maldistribution; possible increased bleeding episodes in patients with hemophilia. Take with RTV as booster, if prescribed. Serious liver problems, bleeding on the brain, rash, increased cholesterol and triglyceride levels, and changes in body fat; women taking birth control pills that contain estrogen may be more likely to develop a rash. Individuals with hemophilia may have increased bleeding. Take with RTV, if prescribed. Diarrhea; nausea; headache; and coldlike symptoms, including runny nose or sore throat; inflammation of the liver; abnormal liver function tests; severe skin rash; fever; and abnormally high cholesterol and triglyceride levels have been reported. Take with RTV.

Taken with or without food; requires CCR5 tropism blood test before starting

Local injection site reactions—almost 100% of patients (pain, erythema, induration, nodules and cysts, pruritus, ecchymosis); increased rate of bacterial pneumonia; hypersensitivity reaction—symptoms may include rash, fever, nausea, vomiting, chills, rigours, hypotension, or elevated serum transaminases; may recur on challenge Cough, fever, dizziness, headache, lowered blood pressure, nausea, and bladder irritation; possible liver problems and cardiac events; an increased risk for some infections; a slight increase in cholesterol levels

No food restrictions identified

Diarrhea, nausea, headache, and fever have been reported.

Multiclass Combination Products Efavirenz, emtricitabine, and tenofovir Atripla *This information changes often. Check the U.S. Food and Drug Administration Web site (www.fda.gov/oashi/aids/virals.html) and www.aidsinfo.nih.gov/DrugsNew/Default.aspx?MenuItem=Drugs for current information when caring for people with HIV/AIDS.

can obtain web-based information to remain current about medications used to treat HIV/AIDS. The U.S. Department of Health and Human Services maintains an AIDSInfo Drug Database Web site (see Resources and Web Sites section). Increasing numbers of patients with HIV disease receiving medications are presenting with metabolic complications such as increases in cholesterol and triglyceride levels, hyperglycemia, and altered body habitus (National Institute of Allergy and Infectious Diseases [NIAID],

2006). Toxicity to cell mitochondria may be involved in many of the side effects of HIV medications, including peripheral neuropathy, myopathy and cardiomyopathy, lactic acidosis and hepatic steatosis (fatty degeneration of liver), pancreatitis, osteopenia and osteoporosis, and bone marrow suppression. Fat redistribution (lipodystrophy syndrome, also known as pseudo-Cushing’s syndrome) is a potential systemic side effect. Many people who have lipodystrophy experience an increase in fat loss in the

CHAPTER 53

legs, arms, and face and/or a buildup of fat around the abdomen and at the base of the neck. Patients may also experience an increase in breast size. These changes in body image can be very disturbing to persons living with HIV illness and have been reported to occur in 6% to 80% of patients receiving HAART (see following discussion). Hepatotoxicity associated with certain PIs may limit the use of these agents, especially in patients with underlying liver dysfunction (Panel, 2012). Drugs from established classes (NRTIs, NNRTIs, and PIs) continue to serve as the mainstays of antiretroviral therapy (Kuritzkes, 2008). In 2008, the integrate inhibitor (raltegravir [Isentress]) and the CCR5 antagonist (maraviroc [Selzentry]), a novel EI, were approved and joined the other fusion inhibitors such as enfuvirtide (T-20), which inhibits entry of HIV into the CD4+ T cell (Moyle, Gatell, Perno, et al., 2008). In patients with resistant HIV disease, these new classes of antiretroviral agents offer considerable potential benefit because of the absence of cross-resistance (Cooper, Steigbiegel, Gatell, et al., 2008). To achieve sustained viral suppression, patients must take more than one antiretroviral medication. Although HAART was defined originally as a regimen that included at least one PI, it has evolved to include any regimen with at least two to three different medications. Some pharmaceutical companies have combined two to three agents into one tablet or capsule, such as Kaletra (lopinavir and ritonavir) and Atripla (efavirenz, emtricitabine, and tenofovir) in a single tablet for once-a-day use. Simplifying treatment regimens and decreasing the number of medications that must be taken each day may increase patients’ adherence to therapy. It is difficult to predict which patients will adhere to medication regimens (Holzemer, Corless, Nokes, et al., 2004). Perceived engagement with the health care provider has been associated with greater adherence to HIV medication regimens (Bakken, Holzemer, Brown, et al., 2000). Individualized plans of care that take into consideration housing, social support issues in addition to social determinants of health are essential. Adherence to long-term treatment is required to manage HIV infection and many other chronic illnesses; however, overall adherence rates remain low (30% to 50%). Although antiretroviral regimens have become less complex, side effects create barriers to adherence, and this can lead to viral resistance. The goals of treatment include maximal and sustained suppression of viral load to a nondetectable level, restoration or preservation of immunologic function, improved quality of life, and reduction of HIV-related morbidity and mortality. Viral load testing is recommended at the time of diagnosis of HIV disease and every 3 to 4 months thereafter in the untreated person; T-cell counts should be measured at diagnosis and usually every 3 to 6 months thereafter (Guidelines, 2008). In the majority of patients, HAART leads to sustained reductions in HIV replication, a rise in CD4+ T-cell counts with reconstitution of immune function, and significant reductions in morbidity and mortality. It is difficult to predict patients’ adherence to medication regimens, but a positive relationship between the patient and health care provider is associated with better adherence. Individualized plans of care that take into consideration housing and social support issues, in addition to

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health indicators, are essential. Adherence to the antiretroviral treatment plan involves very complex behaviour that can change over the duration of the medication regimen. Self-reported adherence measures can distinguish clinically meaningful patterns of medication-taking behaviours; therefore, nurses should ask patients if they are taking their medications as prescribed. Factors associated with nonadherence include active substance abuse, depression, and lack of social support. Gender, race, pregnancy, and history of past substance use have not been associated with nonadherence (Guidelines, 2008). Chart 53-7 summarizes various strategies that health care providers can encourage to promote treatment regimen adherence. Every health care encounter should be used as an opportunity to briefly review the treatment regimen, identify any new issues, and reinforce successful behaviours. Results of therapy are evaluated with viral load tests (Guidelines, 2012). Viral load levels should be measured immediately prior to and again at 2 to 8 weeks after initiation of antiretroviral therapy, since in most patients adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. The viral load should continue to decline over the following weeks and in most individuals will drop below detectable levels by 24 weeks. The lower limits of detection are dependent on the HIV viral load assay being used but is generally less than 75 copies/mL of plasma. The rate of viral load decline toward undetectable levels is affected by the baseline T-cell count, the initial viral load, the potency of the medication, adherence of the patient to the medication regimen, prior exposure to antiretroviral agents, and the presence of any OIs (Panel, 2012). The confirmed absence of a viral load response should prompt the health care team to re-evaluate the regimen, the patient’s adherence to the medication regimen, and potential factors that may inhibit absorption or activity of the medications. Adverse effects associated with all HIV treatment regimens include hepatotoxicity, nephrotoxicity, and osteopenia, along with increased risk of cardiovascular disease and myocardial infarction (Moyle et al., 2008) (Table 53-3). Many of the antiretroviral agents that prolong life may simultaneously cause fat redistribution syndrome and metabolic alterations such as dyslipidemia and insulin resistance, which put the patient at risk for early-onset heart disease and diabetes (Calza, Manfredi, Pocaterra, et al., 2008). The fat redistribution syndrome consists of lipoatrophy (localized subcutaneous fat loss in the face, arms, legs, and buttocks) and lipohypertrophy (central visceral fat [lipomata] accumulation in the abdomen, although possibly in the breasts, dorsocervical region [buffalo hump], and within the muscle and liver) (Calza et al., 2008). These changes can be very disturbing to the body image of people living with HIV/AIDS and may be a reason that they decline treatment, especially with regimens that include a PI. Facial wasting, characterized as a sinking of the cheeks, eyes, and temples caused by the loss of fat tissue under the skin, may be treated by injectable fillers such as poly-Llactic acid (Sculptra) (Fig. 53-2). Hepatotoxicity associated with certain PIs may limit the use of these agents, especially in patients with underlying liver dysfunction (Guidelines, 2008).

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CHART 53-7

HOME CARE CHECKLIST •

Adhering to Medication Therapy for HIV

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• Verbalize knowledge of each medication name.

✔

✔

• State the action of each medication.

✔

✔

• State the correct times that medications are to be taken.

✔

✔

• Identify special guidelines to follow when taking medications (e.g., with meals, on an empty

✔

✔

• Demonstrate methods of keeping track of the medication regimen and storage of the pre-

✔

✔

• Identify specific laboratory tests such as viral load that are necessary to monitor the effec-

✔

✔

• List expected side effects of each medication.

✔

✔

• Identify side effects that should be reported to health care providers.

✔

✔

• Explain the importance of and necessity for adherence with prescribed medication regimen.

✔

✔

• Demonstrate correct administration of IM, subcutaneous, or IV medications.

✔

✔

• Demonstrate correct use and safe disposal of needles, syringes, and other IV equipment.

✔

✔

• Discuss with health care providers any problems that he or she is having with side effects

✔

✔

• Discuss episodes of nonadherence to the medication regimen.

✔

✔

stomach, medications that are not to be taken together).

scribed medications and use reminders such as beepers and/or pill boxes. tiveness of the prescribed medication regimen.

and adherence.

Drug Resistance Drug resistance can be broadly defined as the ability of pathogens to withstand the effects of medications that are intended to be toxic to them. There are two major components of antiretroviral drug resistance: (1) transmission of drug-resistant HIV at the time of initial infection and

FIGURE 53-2. Facial lipoatrophy.

(2) selective drug resistance in patients who are receiving nonsuppressive regimens (Kuritzkes, 2008). Factors associated with the development of drug resistance include monotherapy (taking one medication), difficulty with adherence to complex and toxic regimens, and initiation of therapy late in the course of HIV infection. Central to the complexity of HIV drug resistance are the phenomena of HIV quasi-species (the simultaneous presence in a patient of multiple viral variants), the extent of cross-resistance among antiviral agents, the existence in each individual of archival HIV DNA copies representing all viruses that emerged under the patient’s previous treatment, and the pre-existence of resistant variants even without prior exposure to the medication. Measurement of HIV drug susceptibility for management of HIV disease is now practical using recombinant DNA technology (Panel, 2012). HIV genotypic resistance testing is recommended for all newly diagnosed patients at the time of diagnosis, in all pregnant women prior to the initiation of antiretroviral therapy, and in individuals where treatment failure is suspected. Currently the reported rates of transmitted drug resistance are 8% to 16% (primary drug resistance). Resistance testing has a number of limitations and is more helpful in determining which antiretroviral agents should be eliminated rather than which ones should be used. Genotypic testing determines the sequence of viral RNA encoding relevant genes, which allows detection of amino acid mutations that are either proven or suspected to be associated with phenotypic resistance. Phenotypic testing determines the drug concentration needed to inhibit

CHAPTER 53

replication of a recombinant virus by 50% of a patient’s isolate, when compared with a susceptible reference. Resistance testing is of greatest value when it is performed before drugs are discontinued or immediately afterward (within 4 weeks). Drug resistance testing is not advised for patients with a viral load of less than 1,000 copies/mL, because the amount of the virus in the blood is too small to ensure reliable results (Guidelines, 2008). In addition to resistance testing, several factors must be considered in choosing medications for a new regimen, once the prior regimen has failed. These factors include the patient’s past treatment history, viral load, and medication tolerance; the likelihood of the patient’s adhering to the medication regimen; and concomitant medical conditions or medications. Blood specimens should be obtained for resistance testing before the failing drug regimen is stopped or immediately afterward (within 4 weeks) (Panel, 2012).

Treatment Interruption Discontinuation of antiretroviral therapy may result in viral rebound, immune decompensation, and clinical progression. Unplanned interruption of antiretroviral therapy may become necessary because of severe drug toxicity, intervening illness, surgery that precludes oral therapy, pregnancy, or unavailability of antiretroviral medications. Planned treatment interruption, outside of clinical research trials, is not recommended (Panel, 2012).

Immune Reconstitution Inflammatory Syndrome Immune reconstitution inflammatory syndrome (IRIS) results from rapid restoration of pathogen-specific immune responses to OIs that cause either the deterioration of a treated infection or new presentation of a subclinical infection. This syndrome typically occurs during the initial months after beginning antiretroviral treatment and is associated with a wide spectrum of pathogens, most commonly mycobacteria, herpes viruses, and deep fungal infections (Meintjes, Lawn, Scano, et al., 2008). IRIS is characterized by fever, respiratory and/or abdominal symptoms, and worsening of the clinical manifestations of an OI or the appearance of new manifestations. The nurse should be alert to the possibility of IRIS, especially in the 3-month period after treatment with antiretroviral agents is initiated, because this syndrome is associated with significant morbidity and patients often require hospital admission. IRIS typically occurs in patients with a low initial CD4 count (usually less than 50 cells/mm3) and rapid decline of HIV viral load. Rates of morbidity and mortality attributable to paradoxical TB-associated IRIS may be higher in settings with limited diagnostic and treatment options (e.g., sub-Saharan Africa).

Clinical Manifestations Patients with HIV illness experience a number of symptoms related to the disease, side effects of treatment,

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and other illnesses such as hepatitis (Bova, Jaffarian, Himlan, et al., 2008). The clinical manifestations of HIV are widespread and may involve virtually any organ system. Diseases associated with HIV infection and AIDS result from infections, malignancies, or the direct effect of HIV on body tissues. Nurses need to understand the causes, signs and symptoms, and interventions, including self-care strategies, which can enhance the quality of life for patients throughout the illness. Symptom assessment tools can be used to assess patients’ symptom intensity and severity. People with HIV illness use a variety of self-care strategies to minimize common symptoms which can arise from HIV infection, comorbidities, or the effects of medications used to treat HIV and OIs. Fatigue is frequently cited by people living with HIV illness as one of the most bothersome symptoms. It has a multifactorial etiology. For more information about fatigue in HIV, see Chart 53-8.

Respiratory Manifestations Shortness of breath, dyspnea (laboured breathing), cough, chest pain, and fever are associated with various OIs, such as those caused by P. jiroveci, Mycobacterium aviumintracellulare, CMV, and Legionella species.

Pneumocystis Pneumonia The most common opportunisitic infection resulting in an AIDS diagnosis is PJP. P. jiroveci was originally classified as a protozoan; however, studies and analysis of its ribosomal RNA structure suggest that it is a fungus. Its structure and antimicrobial sensitivity are very different from other disease-causing fungi. PJP causes disease only in immunocompromised hosts, invading and proliferating within the pulmonary alveoli with resultant consolidation of the pulmonary parenchyma. Without prophylactic therapy 80% of all people infected with HIV will develop PJP. The clinical presentation of PJP in HIV infection is generally less acute than in people who are immunosuppressed as a result of other conditions. The time between the onset of symptoms and the actual documentation of disease may be weeks to months. Patients with AIDS initially develop nonspecific signs and symptoms, such as nonproductive cough, fever, chills, shortness of breath, dyspnea, and occasionally chest pain. PJP may be present despite the absence of crackles. Arterial oxygen concentrations in patients who are breathing room air may be mildly decreased, indicating minimal hypoxemia. PJP can be diagnosed definitively by identifying the organism in lung tissue or bronchial secretions. This is accomplished through sputum induction, bronchialalveolar lavage, and transbronchial biopsy (by fibreoptic bronchoscopy). Untreated, PJP eventually progresses and causes significant pulmonary impairment and, ultimately, respiratory failure. A few patients have a dramatic onset and a fulminating course involving severe hypoxemia, cyanosis, tachypnea, and altered mental status. Respiratory failure can develop within 2 to 3 days after the initial appearance of symptoms.

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NURSING RESEARCH PROFILE

Chart 53-8. HIV-Related Fatigue Barroso, J., Pence, B., Salahuddin, N., et al. (2008). Physiological correlates of HIV-related fatigue. Clinical Nursing Research, 17(1), 5–19. Purpose Symptom management in people with HIV infection is an increasingly pressing concern. The most frequent and debilitating symptom of HIV is fatigue, which has been defined as “awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and/or restoration of resources needed to perform activity” (p. 6). Design This study used a longitudinal, repeated-measures design over a 3-year period with a total of seven study visits. The researchers investigated the cross-sectional relationship between fatigue and a wide range of physiologic characteristics in a sample of 128 HIV-positive individuals. Participants completed the HIV-related Fatigue Scale (HRFS), which consists of two subscales: (1) fatigue intensity and (2) impact of fatigue on daily functioning. After completion of the HRFS, blood was drawn to measure hepatic function, thyroid function, HIV viral load, immunologic function, gonadal function, hematologic function, and cellular injury. Findings None of the physiologic variables was significantly correlated with the HRFS scales in multivariate linear regression after

Mycobacterium avium Complex Mycobacterium avium complex (MAC) disease is a leading OI in people with AIDS. Organisms belonging to MAC include M. avium and M. intracellulare. MAC, comprising a group of acid-fast bacilli, is commonly found in the lungs, gastrointestinal (GI) tract, lymph nodes, and bone marrow. Lung disease is uncommon but can occur. Signs and symptoms include fever, night sweats, weight loss, abdominal pain, and diarrhea. Anemia is a common laboratory finding. MAC is seen almost exclusively in HIV+ individuals with a CD4 count less than 50 cells/mm3 and associated with IRIS.

Tuberculosis Mycobacterium tuberculosis tends to occur in people with a pre-existing high prevalence of TB infection. Unlike other OIs, TB tends to occur early in the course of HIV disease, usually preceding the diagnosis of AIDS. This early occurrence is associated with the development of caseating granulomas (dry, cheese-like masses of granulation tissue), which should raise the suspicion of TB. At this stage, TB responds well to anti-TB therapy. TB that occurs late in HIV disease is characterized by the absence of an immune response to a tuberculin skin test response. This is known as anergy and results because the compromised immune system can no longer respond to the TB antigen. In the later stages of HIV dis-

controlling for income and years since HIV diagnosis. Income and years of HIV infection were more correlated with fatigue than any of the physiologic measures. Most of the participants had moderate fatigue. Nursing Implications Although fatigue is a common symptom that affects daily functioning and quality of life, and it was expected that physiologic variables such as viral load, liver function, and thyroid levels would be associated with fatigue, no statistically significant relationship was found. Fatigue affects the patient’s ability to participate in activities of daily living such as grocery shopping and house cleaning and affects the patient’s ability to maintain social relationships. Less income for people with HIV often means there are fewer choices and more energy is required to meet basic needs. The relationship between the length of time that patients have been HIV positive and have had fatigue might be a result of patients simply growing tired of living with the day-to-day challenges of HIV infection. Until a better cause of fatigue is identified and treatments are developed, nurses need to help patients cope with this feeling of profound exhaustion. Nurses need to assist patients to create daily schedules around their periods of maximum energy and to assure them that fatigue is not necessarily associated with getting sicker. Nurses can support patients in accessing resources and also provide the emotional support needed to cope with an unpredictable chronic illness.

ease, TB is associated with dissemination to extrapulmonary sites such as the CNS, bone, pericardium, stomach, peritoneum, and scrotum. Multiple drug-resistant strains of the bacillus have emerged and are often associated with lack of adherence to anti-TB therapy.

Gastrointestinal Manifestations The GI manifestations of AIDS include loss of appetite, nausea, vomiting, oral and esophageal candidiasis, and chronic diarrhea. Diarrhea is a problem in 50% to 90% of all patients with AIDS. GI symptoms may be related to the direct effect of HIV on the cells lining the intestines. Some of the enteric pathogens that occur most frequently, identified by stool cultures or intestinal biopsy, are Cryptosporidium muris, Salmonella species, Isospora belli, Giardia lamblia, CMV, Clostridium difficile, and M. avium-intracellulare. In patients with AIDS, the effects of diarrhea can be devastating in terms of profound weight loss (more than 10% of body weight), fluid and electrolyte imbalances, perianal skin excoriation, weakness, and inability to perform the usual activities of daily living.

Oral Candidiasis Candidiasis, a fungal infection, occurs in almost all patients with AIDS and AIDS-related conditions. Commonly preceding other life-threatening infections, it is characterized by creamy-white patches in the oral cavity.

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If left untreated, oral candidiasis progresses to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain. Some patients also develop ulcerating oral lesions and are particularly susceptible to dissemination of candidiasis to other body systems.

Syndrome Wasting syndrome is part of the category C case definition for AIDS. Diagnostic criteria include profound involuntary weight loss exceeding 10% of baseline body weight and either chronic diarrhea for more than 30 days or chronic weakness and documented intermittent or constant fever in the absence of any concurrent illness that could explain these findings. This protein–energy malnutrition is multifactorial. In some AIDS-associated illnesses, patients experience a hypermetabolic state in which excessive calories are burned and lean body mass is lost. This state is similar to that seen in sepsis or trauma and can lead to organ failure. The distinction between cachexia (wasting) and malnutrition, or between cachexia and simple weight loss, is important, because the metabolic derangement seen in wasting syndrome may not be modified by nutritional support alone. Anorexia, diarrhea, GI malabsorption, and lack of nutrition in chronic disease all contribute to wasting syndrome. Progressive tissue wasting, however, may occur with only modest GI involvement and without diarrhea. TNF and IL-1 are cytokines that play important roles in AIDSrelated wasting syndrome. Both act directly on the hypothalamus to cause anorexia. Cytokine-induced fever accelerates the body’s metabolism by 8.5% for every 1°C increase in temperature. TNF causes inefficient use of lipids by reducing enzymes that are needed for fat metabolism, whereas IL-1 triggers the release of amino acids from muscle tissue. People with AIDS generally experience increased protein metabolism in relation to fat metabolism, which results in significant decreases in lean body mass due to muscle and protein breakdown. Hypertriglyceridemia, seen in people with AIDS and attributed to chronically elevated cytokine levels, can persist for months without tissue wasting and loss of lean body mass. It is believed that infections and sepsis lead to transient increases in TNF, IL-1, and other cell mediators above the chronically elevated levels that are often seen with AIDS. These transient increases in TNF and IL-1 trigger muscle wasting.

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Kaposi’s Sarcoma Kaposi’s sarcoma (KS), the most common HIV-related malignancy, is a disease that involves the endothelial layer of blood and lymphatic vessels. In people with AIDS, KS is most often seen among men who have sex with men. It is seen less frequently in the era of antiretroviral therapy. AIDS-related KS exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs may be the first manifestation of HIV; they can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymoses (hemorrhagic patches) and edema (Fig. 53-3). Rapid development of lesions involving large areas of skin is associated with extensive disfigurement. The location and size of some lesions can lead to venous stasis, lymphedema, and pain. Ulcerative lesions disrupt skin integrity and increase discomfort and susceptibility to infection. The most common sites of visceral involvement are the lymph nodes, GI tract, and lungs. Involvement of internal organs may eventually lead to organ failure, hemorrhage, infection, and death. Diagnosis of KS is confirmed by biopsy of suspected lesions. Prognosis depends on the extent of the tumour, the presence of other symptoms of HIV infection, and the CD4+ count. Death may result from tumour progression. More often, however, it results from other complications of HIV infection.

B-Cell Lymphomas B-cell lymphomas are the second most common malignancy occurring in people with AIDS. Lymphomas associated with AIDS usually differ from those occurring in the general population. Patients with AIDS are typically much younger than the usual population affected by non-Hodgkin lymphoma. In addition, AIDS-related lymphomas tend to develop outside the lymph nodes, most commonly in the brain, bone marrow, and GI tract. These types of lymphomas are characteristically of a higher grade, indicating aggressive growth and resistance to treatment. The

Oncologic Manifestations Certain types of cancer occur often in people with AIDS. As a result, these cancers are considered AIDS-defining conditions; that is, their presence in a person infected with HIV is a clear sign that AIDS has developed. These AIDS-related cancers include Kaposi’s sarcoma (KS), lymphoma (especially non-Hodgkin lymphoma and primary central nervous system lymphoma), and invasive cervical cancer. With HAART, the incidence of both KS and non-Hodgkin lymphoma has decreased considerably (Levine, 2008). KS and lymphoma are discussed below. Cervical carcinoma is described later in Gynecologic Manifestations.

FIGURE 53-3. Lesions of the AIDS-related Kaposi’s sarcoma.

Whereas some patients may have lesions that remain flat, others experience extensively disseminated, raised lesions with edema. From DeVita Jr., V. T., Hellman, S., & Rosenberg, S. (Eds.) (1993). AIDS: Etiology, diagnosis, treatment, and prevention (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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course of AIDS-related lymphomas includes multiple sites of organ involvement and complications related to OIs. Although aggressive combination chemotherapy is frequently successful in the treatment of non-Hodgkin lymphoma that is not associated with HIV infection, treatment is less successful in people with AIDS because of severe hematologic toxicity and complications of OIs that can occur from treatment. Continuation or initiation of antiretroviral therapy is recommended.

Neurologic Manifestations The advent of HAART greatly lowered the incidence of HIV-associated dementia and increased the survival of people with HIV-associated neurocognitive disorders (McArthur, 2008). These disorders consist of cognitive impairment that is often accompanied by motor dysfunction and behavioural change. Neurologic dysfunction results from direct effects of HIV on nervous system tissue, OIs, primary or metastatic neoplasms, cerebrovascular changes, metabolic encephalopathies, or complications secondary to therapy. Immune system response to HIV infection in the CNS includes inflammation, atrophy, demyelination, degeneration, and necrosis.

Peripheral Neuropathy HIV-associated peripheral neuropathy is common across the trajectory of HIV disease and may occur in a variety of

patterns, with distal sensory polyneuropathy (DSPN) or distal symmetric polyneuropathy the most frequently occurring type. DSPN occurs in advanced HIV disease as a result of immunosuppression, antiretroviral drug toxicity, and/or mitochondrial toxicity. It can lead to significant pain and decreased function (Nicholas, Voss, Corless, et al., 2007).

HIV-Associated Dementia (HAD) HAD, or AIDS dementia complex (Chart 53-9), is a clinical syndrome is characterized by a progressive decline in cognitive, behavioural, and motor functions. Milder cognitive impairment is called HIV-associated neurocognitive dysfunction (HAND). Substantial evidence exists that HAD is a direct result of HIV infection. HIV has been found in the brain and cerebrospinal fluid (CSF) of patients with HAD and is thought to trigger the release of toxins or lymphokines that result in cellular dysfunction or interference with neurotransmitter function. Signs and symptoms may be subtle and difficult to distinguish from fatigue, depression, or the adverse effects of treatment for infections and malignancies. Early manifestations include memory deficits, headache, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include global cognitive impairments, delay in verbal responses, a vacant stare, spastic paraparesis, hyperreflexia, psychosis, hallucinations, tremor, incontinence, seizures, mutism, and death.

CHART 53-9

Care of the Patient With HIV-associated Dementia (HAD) Disturbed Thought Processes

Risk for Injury

• Assess mental status and neurologic functioning. • Monitor for medication interactions, infections, electrolyte

• Assess the patient’s level of anxiety, confusion, or disorien-

• • • • • • • • •

imbalance, and depression. Frequently orient the patient to time, place, person, reality, and the environment. Use simple explanations. Teach the patient to perform tasks in incremental steps. Provide memory aids (clocks and calendars). Provide memory aids for medication administration. Post activity schedule. Give positive feedback for appropriate behaviour. Teach caretakers how to orient patient to time, place, person, reality, and the environment. Encourage the patient to designate a responsible person to assume power of attorney.

Disturbed Sensory Perception • • • • • •

Assess sensory impairment. Decrease amount of stimuli in the patient’s environment. Correct inaccurate perceptions. Provide reassurance and safety if the patient displays fear. Provide a secure and stable environment. Teach caregivers how to recognize inaccurate sensory perceptions. • Teach caregivers techniques to correct inaccurate perceptions. • Teach the patient and caregivers to report any changes in the patient’s vision to the patient’s health care provider.

tation.

• Assess the patient for delusions or hallucinations. • Remove potentially dangerous objects from the patient’s environment.

• Structure the environment for safety (ensure adequate lighting, avoid clutter, provide bed rails if needed). Supervise smoking. Do not let the patient drive a car if confusion is present. Instruct the patient and caregiver in home safety. Provide assistance as needed for ambulation and in getting in and out of bed. • Pad headboard and side rails if the patient has seizures.

• • • •

Self-Care Deficits • Encourage activities of daily living within the patient’s level of ability.

• Encourage independence but assist if the patient cannot perform an activity.

• Demonstrate any activity that the patient is having difficulty accomplishing.

• Monitor food and fluid intake. • Weigh patient weekly. • Encourage the patient to eat, and offer nutritious meals, snacks, and adequate fluids.

• If patient is incontinent, establish a routine toileting schedule.

• Teach caregivers how to meet the patient’s self-care needs.

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Confirming the diagnosis of HAD can be difficult. Extensive neurologic evaluation includes a computed tomography (CT) scan or magnetic resonance imaging (MRI) which may indicate diffuse cerebral atrophy and ventricular enlargement. Other tests that may detect abnormalities include analysis of CSF through lumbar puncture, and brain biopsy. HAND can be identified on neurocognitive testing.

AIDS may also exhibit a generalized folliculitis associated with dry, flaking skin or atopic dermatitis, such as eczema or psoriasis. Up to 60% of patients treated with the antibacterial agent trimethoprim-sulfamethoxazole (TMPSMZ) develop a drug-related rash that is pruritic with pinkish-red macules and papules. Regardless of the origin of these rashes, patients experience discomfort and are at increased risk for infection from disrupted skin integrity.

Cryptococcus neoformans

Endocrine Manifestations

A fungal infection, Cryptococcus neoformans is another common OI among patients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures. Diagnosis is confirmed by CSF analysis.

The endocrine manifestations of HIV infection are not completely understood. At autopsy, endocrine glands show infiltration and destruction from OIs or neoplasms. Endocrine function may also be affected by therapeutic agents.

Progressive Multifocal Leukoencephalopathy

Gynecologic Manifestations

Progressive multifocal leukoencephalopathy (PML) is a demyelinating CNS disorder that affects the oligodendroglia. Clinical manifestations often begin with mental confusion and rapidly progress to include blindness, aphasia, muscle weakness, paresis (partial or complete paralysis), and death. Prolonged survival and remission have been reported with antiretroviral therapy, but this response has not been consistent.

Persistent, recurrent vaginal candidiasis may be the first sign of HIV illness in women. Past or present genital ulcers are a risk factor for the transmission of the virus. Women with HIV illness are more susceptible to and have increased rates and recurrence of genital ulcers and venereal warts. Ulcerative STIs such as chancroid, syphilis, and herpes are more severe in women with HIV infection. Human papillomavirus (HPV) causes venereal warts and is a risk factor for cervical intraepithelial neoplasia, a cellular change that is frequently a precursor to cervical cancer. Women with HIV are 10 times more likely to develop cervical intraepithelial neoplasia than those not infected with HIV. There is a strong association between abnormal Papanicolaou (PAP) smears and HIV seropositivity. HIVseropositive women with cervical carcinoma present at a more advanced stage of disease and have more persistent and recurrent disease and a shorter interval to recurrence and death than women without HIV infection. Women with HIV are at increased risk for pelvic inflammatory disease (PID), and the associated inflammation may potentiate the transmission of HIV infection. Moreover, women with HIV infection appear to have a higher incidence of menstrual abnormalities, including amenorrhea or bleeding between periods, than do women without HIV infection. The failure of health care providers to consider HIV infection in women may lead to a later diagnosis, thereby denying these patients appropriate and timely treatment.

Other Neurologic Disorders Other common infections involving the nervous system include Toxoplasma gondii, CMV, and Mycobacterium tuberculosis infections. Additional neurologic manifestations include both central and peripheral neuropathies. Vascular myelopathy is a degenerative disorder that affects the lateral and posterior columns of the spinal cord, resulting in progressive spastic paraparesis, ataxia, and incontinence.

Depressive Manifestations The prevalence of depression among people with HIV illness is two to three times higher than in the general population. The causes of depression are multifactorial and may include a history of pre-existing mental illness, neuropsychiatric disturbances, hepatitis C, and psychosocial factors. Depression also occurs in people with HIV infection in response to the physical symptoms, including pain and weight loss, and the lack of social support. People with HIV illness who are depressed may experience irrational guilt and shame, loss of self-esteem, feelings of helplessness and worthlessness, and suicidal ideation.

Integumentary Manifestations Cutaneous manifestations are associated with HIV infection and the accompanying OIs and malignancies. KS (described earlier) and OIs such as herpes zoster and herpes simplex are associated with painful vesicles that disrupt skin integrity. Molluscum contagiosum is a viral infection characterized by deforming plaque formation. Seborrheic dermatitis is associated with an indurated, diffuse, scaly rash involving the scalp and face. Patients with

Medical Management Treatment of Infections TMP-SMZ (Bactrim, Septra) is an antibacterial agent for treating various organisms that cause infection. Persons with HIV illness who have a T-cell count of less than 200 cells/mm3 should receive chemoprophylaxis against PJP with TMP-SMZ, if possible. PJP prophylaxis can be safely discontinued in patients responding to antiretroviral therapy with a sustained increase in T lymphocytes. Its use also confers cross-protection against toxoplasmosis and some common respiratory bacterial infections. Patients with AIDS who are treated with TMP-SMZ experience a

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high incidence of adverse effects, such as fever, rashes, leukopenia, thrombocytopenia, and renal dysfunction. Reintroduction of TMP-SMZ using a gradual increase in dose (desensitization) may be successful in up to 70% of patients.

Pneumocystis jiroveci Pneumonia In the past several years, there have been many advances in the treatment of PJP. TMP-SMZ, the drug of choice for PJP in patients with AIDS and in immunocompromised patients without HIV illness, is available in both intravenous (IV) and oral preparations. Other alternative regimens are available for the treatment and prophylaxis of PJP and include the use of other antimicrobials such as dapsone. If adverse effects develop or if patients do not improve clinically when treated with TMP-SMZ or other regimens, the health care provider may recommend pentamidine. Intramuscular administration is avoided because of the potential for painful sterile abscess formation and IV pentamidine may cause severe hypotension if administered too rapidly. Other adverse effects include impaired glucose metabolism (with diabetes mellitus), renal damage, hepatic dysfunction, and neutropenia. Initially, the success of aerosolized pentamidine led to its use as a treatment for mild to moderate PJP. However, it has proved to be less effective and more costly than TMP-SMZ, and early relapses are common. Because of these limitations, the inhalant form of pentamidine is usually reserved for prophylaxis of PJP in individuals with CD4 counts less than 200 who are intolerant of other treatments. The combination of TMP-SMZ and pentamidine has shown no additional benefit and is avoided because of the cumulative toxic effects that may result.

Mycobacterium Avium Complex HIV-infected adults and adolescents should receive chemoprophylaxis against disseminated MAC disease if they have a CD4+ count less than 50 cells/µL. Chemoprophylaxis for MAC involves the use of either clarithromycin (Biaxin) or azithromycin (Zithromax). Rifabutin (Mycobutin) is an alternative agent for chemoprophylaxis but has an increased occurrence of adverse effects and potential for significant drug interactions (especially with some classes of antiretroviral medication). Secondary prophylaxis for disseminated MAC may be discontinued in patients with sustained increases (e.g., longer than 6 months) in CD4 counts greater than 100 in response to HAART antiretroviral therapy, if they have completed 12 months of MAC therapy and have no signs or symptoms attributable to MAC. Primary prophylaxis for disseminated MAC may be discontinued in patients who have responded to HAART antiretroviral therapy with CD4 counts of 100 or more for at least 3 months and reintroduced if counts decrease to 50 to 100.

Cryptococcal Meningitis Cryptococcosis among patients with HIV infection most commonly occurs as a subacute meningitis or meningoencephalitis with fever, malaise, and headache. Current primary therapy for cryptococcal meningitis is IV amphotericin B with or without oral flucytosine (5-FC, Ancobon) or fluconazole (Diflucan).

Serious potential adverse effects of amphotericin B include anaphylaxis, renal and hepatic impairment, electrolyte imbalances, anemia, fever, and severe chills. Intrathecal administration of amphotericin B has been used in place of or in combination with IV administration in patients who have failed to respond to the latter. Until fluconazole, an antifungal agent, was approved and used for lifelong suppressive therapy, frequent relapses and high mortality rates often necessitated prolonged therapy with amphotericin B. In some instances, the patient continues to receive IV amphotericin in the home setting. Oral fluconazole is used as suppressive therapy when the CSF tests negative for the organism. This medication is less toxic and better tolerated than amphotericin B.

Cytomegalovirus Retinitis Prophylaxis with oral ganciclovir or valganciclovir may be considered for HIV-infected persons with T-cell counts less than 50. Three antiviral agents, ganciclovir (DHPG, Cytovene, Vitrasert), valganciclovir (Valcyte), and foscarnet (Foscavir), offer effective treatment but not a cure for CMV retinitis. Because these medications do not kill the virus but rather control its growth, they may need to be taken lifelong. Relapse rates of the three agents are similar. Discontinuation of the medication is associated with the rapid relapse of retinitis. A common adverse reaction to ganciclovir and valganciclovir is severe neutropenia, which limits the concomitant use of zidovudine (AZT, Retrovir). For patients who cannot tolerate systemic ganciclovir or valganciclovir because of severe neutropenia, infection at the venous access site, or the need to take zidovudine, intravitreal injections of ganciclovir have been effective. Zidovudine can be given with foscarnet (Foscavir). Common adverse reactions to foscarnet are nephrotoxicity, including acute renal failure, and electrolyte imbalances, including hypocalcemia, hyperphosphatemia, and hypomagnesemia, which can be life threatening. Other common adverse effects include seizures, GI disturbances, anemia, phlebitis at the infusion site, and low back pain. Possible bone marrow suppression (producing a decrease in white blood cell and platelet counts), oral candidiasis, and liver and renal impairments require close patient monitoring.

Other Infections Oral acyclovir, famciclovir, or valacyclovir may be used to treat infections caused by herpes simplex or herpes zoster. Esophageal or oral candidiasis is treated topically with clotrimazole (Mycelex) oral troches or nystatin suspension. Chronic refractory infection with candidiasis (thrush) or esophageal involvement is treated with fluconazole (Diflucan) or itraconazole (Sporanox). Ketoconazole is an alternative agent but has significant interactions with some antiretroviral medication.

Antidiarrheal Therapy Although many forms of diarrhea respond to treatment, it is not unusual for this condition to recur and become a chronic problem for the patient with HIV infection. Improvement or resolution is linked to identifying the underlying pathogen, improvement of CD4+ count, and

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suppression of the viral load with HAART. Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. High concentrations of somatostatin receptors have been found in the GI tract and in other tissues. Somatostatin inhibits many physiologic functions, including GI motility and intestinal secretion of water and electrolytes.

Chemotherapy Kaposi’s Sarcoma Management of KS is usually difficult because of the variability of symptoms and the organ systems involved. Treatment goals are to reduce symptoms by decreasing the size of the skin lesions, to reduce discomfort associated with edema and ulcerations, and to control symptoms associated with mucosal or visceral involvement. Localized treatment includes surgical excision of the lesions or application of liquid nitrogen to local skin lesions and injections of intraoral lesions with dilute vinblastine. Injection of intraoral lesions has been associated with local pain and skin irritation. Radiation therapy is effective as a palliative measure to relieve localized pain due to tumour mass (especially in the legs) and for KS lesions that are in sites such as the oral mucosa, conjunctiva, face, and soles of the feet. Systemic treatment includes the use of liposomal doxorubicin or liposomal daunorubicin. Treatment with antiretroviral therapy, resulting in improved CD4+ count, correlates highly with improvement of KS. Interferon is known for its antiviral and antitumour effects. Patients with cutaneous KS treated with alphainterferon have experienced tumour regression and improved immune system function. Alpha-interferon is administered by the IV, intramuscular, or subcutaneous route. Patients may self-administer interferon at home or receive interferon in an outpatient setting.

Lymphoma Successful treatment of AIDS-related lymphomas has been limited because of the rapid progression of these malignancies. Combination chemotherapy and radiation therapy regimens may produce an initial response, but it is usually short-lived. Because standard regimens for nonAIDS lymphomas have been ineffective, many clinicians suggest that AIDS-related lymphomas should be studied as a separate group in clinical trials.

Antidepressant Therapy Treatment for depression in people with HIV infection involves psychotherapy integrated with pharmacotherapy. If depressive symptoms are severe and of sufficient duration, treatment with antidepressants may be initiated. Tricyclic antidepressants such as imipramine (Tofranil), desipramine (Norpramin), and selective serotonin-reuptake inhibitors such as fluoxetine (Prozac) may be used, because these medications also alleviate the fatigue and lethargy that are associated with depression. A psychostimulant such as methylphenidate (Ritalin) may be used in low

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doses in patients with neuropsychiatric impairment. Electroconvulsive therapy may be an option for patients with severe depression who do not respond to pharmacologic interventions.

Nutrition Therapy Malnutrition increases the risk of infection and the incidence of OIs. Nutrition therapy should be part of the overall management plan and should be tailored to meet the nutritional needs of the patient, whether by oral diet, enteral tube feedings, or parenteral nutritional support, if needed. As with all patients, a healthy diet is essential for the patient with HIV infection. For patients with diarrhea, a diet low in fat, lactose, insoluble fibre, and caffeine and high in soluble fibre is helpful (Anastasi, Capili, Kim, et al., 2006). For all patients with HIV illness who experience unexplained weight loss, calorie counts should be obtained to evaluate nutritional status and initiate appropriate therapy. The goal is to maintain the ideal weight and, when necessary, to increase weight. Appetite stimulants have been successfully used in patients with AIDS-related anorexia. Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain and inhibits cytokine IL-1 synthesis. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Dronabinol (Marinol), which is a synthetic tetrahydrocannabinol (THC), the active ingredient in marijuana, has been used to relieve nausea and vomiting associated with cancer chemotherapy. After beginning dronabinol therapy, almost all patients with HIV infection experience a modest weight gain. The effects on body composition are unknown. Oral supplements may be used to enhance diets that are deficient in calories and protein. Ideally, oral supplements should be lactose-free (many people with HIV infection are intolerant to lactose), high in calories and easily digestible protein, low in fat with the fat easily digestible, palatable, inexpensive, and tolerated without causing diarrhea. Enteral therapy may be an option for specific patients who experience anorexia. Parenteral nutrition is the final option because of its prohibitive cost and associated risks, including risk of infections.

Complementary and Alternative Modalities Complementary and alternative medicine (or CAM) refers to medical practices that are “outside the standard Western medical model” (Canadian AIDS Treatment Information Exchange [CATIE], 2009), and is also known as holistic or integrative medicine. CAM stresses the need to treat the whole person, recognizing the interaction of the body, mind, and spirit. While a Western biomedical approach has dominated much HIV/AIDS care, treatment and prevention, many people affected by HIV have also turned to CAM. The boundaries between CAM and medical science are not always fixed or clear and limited clinical research makes it difficult to evaluate CAM. CAM also raises complex legal, ethical, and clinical issues (Gilmour, Harrison, Cohen, et al., 2011). Mill (2000) found that since Aboriginal women’s

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views about the etiology and treatment for their HIV illness were different from the conventional biomedical view of HIV disease, the women used a combination of biomedical, traditional, and alternative treatments for their illness. At other times fear of judgment, discrimination, and stigma have made it less likely for Aboriginal women to access Western health care (McCall & Pauly, 2012; Chart 53-10). Persons with HIV illness report substantial use of complementary and alternative medical therapies for symptom management (CATIE, 2004). The use of alternative therapy in HIV disease and AIDS has resulted from disillusionment with standard medical treatment, which to date has provided no cure. Although there is insufficient research on the effects of alternative therapies, there is a growing body of literature reporting benefits in the areas of nutrition, exercise, psychosocial treatment, and Chinese medicine. Clinical trials are in progress to examine the effect of Chinese herbal treatments of HIV-associated symptoms related to inadequate nutrition, such as fatigue, nausea, vomiting, painful or difficulty swallowing, altered taste sensation, and diarrhea. At present, there are no definitive study results indicating that these treatments are effective, but some appear promising. In a recent randomized trial at Mount Sinai Hospital in Toronto researchers explore mindfulness-based stress reduction for HIV positive men. While the results are mixed they seem to indicate that enhanced psychological function is supported by mindfulness-based stress reduction therapy (Vollestad, Silvertsen, & Biuelsen, 2011). Used with biomedical therapies, alternative therapies may improve the patient’s overall well-being.

Complementary approaches comprise a wide range of therapies that belong to one of five domains (College and Association of Registered Nurses of Alberta, 2011): 1. Biologically based practices and products that supplement the diet and include substances such as herbal medicines, probiotics, and vitamins 2. Mind and body medicine employs approaches that enhance the influence of the mind on the body’s functioning, including mediation, acupuncture, guided imagery, and yoga 3. Manipulative and body-based practices focus on the structures and systems of the body, such as spinal manipulation and massage therapy 4. Energy medicine promotes healing through manipulation of energy fields using techniques such as qi gong, healing touch, and Reiki Whole medicine systems that comprise practices based on evidence accumulated over long periods of time, such as Ayurvedic and traditional Chinese medicine. Many patients who use these therapies do not report their use to health care providers. To obtain a complete health history, the nurse should ask about the patient’s use of such therapies. Patients may need to be encouraged to report use to their primary health care provider. Problems may arise, for example, when patients are using alternative therapies while participating in clinical drug trials, or when care providers are trying to determine complex drug interactions and side effects. They can have significant adverse side effects, making it difficult to assess the effects of the experimental medications. The nurse needs to

NURSING RESEARCH PROFILE

Chart 53-10. Aboriginal Women’s View of HIV Care

Purpose Aboriginal women living HIV/AIDS are more likely to die of AIDS-related illnesses and less likely to access treatment for their HIV infection than the general population infected with HIV. The study examines the lives and experiences of Aboriginal women facing significant social-economic barriers and living with HIV illness in relation to accessing care.

Findings A number of themes were uncovered related to Aboriginal women’s experiences with health care, including fear of rejection. The participants were reluctant to access health services because they felt unsafe. The participants in this study faced barriers to forming therapeutic relationships with the providers with whom they came in contact, due to a lack of communication and a sense of powerlessness and fearfulness about how they would be treated. The women’s experiences of judgment and stigma compounded their discomforts with the care that was provided.

Study Sample and Design A qualitative research design was selected for the study, and in-depth semi-structured interviews were the primary data collection methods. The sample consisted of eight Aboriginal women who self identified as HIV positive. Participants were recruited through one inpatient HIV unit and one outpatient HIV clinic. The interviews were audio recorded and transcribed verbatim. The transcripts were read repeatedly to identify recurring, converting, and contradictory patterns of interaction; key concept; emerging themes; symbolic examples; and possible connections to the underlying theory. The transcripts were coded and emerging themes and categories were identified and reviewed with participants.

Nursing Implications The authors examine how cultural safety principles might be applied in therapeutic relationships with Aboriginal women as part of the process of facilitating access to care that is acceptable and timely. It is clear from the findings that it is critical for nurses and other health care workers to understand the positioning of Aboriginal women in the health care system and the need for safer environments. Through the use of a cultural safety framework, nurses are able to develop therapeutic and safe relationships with their patients. When nurses practice in a culturally safe manner, they not only help improve the lives of their patients but they also stand to achieve a heightened state of self-awareness and professional growth.

McCall, J., & Pauly, B. (2012). Providing a safe place: Adopting a cultural safety perspective in the care of Aboriginal women living with HIV/AIDS.

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become familiar with the potential interactions among these therapies, as well as their effects on antiretroviral therapy uptake and adherence (Littlewood & Vanable, 2011). The nurse who believes that the alternative therapy is causing a side effect needs to discuss this with the patient, the alternative therapy provider, and the primary health care provider. It is important for the nurse to view these therapies with an open mind, cognizant of risks and responsibilities, and to try to understand the importance of this treatment to the patient.

Supportive Care Patients who are weak and debilitated as a result of chronic illness associated with HIV illness typically require many kinds of supportive care. Nutritional support may be as simple as providing assistance in obtaining or preparing meals. For patients with more advanced nutritional impairment resulting from decreased intake, wasting syndrome, or GI malabsorption associated with diarrhea, parenteral feedings may be required. Imbalances that result from nausea, vomiting, and profuse diarrhea often necessitate IV fluid and electrolyte replacement. Management of skin breakdown associated with KS, perianal skin excoriation, or immobility entails thorough and meticulous skin care that involves regular turning, cleansing, and applications of medicated ointments and dressings. To combat pain associated with skin breakdown, abdominal cramping, peripheral neuropathy, or KS, it is necessary to administer analgesic agents at regular intervals around the clock. Relaxation and guided imagery may be helpful in reducing pain and anxiety. Pulmonary symptoms, such as dyspnea and shortness of breath, may be related to infection, KS, or fatigue. For these patients, oxygen therapy, relaxation training, and energy conservation techniques may be effective. Patients with severe respiratory dysfunction may require mechanical ventilation. Before mechanical ventilation is instituted, the procedure is explained to the patient and the caregiver. If the patient decides to forgo mechanical ventilation, his or her wishes should be followed. Ideally, the patient has prepared an advance directive identifying preferences for treatments and end-of-life care, including hospice care. If the patient has not identified preferences in advance, treatment options are described so that the patient can make informed decisions and have those wishes respected.

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Nursing Process

The Patient With HIV Illness The nursing care of patients with HIV illness is challenging because of the potential for any organ system to be the target of infections or cancer. In addition, this disease is complicated by many emotional, social, and ethical issues. The plan of care for the patient with AIDS (Chart 53-11) is individualized to meet the needs of the patient. The best practice guidelines of HIV/AIDS nursing developed by the

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Canadian Association of Nurses in AIDS Care (2012) direct nursing practice. Care includes many of the interventions and concerns cited in the section on supportive care.

Assessment Nursing assessment includes identification of potential risk factors, including a history of sexual practices or IV/injection drug use. The patient’s physical status and psychological status are assessed, as well as the client’s understanding of the meaning and implications of the symptoms. All factors affecting immune system functioning are thoroughly explored. It is important to note that the focus of the assessment presented in this chapter is on adult clients; children and families affected by HIV and AIDS need additional considerations that are beyond the scope of this chapter. As well, it is important to remain aware of gender specific assessments, as well as interventions.

Nutritional Status Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patient’s ability to purchase, prepare, and safely store food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and serum albumin, iron studies, and vitamin D levels provide objective measurements of nutritional status. Assessment in relation to poverty and access to food provides insight to complex social issues. Nurses must be prepared to make appropriate referrals both within their institutional settings as well as to community agencies.

Skin Integrity The skin and mucous membranes are inspected daily for evidence of breakdown, ulceration, or infection. The oral cavity is monitored for redness, ulcerations, and the presence of creamy-white patches indicative of candidiasis. Assessment of the perianal area for excoriation and infection in patients with profuse diarrhea is important. Wounds are cultured to identify infectious organisms.

Respiratory Status Respiratory status is assessed by monitoring the patient for cough, sputum production (i.e., amount and colour), dyspnea, orthopnea, tachypnea, and chest pain. The presence and quality of breath sounds are investigated. Other measures of pulmonary function include chest x-ray results, arterial blood gas values, pulse oximetry, and pulmonary function test results.

Neurologic Status Neurologic status is determined by assessing level of consciousness; orientation to person, place, and time; (text continued on page 1697)

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 53-11. Care of the Patient With HIV or AIDS RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Diarrhea related to enteric pathogens or HIV infection Goal: Resumption of usual bowel habits 1. Assess patient’s normal bowel habits. 2. Assess for diarrhea: frequent, loose stools; abdominal pain or cramping, volume of liquid stools, and exacerbating and alleviating factors. 3. Obtain stool cultures and administer antimicrobial therapy as prescribed. 4. Initiate measures to reduce hyperactivity of bowel: a. Maintain food and fluid restrictions as prescribed. Suggest BRAT diet (bananas, rice, applesauce, tea and toast). b. Discourage smoking. c. Avoid bowel irritants such as fatty or fried foods, raw vegetables, and nuts. Offer small, frequent meals. 5. Administer anticholinergic antispasmodics and opioids or other medications as prescribed. 6. Maintain fluid intake of at least 3 L/day unless contraindicated.

1. Provides baseline for evaluation 2. Detects changes in status, quantifies loss of fluid, and provides basis for nursing measures 3. Identifies pathogenic organism; therapy targets specific organism 4. Promotes bowel rest, which may decrease acute episodes a. Reduces stimulation of bowel

• Exhibits return to normal bowel patterns

• Reports decreasing episodes of

diarrhea and abdominal cramping

• Identifies and avoids foods that irritate the gastrointestinal tract

• Appropriate therapy is initiated as prescribed

• Exhibits normal stool cultures • Maintains adequate fluid intake • Maintains body weight and reports no additional weight loss

b. Eliminates nicotine, which acts as bowel stimulant c. Prevents stimulation of bowel and abdominal distention and promotes adequate nutrition 5. Decreases intestinal spasms and motility

• States rationale for avoiding • • • •

6. Prevents hypovolemia

smoking Enrolls in program to stop smoking Uses medication as prescribed Maintains adequate fluid status Exhibits normal skin turgor, moist mucous membranes, adequate urine output, and absence of excessive thirst

Nursing Diagnosis: Risk for infection related to immunodeficiency Goal: Absence of infection 1. Monitor for infection: fever, chills, and diaphoresis; cough; shortness of breath; oral pain or painful swallowing; creamy-white patches in oral cavity; urinary frequency, urgency, or dysuria; redness, swelling, or drainage from wounds; vesicular lesions on face, lips, or perianal area. 2. Teach patient or caregiver about need to report possible infection. 3. Monitor white blood cell count and differential. 4. Obtain cultures of wound drainage, skin lesions, urine, stool, sputum, mouth, and blood as prescribed. Administer antimicrobial therapy as prescribed. 5. Instruct patient in ways to prevent infection: a. Clean kitchen and bathroom surfaces with disinfectants. b. Clean hands thoroughly after exposure to body fluids. c. Avoid exposure to others’ body fluids or sharing eating utensils. d. Turn, cough, and deep breathe, especially when activity is decreased.

1. Allows for early detection of infection, essential for prompt initiation of treatment. Repeated and prolonged infections contribute to patient’s debilitation.

• Identifies reportable signs and symptoms of infection

• Reports signs and symptoms of infection if present

• Exhibits and reports absence of fever, chills, and diaphoresis

• Exhibits normal (clear) breath 2. Allows early detection of infection 3. Identifies elevated WBC possibly associated with infection 4. Assists in determining offending organism to initiate appropriate treatment 5. Minimizes exposure to infection and transmission of HIV infection to others

• • • • • • • • • • •

sounds without adventitious breath sounds Maintains weight Reports adequate energy level without excessive fatigue Reports absence of shortness of breath and cough Exhibits pink, moist oral mucous membranes without fissures or lesions Takes appropriate therapy as prescribed Experiences no infection States rationale for strategies to avoid infection Modifies activities to reduce exposure to infection or infectious persons Practices “safer sex” Avoids sharing eating utensils and toothbrush Exhibits normal body temperature

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Plan of Nursing Care NURSING INTERVENTIONS e. Maintain cleanliness of perianal area. f. Avoid handling pet excreta or cleaning litter boxes, bird cages, or aquariums. g. Cook meat and eggs thoroughly. 6. Maintain aseptic technique when performing invasive procedures such as venipunctures, bladder catheterizations, and injections.

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Chart 53-11. Care of the Patient With HIV or AIDS, Continued RATIONALE

EXPECTED OUTCOMES

• Uses recommended techniques to

6. Prevents hospital-acquired infections

maintain cleanliness of skin, skin lesions, and perianal area • Has others handle pet excreta and cleanup • Uses recommended cooking techniques

Nursing Diagnosis: Ineffective airway clearance related to Pneumocystis pneumonia, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue Goal: Improved airway clearance 1. Assess and report signs and symptoms of altered respiratory status, tachypnea, use of accessory muscles, cough, colour and amount of sputum, abnormal breath sounds, dusky or cyanotic skin colour, restlessness, confusion, or somnolence. 2. Obtain sputum sample for culture prescribed. Administer antimicrobial therapy as prescribed. 3. Provide pulmonary care (cough, deep breathing, postural drainage, and vibration) every 2 to 4 hours. 4. Assist patient in attaining semi- or high Fowler’s position. 5. Encourage adequate rest periods. 6. Initiate measures to decrease viscosity of secretions: a. Maintain fluid intake of at least 3 L/day unless contraindicated. b. Humidify inspired air as prescribed. c. Consult with physician concerning use of mucolytic agents delivered through nebulizer. 7. Perform tracheal suctioning as needed. 8. Administer oxygen therapy as prescribed. 9. Assist with endotracheal intubation; maintain ventilator settings as prescribed.

1. Indicates abnormal respiratory function

• Maintains normal airway clearance:

2. Aids in identification of pathogenic organisms 3. Prevents stasis of secretions and promotes airway clearance 4. Facilities breathing and airway clearance 5. Maximizes energy expenditure and prevents excessive fatigue 6. Facilitates expectoration of secretions; prevents stasis of secretions

• • • • • • • • •

7. Removes secretions if patient is unable to do so 8. Increases availability of oxygen

•

9. Maintains ventilation

•

•

• •

Respiratory rate

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 53-11. Care of the Patient With HIV or AIDS, Continued RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to decreased oral intake Goal: Improvement of nutritional status 1. Assess for malnutrition with height, weight, age, albumin, and iron studies, hemoglobin, and hematocrit. 2. Obtain dietary history, including likes and dislikes and food intolerances. 3. Assess factors that interfere with oral intake. 4. Consult with dietician to determine patient’s nutritional needs. 5. Reduce factors limiting oral intake: a. Encourage patient to rest before meals. b. Plan meals so that they do not occur immediately after painful or unpleasant procedures. c. Encourage patient to eat meals with visitors or others when possible. d. Encourage patient to prepare simple meals or to obtain assistance with meal preparation if possible. e. Serve small, frequent meals: 6 per day. f. Limit fluids 1 hour before meals and with meals. 6. Instruct patient in ways to supplement nutrition: consume protein-rich foods (meat, poultry, fish) and carbohydrates (pasta, fruit, breads). 7. Consult with physician and dietician about alternative feeding (enteral or parenteral nutrition). 8. Consult with social worker or community liaison about financial assistance if patient cannot afford food.

1. Provides objective measurement of nutritional status

• Identifies factors limiting oral intake

2. Defines need for nutritional education; helps individualize interventions 3. Provides basis and directions for interventions 4. Facilitates meal planning

• •

5. Addresses factors limiting intake: a. Minimizes fatigue, which can decrease appetite b. Decreases noxious stimuli c. Limits social isolation d. Limits energy expenditure

• • • • • • • • •

e. Prevents overwhelming patient

•

f. Reduces satiety

•

6. Provides additional proteins and calories 7. Provides nutritional support if patient is unable to take sufficient amounts by mouth 8. Increases availability of resources and nutrition

• • •

and uses resources to promote adequate dietary intake Reports increased appetite States understanding of nutritional needs Identifies ways to reduce factors that limit oral intake Rests before meals Eats in pleasant, odour-free environment Arranges meals to coincide with visitors’ visits Reports increased dietary intake Uses oral hygiene before meals Takes analgesic agents before meals as prescribed Identifies ways to increase protein and caloric intake Identifies foods high in protein and calories Consumes foods high in protein and calories Reports decreased rate of weight loss Maintains adequate intake States rationale for enteral or parenteral nutrition if needed Demonstrates skill in preparing alternative sources of nutrition

Nursing Diagnosis: Deficient knowledge related to means of preventing HIV transmission Goal: Increased knowledge concerning means of preventing disease transmission 1. Instruct patient, family, and friends about routes of transmission of HIV. 2. Instruct patient, family, and friends about means of preventing transmission of HIV: a. Avoid sexual contact with multiple partners, and use precautions if sexual partner’s HIV status is not certain. b. Use condoms during sexual intercourse (vaginal, anal, oral–genital); avoid mouth contact with the penis, vagina, or rectum; avoid sexual practices that can cause cuts or tears in the lining of the rectum, vagina, or penis.

1. Knowledge about disease transmission can help prevent spread of disease; may also alleviate fears. 2. Reduces transmission risk a. The risk of infection increases with the number of sexual partners, male or female, and sexual contact with those who engage in high-risk behaviours. b. Risk of HIV transmission is reduced.

• Patient, family, and friends state means of transmission.

• Reports and demonstrates practices to reduce exposure of others to HIV

• Demonstrates knowledge of safer sexual practices

• Identifies means of preventing disease transmission

• States that sexual partners are

informed about patient’s positive HIV status in blood • Avoids IV/injection drug use and sharing of drug equipment with others

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Plan of Nursing Care NURSING INTERVENTIONS c. Avoid sex with sex workers and others at high risk. d. Do not use IV/injection drugs; if addicted and unable or unwilling to change behaviour, use clean needles and syringes.

e. Women who may have been exposed to HIV through sexual or drug practices should consult with a physician before becoming pregnant; consider use of antiretroviral agents if pregnant.

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Chart 53-11. Care of the Patient With HIV or AIDS, Continued RATIONALE

EXPECTED OUTCOMES

c. Many sex workers are infected with HIV through sexual contact with multiple partners or IV/ injection drug use. d. Clean needles and syringes are the only way to prevent HIV transmission for those who continue to use drugs. Taking precautions is important for those who are antibody positive to prevent transmitting HIV. e. HIV can be transmitted from mother to child in utero; use of antiretroviral agents during pregnancy significantly reduces perinatal transmission of HIV.

Nursing Diagnosis: Social isolation related to stigma of the disease, withdrawal of support systems, isolation procedures, and fear of infecting others Goal: Decreased sense of social isolation 1. Assess patient’s usual patterns of social interaction. 2. Observe for behaviours indicative of social isolation, such as decreased interaction with others, hostility, noncompliance, sad affect, and stated feelings of rejection or loneliness. 3. Provide instruction concerning modes of transmission of HIV. 4. Assist patient to identify and explore resources for support and positive mechanisms for coping (e.g., contact with family, friends, HIV support organizations). 5. Allow time to be with patient other than for medications and procedures. 6. Encourage participation in diversional activities such as reading, television, or hand crafts.

1. Establishes basis for individualized interventions 2. Promotes early detection of social isolation, which may be manifested in several ways

• Shares with others the need for val-

3. Provides accurate information, corrects misconceptions, and alleviates anxiety 4. Enables mobilization of resources and supports

•

ued social interaction

• Demonstrates interest in events, activities, and communication

• Verbalizes feelings and reactions to

•

• 5. Promotes feelings of self-worth and provides social interaction 6. Provides distraction

• • • • • •

diagnosis, prognosis, and life changes Identifies modes of transmission of HIV States ways of preventing transmission of AIDS virus to others while maintaining contact with valued friends and relatives Reveals HIV diagnosis to others when appropriate Identifies resources (i.e., family, friends, and support groups) Uses resources when appropriate Accepts offers of assistance and support Reports decreased sense of isolation Maintains contacts with those of importance to him or her Develops or continues hobbies that effectively serve as diversion or distraction

Collaborative Problems: Opportunistic infections; impaired breathing; wasting syndrome and fluid and electrolyte imbalances; adverse reaction to medications

Goal: Absence of complications Opportunistic Infections 1. Monitor vital signs.

1. Changes in vital signs such as increases in pulse rate, respirations, blood pressure, and temperature may indicate infection.

• Exhibits stable vital signs • Experiences control of infection • Identifies signs and symptoms correctly and experiences no complications

continued >

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Plan of Nursing Care

Chart 53-11. Care of the Patient With HIV or AIDS, Continued

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

2. Obtain laboratory specimens and monitor test results.

2. Smears and cultures can identify causative agents such as bacteria, fungi, and protozoa, and sensitivity studies can identify antibiotics or other medications effective against the causative agent. 3. Early recognition of symptoms facilitates prompt treatment and avoids extra complications.

• Identifies signs and symptoms that

1. Rapid shallow breathing, diminished breath sounds, and shortness of breath may indicate respiratory failure resulting in hypoxia. 2. Crackles and wheezes may indicate fluid in the lungs, which disrupts respiratory function and alters the blood’s oxygen-carrying capacity. 3. Changes in pulse rate, blood pressure, and oxygen levels may indicate the development of respiratory or cardiac failure.

• Maintains stable respiratory rate

1. Weight loss, malnutrition, and anemia are common in HIV infection and increase risk for superinfection. 2. Chronic diarrhea, inadequate oral intake, vomiting, and profuse sweating deplete electrolytes. Small intestine inflammation may impair the absorption of fluids and electrolytes. 3. Fluid loss results in decreased circulating volume leading to tachycardia, dry skin and mucous membranes, poor skin turgor, elevated urine specific gravity, and thirst. Early detection allows early treatment.

• Maintains stable weight • Eats a nutritious diet • Attains and maintains hemoglobin,

1. People with HIV infection can receive many medications for HIV and for disease complications. Early detection of medication interactions is necessary to prevent complications. 2. Side effects from antiretroviral agents can be life-threatening. Serious side effects include anemia, pancreatitis, peripheral neuropathy, mental confusion, and persistent nausea and vomiting. Corrective measures need to be instituted. 3. Knowledge of the medication purpose, correct administration, side effects, and strategies to manage or prevent side effects promotes safety and greater compliance with treatment. Patient informs health care provider of any changes to medications or complementary therapies.

• Experiences no serious side effects or

3. Instruct the patient and caregiver about signs and symptoms of infection and the need to report them early. Impaired Breathing 1. Monitor respiratory rate and pattern.

2. Auscultate the chest for breath sounds and abnormal lung sounds. 3. Monitor pulse rate, blood pressure, and oxygen saturation levels.

Wasting Syndrome and Fluid and Electrolyte Disturbances 1. Monitor weight and laboratory values for nutritional status. 2. Monitor intake and output and laboratory values for fluid and electrolyte imbalance (potassium, sodium, chloride, calcium, phosphorus, magnesium). 3. Monitor for and report signs and symptoms of dehydration.

Reactions to Medications 1. Monitor for medication interactions.

2. Monitor for and promptly report side effects from antiretroviral agents.

3. Instruct the patient and caregiver in the medication regimen.

are reportable to the physician

• Takes medications as prescribed

and pattern within the normal limits

• Exhibits no adventitious lung

sounds; normal breath sounds

• Has stable pulse rate and blood

pressure within normal limits, and exhibits no evidence of hypoxia • Oxygen saturation levels within acceptable range

hematocrit, and ferritin levels within normal limits • Sustains fluid and electrolyte balance within normal limits • Exhibits no signs and symptoms of dehydration

complications from medications

• Correctly describes medication regi-

men and complies with therapy, including adaptations in eating routines and type of food used with prescribed medications

CHAPTER 53

and memory lapses. Mental status is assessed as early as possible to provide a baseline. The patient is also assessed for sensory deficits (visual changes, headache, or numbness and tingling in the extremities), motor involvement (altered gait, paresis, or paralysis), and seizure activity.

Fluid and Electrolyte Balance Fluid and electrolyte status is assessed by examining the skin and mucous membranes for turgor and dryness. Dehydration may be indicated by increased thirst, decreased urine output, postural hypotension, weak and rapid pulse, and urine specific gravity of 1.025 or more. Electrolyte imbalances, such as decreased serum sodium, potassium, calcium, magnesium, and chloride, typically result from profuse diarrhea. The patient is assessed for signs and symptoms of electrolyte deficits, including decreased mental status, muscle twitching, muscle cramps, irregular pulse, nausea and vomiting, and shallow respirations.

Knowledge Level The patient’s level of knowledge about the disease and the modes of disease transmission is evaluated. In addition, the level of knowledge of family and friends is assessed. The patient’s psychological reaction to the diagnosis of HIV infectionis important to explore. Reactions vary among patients and may include denial, anger, fear, shame, withdrawal from social interactions, and depression. It is often helpful to gain an understanding of how the patient has dealt with illness and major life stresses in the past. The patient’s resources for support are also identified. The experience of stigma has in same cases silenced people living with HIV from sharing their diagnosis with care providers and friends, or has led to a refusal to access care. It is important to assess the impact of stigma, as it can interfere with access to appropriate care and add to social isolation, depression and shame. Discussing experiences of stigma openly is important to ensure trust, as well as to identify the need for referrals to psychologists, psychiatrist or other counsellors. At the same time nurses have the obligation to advocate for meaningful, supportive, and relevant resources and environments that support clients.

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• Activity intolerance related to weakness, fatigue, malnutrition, impaired fluid and electrolyte balance, and hypoxia associated with pulmonary infections • Disturbed thought processes related to shortened attention span, impaired memory, confusion, and disorientation associated with HIV-associated dementia • Ineffective airway clearance related to PJP, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue • Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy • Imbalanced nutrition, less than body requirements, related to decreased oral intake • Social isolation related to stigma of the disease, withdrawal of support systems, isolation procedures, and fear of infecting others • Anticipatory grieving related to changes in lifestyle and roles and unfavourable prognosis • Deficient knowledge related to HIV infection, means of preventing HIV transmission, and self-care

Collaborative Problems/ Potential Complications Based on the assessment data, possible complications may include the following: • OIs • Impaired breathing or respiratory failure • Wasting syndrome and fluid and electrolyte imbalance • Adverse reaction to medications

Planning and Goals Goals for the patient may include achievement and maintenance of skin integrity, resumption of usual bowel patterns, absence of infection, improved activity tolerance, improved thought processes, improved airway clearance, increased comfort, improved nutritional status, increased socialization, expression of grief, increased knowledge regarding disease prevention and self-care, and absence of complications.

Nursing Interventions

Diagnosis

Promoting Skin Integrity

Nursing Diagnoses

The skin and oral mucosa are assessed routinely for changes in appearance, location and size of lesions, and evidence of infection and breakdown. The patient is encouraged to maintain a balance between rest and mobility whenever possible. Patients who are immobile are assisted to change position every 2 hours. Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Patients are encouraged to avoid scratching; to use nonabrasive, nondrying soaps; and to apply nonperfumed skin moisturizers to dry skin. Regular oral care is also encouraged.

The list of potential nursing diagnoses is extensive because of the complex nature of this disease. However, based on assessment data, major nursing diagnoses for the patient may include the following: • Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea • Diarrhea related to enteric pathogens or HIV infection • Risk for infection related to immunodeficiency

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Medicated lotions, ointments, and dressings are applied to affected skin surfaces as prescribed. Adhesive tape is avoided. Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Patients with foot lesions are advised to wear cotton socks and shoes that do not cause the feet to perspire. Antipruritic, antibiotic, and analgesic agents are administered as prescribed. The perianal region is assessed frequently for infection and impairment of skin integrity. The patient is instructed to keep the area as clean as possible by using nonabrasive soap and water after each bowel movement to prevent further excoriation and breakdown of the skin and infection. If the area is very painful, soft cloths or cotton sponges may be less irritating than washcloths. In addition, sitz baths or gentle irrigation may facilitate cleaning and promote comfort. The area is dried thoroughly after cleaning. Topical lotions or ointments may be prescribed to promote healing. Wounds are cultured if infection is suspected, so that the appropriate antimicrobial treatment can be initiated. Debilitated patients may require assistance in maintaining hygienic practices.

Promoting Usual Bowel Patterns Bowel patterns are assessed for diarrhea. The nurse monitors the frequency and consistency of stools and the patient’s reports of abdominal pain or cramping associated with bowel movements. Factors that exacerbate frequent diarrhea are also assessed. The quantity and volume of liquid stools are measured to document fluid volume losses. Stool cultures are obtained to identify pathogenic organisms. The patient is counselled about ways to decrease diarrhea. The physician may recommend restriction of oral intake to rest the bowel during periods of acute inflammation associated with severe enteric infections. As the patient’s dietary intake is increased, foods that act as bowel irritants, such as raw fruits and vegetables, popcorn, carbonated beverages, spicy foods, and foods of extreme temperatures, should be avoided. Small, frequent meals help to prevent abdominal distention. Medications, such as anticholinergic agents, antispasmodic, agents, or opioids, can be prescribed to decrease diarrhea by decreasing intestinal spasms and motility. Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis. Antibiotics and antifungal agents may also be prescribed to combat pathogens identified by stool cultures. Assessment of self-care strategies being used is essential.

Preventing Infection The patient and caregivers are instructed to monitor for signs and symptoms of infection: fever; chills; night sweats; cough with or without sputum production; shortness of breath; difficulty breathing; oral pain or difficulty swallowing; creamy-white patches in the oral cavity; unexplained weight loss; swollen

lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; headache; visual changes or memory lapses; redness, swelling, or drainage from skin wounds; and vesicular lesions on the face, lips, or perianal area. The nurse also monitors laboratory test results that indicate infection, such as the white blood cell count and differential. Cultures of specimens from wound drainage, skin lesions, urine, stool, sputum, mouth, and blood are obtained to identify pathogenic organisms and the most appropriate antimicrobial therapy. The patient is instructed to avoid others with active infections such as upper respiratory infections.

Improving Activity Tolerance Activity tolerance is assessed by monitoring the patient’s ability to ambulate and perform activities of daily living. Patients may be unable to maintain their usual levels of activity because of weakness, fatigue, shortness of breath, dizziness, and neurologic involvement. Assistance in planning daily routines that maintain a balance between activity and rest may be necessary. In addition, patients benefit from guidance about energy conservation techniques, such as sitting while washing or while preparing meals. Personal items that are frequently used should be kept within the patient’s reach. Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Collaboration with other members of the health care team may uncover other factors associated with increasing fatigue and strategies to address them. For example, if fatigue is related to anemia, administering epoetin alfa (Epogen) as prescribed may relieve fatigue and increase activity tolerance.

Maintaining Thought Processes The patient is assessed for alterations in mental status that may be related to neurologic involvement, metabolic abnormalities, infection, side effects of treatment, and coping mechanisms. Manifestations of neurologic impairment may be difficult to distinguish from psychological reactions to HIV illness, such as anger and depression. If the patient experiences altered mental or cognitive status, family and support network members are instructed to speak to the patient in simple, clear language and give the patient sufficient time to respond to questions. The patient’s support network is encouraged to orient the patient to the daily routine by talking about what is taking place during daily activities and encouraged to provide the patient with a regular daily schedule for medication administration, grooming, meal times, bedtimes, and awakening times. Posting the schedule in a prominent area (e.g., on the refrigerator), providing night lights for the bedroom and bathroom, and planning safe leisure activities allow the patient to maintain a regular routine in a safe manner. Activities that the patient previously enjoyed are encouraged. These should be easy to accomplish and fairly short in

CHAPTER 53

duration. The nurse encourages the social support network to remain calm and not to argue with the patient while protecting the patient from injury. Around-the-clock supervision may be necessary, and strategies can be implemented to prevent the patient from engaging in potentially dangerous activities, such as driving, using the stove, or mowing the lawn. Strategies for improving or maintaining functional abilities and for providing a safe environment are used for patients with HAD (see Chart 53-9).

Improving Airway Clearance Respiratory status, including rate, rhythm, use of accessory muscles, and breath sounds; mental status; and skin colour must be assessed at least daily. Any cough and the quantity and characteristics of sputum are documented. Sputum specimens are analyzed for infectious organisms. Pulmonary therapy (coughing, deep breathing, postural drainage, percussion, and vibration) is provided as often as every 2 hours to prevent stasis of secretions and to promote airway clearance. Because of weakness and fatigue, many patients require assistance in attaining a position (such as a high Fowler’s or semi-Fowler’s position) that facilitates breathing and airway clearance. Adequate rest is essential to minimize energy expenditure and prevent excessive fatigue. The fluid volume status is evaluated so that adequate hydration can be maintained. Unless contraindicated because of renal or cardiac disease, daily intake of 3 L of fluid is encouraged. Humidified oxygen may be prescribed, and nasopharyngeal or tracheal suctioning, intubation, and mechanical ventilation may be necessary to maintain adequate ventilation.

Relieving Pain and Discomfort The patient is assessed for the quality and severity of pain associated with impaired perianal skin integrity, the lesions of KS, and peripheral neuropathy. In addition, the effects of pain on elimination, nutrition, sleep, affect, and communication are explored, along with exacerbating and relieving factors. Cleaning the perianal area, as previously described, can promote comfort. Topical anesthetic medications or ointments may be prescribed. Use of soft cushions or foam pads may increase comfort while sitting. The patient is instructed to avoid foods that act as bowel irritants. Antispasmodic and antidiarrheal medications may be prescribed to reduce the discomfort and frequency of bowel movements. If necessary, systemic analgesic agents may also be prescribed. Pain from KS is frequently described as a sharp, throbbing pressure, and heaviness, if lymphedema is present. Pain management may include use of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids plus nonpharmacologic approaches such as relaxation techniques. When NSAIDs are administered to patients who are receiving zidovudine, hepatic and hematologic status must be monitored. NSAID use with tenofovir may predispose the patient to renal disease.The patient with pain related to peripheral neuropathy fre-

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quently describes it as burning, numbness, and “pins and needles.” Pain management approaches may include opioids, tricyclic antidepressants, and antiembolism stockings to equalize pressure. Tricyclic antidepressants have been found to be helpful in controlling the symptoms of neuropathic pain. They also potentiate the actions of opioids and can be used to relieve pain without increasing the dose of the opioid.

Improving Nutritional Status Nutritional status is assessed by monitoring weight, dietary intake, and serum albumin, protein, and iron. The patient is also assessed for factors that interfere with oral intake, such as anorexia, oral and esophageal candidal infection, nausea, pain, weakness, fatigue, and lactose intolerance. Based on the results of assessment, the nurse can implement specific measures to facilitate oral intake. The dietician is consulted to determine the patient’s nutritional requirements. Control of nausea and vomiting with antiemetic medications administered on a regular basis may increase the patient’s dietary intake. Inadequate food intake resulting from pain caused by oral lesions or a sore throat may be managed by administering prescribed opioids and viscous lidocaine (the patient is instructed to rinse the mouth and swallow). In addition, the patient is encouraged to eat foods that are easy to swallow and to avoid rough, spicy, or sticky food items and foods that are excessively hot or cold. Oral hygiene before and after meals is encouraged. If fatigue and weakness interfere with intake, the nurse encourages the patient to rest before meals. If the patient is hospitalized, meals should be scheduled so that they do not occur immediately after painful or unpleasant procedures. The patient with diarrhea and abdominal cramping is encouraged to avoid foods that stimulate intestinal motility and abdominal distention, such as fibre-rich foods or lactose, if the patient is intolerant to lactose. The patient is instructed about ways to enhance the nutritional value of meals. Adding eggs, butter, or fortified milk (milk to which powdered skim milk has been added to increase the caloric content) to gravies, soups, or milkshakes can provide additional calories and protein. Supplements such as puddings, powders, milkshakes, and Boost or Ensure may also be useful. Patients who cannot maintain their nutritional status through oral intake may require enteral feedings or parenteral nutrition.

Decreasing the Sense of Isolation People with HIV infection are at risk for double stigmatization. They have a disease feared by society and they may have a lifestyle that differs from what is considered acceptable by many people. Many people with HIV are young adults at a developmental stage that is usually associated with establishing intimate relationships, personal goals, and career goals, as well as having and raising children. Their focus changes as they are faced with a disease that threatens their life

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expectancy with no cure. In addition, they may be forced to reveal hidden lifestyles or behaviours to family, friends, coworkers, and health care providers. As a result, people with HIV illness may be overwhelmed with emotions such as anxiety, guilt, shame, and fear. They also may be faced with multiple losses, including financial security; normal roles and functions; self-esteem; privacy; ability to control bodily functions; ability to interact meaningfully with the environment; and sexual functioning, as well as rejection by sexual partners, family, and friends. Some patients may harbour feelings of guilt because of their lifestyle or because they may have infected others in current or previous relationships. Other patients may feel anger toward sexual partners who transmitted the virus to them. Infection control measures used in the hospital or at home may further contribute to the patient’s emotional isolation. Any or all of these stressors may cause the patient with HIV illness to withdraw both physically and emotionally from social contact. Nurses are in a key position to provide an atmosphere of acceptance and understanding for people with HIV and their families and partners. The patient’s usual level of social interaction is assessed as early as possible to provide a baseline for monitoring changes in behaviours that suggest social isolation (e.g., decreased interaction with staff or family, hostility, poor adherence to medications). Patients are encouraged to express feelings of isolation and loneliness, with the assurance that these feelings are not unique or abnormal. Providing information about how to protect themselves and others may help patients avoid social isolation. Patients, family, and friends must be reassured that HIV is not spread through casual contact. Education of ancillary personnel, nurses, and physicians helps reduce factors that might contribute to patients’ feelings of isolation. Patient care conferences that address the psychosocial issues associated with HIV infection may help sensitize the health care team to patients’ needs.

Coping With Grief The nurse can help the patient verbalize feelings and explore and identify resources for support and mechanisms for coping, especially when the patient is grieving anticipated losses. The patient is encouraged to maintain contact with family, friends, and coworkers and to use local or national HIV support groups and hotlines. If possible, losses are identified and addressed. The patient is encouraged to continue usual activities whenever possible. Consultations with mental health providers are useful for many patients.

Monitoring and Managing Potential Complications OPPORTUNISTIC INFECTIONS. Patients who are immunosuppressed are at risk for OIs. Therefore, anti-infective agents may be prescribed and laboratory tests obtained to monitor their effect. Signs and symp-

toms of OIs, including fever, malaise, difficulty breathing, nausea or vomiting, diarrhea, difficulty swallowing, and any occurrences of swelling or discharge, should be reported as treated as indicated. RESPIRATORY FAILURE. Impaired breathing is a major complication that increases the patient’s discomfort and anxiety and may lead to respiratory and cardiac failure. The respiratory rate and pattern are monitored, and the lungs are auscultated for abnormal breath sounds. The patient is instructed to report shortness of breath and increasing difficulty in carrying out usual activities. Pulse rate and rhythm, blood pressure, and oxygen saturation are monitored. Suctioning and oxygen therapy may be prescribed to ensure an adequate airway and to prevent hypoxia. Mechanical ventilation may be necessary for the patient who cannot maintain adequate ventilation as a result of pulmonary infection, fluid and electrolyte imbalance, or respiratory muscle weakness. Arterial blood gas values are used to guide ventilator settings. If the patient is intubated, methods must be established to allow communication with the nurse and others. Attention must be given to assisting the patient receiving mechanical ventilation to cope with the stress associated with intubation and ventilator assistance. The possible need for mechanical ventilation in the future should be discussed early in the course of the disease, when the patient is able to make known his or her preferences about treatment. The use of mechanical ventilation should be consistent with the patient’s decisions about end-of-life treatment. (Further discussion of end-of-life care can be found in Chapter 18.) CACHEXIA AND WASTING. Wasting syndrome and fluid and electrolyte disturbances, including dehydration, are common complications of HIV infection and AIDS. The patient’s nutritional and electrolyte status is evaluated by monitoring weight gains or losses, skin turgor, electrolyte, iron and vitamin levels, and hemoglobin and hematocrit values. Vital signs are monitored for decreased systolic blood pressure or increased pulse rate on sitting or standing. Signs and symptoms of electrolyte disturbances, such as muscle cramping, weakness, irregular pulse, decreased mental status, nausea, and vomiting, are documented and reported to the physician. Serum electrolyte values are monitored, and abnormalities are reported. The nurse helps the patient select foods that will replenish electrolytes, such as oranges and bananas (potassium) and cheese and soups (sodium). A fluid intake of 3 L or more per day, unless contraindicated, is encouraged to replace fluid lost with diarrhea, and measures to control diarrhea are initiated. If fluid and electrolyte imbalances persist, the nurse administers IV fluids and electrolytes as prescribed. Effects of parenteral therapy are monitored. SIDE EFFECTS OF MEDICATIONS. Adverse reactions are of concern in patients who receive many medications to treat HIV infection or its complications. Information about the purpose of the medications, their correct administration, side effects, and strategies to manage or prevent side effects is

CHAPTER 53

provided. Patients and their caregivers need to know which signs and symptoms of side effects should be reported immediately to their primary health care provider (Table 53-3). In addition to medications used to treat HIV infection, other medications that may be required include opioids, tricyclic antidepressants, and NSAIDs for pain relief; medications for treatment of OIs; antihistamines (diphenhydramine [Benadryl]) for relief of pruritus; acetaminophen (Tylenol) or ASA for management of fever; and antiemetic agents for control of nausea and vomiting. Concurrent use of these medications can cause many drug interactions, resulting in hepatic, renal, and hematologic abnormalities. Therefore, careful monitoring of laboratory test results is essential. During each contact with the patient, it is important for the nurse to ask not only about side effects but also about how well the patient is managing the medication regimen. The nurse may be able to assist the patient in organizing and planning the medication schedule to promote adherence to the treatment regimen. Clinical pharmacists should be consulted if the nurse identifies issues with medication adherence, side effects or identifies that the patient is taking new medications or herbal products. HIV medications can have significant interactions with other medications which may decrease the efficacy of the antiretroviral therapy or cause toxic side effects.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients, families, and friends are instructed about the routes of transmission of HIV. As discussed earlier, the nurse discusses precautions the patient can use to avoid transmitting HIV sexually (see Charts 53-2 and 53-3) or through sharing of body fluids. Patients and their families or caregivers must receive instructions about how to prevent disease transmission, including handwashing techniques and methods for safely handling and disposing of items soiled with body fluids. Clear guidelines about avoiding and controlling infection, regular health care appointments, symptom management, nutrition, rest, and exercise are necessary. The importance of personal and environmental hygiene is emphasized. Caregivers are taught many of the guidelines (routine practices) described in Chart 53-4. Kitchen and bathroom surfaces should be cleaned regularly with disinfectants to prevent growth of fungi and bacteria. Patients with pets are encouraged to have another person clean areas soiled by animals, such as bird cages and litter boxes. If this is not possible, patients should use gloves and should wash their hands after they clean the area. Patients are advised to avoid exposure to others who are sick or who have been recently vaccinated. The importance of avoiding smoking, excessive alcohol, and over-the-counter and street drugs is emphasized. Patients who are HIV positive or who inject drugs are instructed not to donate blood, organs, or semen. They are also encouraged to engage in harm reduction strategies and are legally obligated to inform potential sexual partners of their status.

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Caregivers in the home are taught how to administer medications, including IV preparations. The medication regimens used for patients with HIV illness and AIDS are often complex and expensive. Patients receiving combination therapies require careful teaching about the importance of taking medications as prescribed and explanations and assistance in fitting the medication regimen into their lives (see Chart 53-7). If the patient requires enteral or parenteral nutrition, instruction is provided to the patient and family about how to administer nutritional therapies at home. Home care nurses provide ongoing teaching and support for the patient and family. CONTINUING CARE. Many people with AIDS remain in their community and continue their usual daily activities, whereas others can no longer work or maintain their independence. Families or caregivers may need assistance in providing supportive care. There are many community-based organizations that provide a variety of services for people living with HIV illness and AIDS; nurses can help identify these services. Community health nurses, home care nurses, and hospice nurses are in an excellent position to provide the expertise and support so often needed in the home setting. Home care nurses are key to the safe and effective administration of parenteral antibiotics, chemotherapy, and nutrition in the home. During home visits, the nurse evaluates the patient’s physical and emotional status and home environment. The patient’s adherence to the therapeutic regimen is assessed, and strategies are suggested to assist with adherence. The patient is assessed for progression of disease and for adverse side effects of medications. Previous teaching is reinforced, and the importance of keeping follow-up appointments is stressed. Complex wound care or respiratory care may be required in the home. Patients and families are often unable to meet these skilled care needs without assistance. Nurses may refer patients to community programs that offer a range of services for patients, friends, and families, including help with housekeeping, hygiene, and meals; transportation and shopping; individual and group therapy; support for caregivers; telephone networks for the homebound; and legal and financial assistance. These services are typically provided by both professionals and nonprofessional volunteers. A social worker may be consulted to identify sources of financial support, if needed. Home care and hospice nurses are increasingly called on to provide physical and emotional support to patients and families as patients with AIDS enter the terminal stages of disease. This support takes on special meaning when people with AIDS lose friends and when family members fear the disease or feel anger concerning the patient’s lifestyle. The nurse encourages the patient and family to discuss end-of-life decisions and to ensure that care is consistent with those decisions, all comfort measures are employed, and the patient is treated with dignity at all times.

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Evaluation Expected Patient Outcomes Expected patient outcomes may include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Maintains skin integrity Resumes usual bowel habits Experiences no infections Maintains adequate level of activity tolerance Maintains usual level of thought processes Maintains effective airway clearance Experiences increased sense of comfort and less pain Maintains adequate nutritional status Experiences decreased sense of social isolation Progresses through grieving process Reports increased understanding of HIV infection/AIDS and participates in self-care activities as possible Remains free of complications

Detailed outcomes are included in the plan of nursing care for a patient with HIV infection (see Chart 53-11).

EMOTIONAL AND ETHICAL CONCERNS Nurses in all settings are called on to provide care for patients with HIV illness. In doing so, they encounter not only the physical challenges of this epidemic but also emotional and ethical concerns. The concerns raised by health care professionals involve issues such as fear of infection, responsibility for giving care, values clarification, confidentiality, developmental stages of patients and caregivers, and poor prognostic outcomes. As well, people living with HIV encounter health care professionals who stigmatize, and/or lack the knowledge to provide comprehensive HIV and AIDS care. Many patients with HIV illness have engaged in “stigmatized” behaviours. Because these behaviours challenge dominant religious and moral values, some nurses may feel reluctant to care for these patients. In addition, health care providers may still have fear and anxiety about disease transmission despite education concerning infection control and the low incidence of transmission to health care providers. Nurses are encouraged to examine their personal beliefs and to use the process of values clarification to approach controversial issues. The Canadian Nurses Association Code of Ethics for Registered Nurses (2008) can also be used to help resolve ethical dilemmas that might affect the quality of care given to patients with HIV illness and AIDS. Nurses are responsible for protecting the patient’s right to privacy by safeguarding confidential information. Inadvertent disclosure of confidential patient information may result in personal, financial, and emotional hardships for the patient and invokes disciplinary action by the nurse’s professional association. The controversy surrounding confidentiality concerns the circumstances in which information may be disclosed to others. Health care team

members need accurate patient information to conduct assessment, planning, implementation, and evaluation of patient care. Failure to disclose HIV status could compromise the quality of patient care. Sexual partners of HIVinfected patients should know about the potential for infection and the need to engage in safer sex practices, as well as the possible need for testing and health care. Nurses are advised to discuss concerns about confidentiality with nurse administrators and to consult professional nursing organizations such as the Canadian Association of Nurses in AIDS Care and legal experts in their province to identify the most appropriate course of action. Chart 53-12 explores issues related to revealing one’s HIV status. Nurses also must ensure that HIV-infected clients are aware of the legal obligations to report their HIV status to their sexual partners. This legislation is controversial and nurses should be aware of the issues (see Canadian HIV/ AIDS Legal Network web site and resources). AIDS has had a high mortality rate, but advances in antiretroviral therapy have demonstrated effectiveness in slowing or controlling disease progression. Many nurses in Canada have never faced an epidemic in which so many young and middle-aged adults experience serious illness and may die during the usual course of the disease process.

CHART 53-12

Ethics and Related Issues: Revealing One’s HIV Status Should All People Who Are Infected With HIV Be Required to Reveal This Status to All Their Sexual and Drug-Sharing Contacts?

Situation The human immunodeficiency virus (HIV) causes infection, which may progress to AIDS. Because sexual contacts and needle-sharing partners are at risk for developing the disease, would a policy that requires notification of contacts infringe on the liberty and privacy of the known HIV-infected person?

Dilemma The person’s right to privacy conflicts with notifying all people who are contacts either through sexual or needle-sharing behaviour (autonomy versus justice). The person’s right to privacy conflicts with society’s need to contain the deadly virus and stem a deadly epidemic (autonomy versus justice).

Discussion 1. What arguments would you offer in favour of notifying all the person’s contacts? 2. What arguments would you offer against notifying all or some of the person’s contacts? 3. Each state has various laws that pertain to whether contacts can be notified and who is responsible for notifying contacts. Is there a law for contact notification in the state in which you live? If there is such a law in your state, who is responsible for contact notification? 4. What would you do if the person responsible for contact notification refuses to do so based on his or her own beliefs for confidentiality of HIV infection status? 5. How would you respond if the HIV-positive person said that he or she is afraid to notify his or her contact because of fear of a violent response?

CHAPTER 53

Nurses may struggle with the value and meaning of their professional roles as they witness repeated instances of deterioration. Exposure to so many deaths can create stress. Contributing to this stress are personal fears of contagion or disapproval of the patient’s lifestyle and behaviours. Unlike cancer or other diseases, HIV illness is associated with controversies challenging our legal and political systems as well as religious and personal beliefs. It is important to recognize that many people living with HIV also experience additional oppression and inequities, including poverty, homelessness, and addictions. Nurses must be prepared to address the often complex interplay of the social determinants of health and to advocate for social justice and human rights. Nurses who feel stressed and overburdened may experience physical and mental distress in the form of fatigue, headache, changes in appetite and sleep patterns, helplessness, irritability, apathy, negativity, and anger. Acknowledgement of and strategies to address physical and moral distress are critical to maintaining personal health and fitness to practice (Harrowing, 2011). Many strategies have been used by nurses to cope with the stress associated with caring for HIV-infected patients. Education and provision of up-to-date information help to alleviate apprehension and prepare nurses to deliver safe, high-quality patient care. Interdisciplinary meetings allow participants to support one another and provide comprehensive patient care. Staff support groups give nurses an opportunity to solve problems and explore values and feelings about caring for HIV-affected people; they also provide a forum for grieving. Other sources of support include nursing administrators, peers, and spiritual advisors. Many HIV-positive clients hold personal practical knowledge that is invaluable in providing meaningful, ethical and comprehensive HIV care (see resource section for references to GIPA principles).

Critical Thinking Exercises 1

A 43-year-old woman who has been using IV/injection drugs regularly for 20 years says that she is not going to stop using drugs but wants to reduce her risk of HIV infection. How would you counsel her? What is the evidence base on safer sex and strategies to reduce risk from use of IV/injection drugs? Is there evidence about the effectiveness of needle exchange programs? How would you determine the strength of the evidence and how would you present information to her?

2 During a code response in the intensive care unit (ICU), a nursing student is inadvertently stuck with a needle used on a patient with HIV who has a high viral load. The student is apprehensive. What should the clinical instructor, in consultation with the nurse manager of the ICU, do? What reporting and documentation are needed (be sure to consider the student’s health record)? What testing, treatment, and counselling are indicated for the student? Who should pay for the treatment? 3

During a home visit to a family in which two adolescents are HIV positive through vertical transmission, you are instructing the adolescents, their siblings,

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and their adult caregivers about strategies to protect the teens from other infections and to protect other family members from HIV transmission. What is the evidence for strategies that you plan to discuss with the adolescents and their family members? What is the strength of that evidence, and what criteria would you use to evaluate the strength of the evidence? 4 A 48-year-old man who is bleeding from several stab wounds presents to the emergency department. He is intoxicated and combative. A Rapid HIV-1 Antibody Test is performed as part of routine health care. What are the implications of this test? How would care in the emergency department be modified because of a positive test result? What are the ethical and legal ramifications of obtaining this test if the patient’s ability to consent to testing is questioned? 5 You are making a home visit to a patient with AIDS who is exhibiting early signs of HAD. Describe the aspects of the home environment that you would assess to ensure safety and adequate care. How would you modify your assessment if the patient lived alone in a third-floor apartment without an elevator? If the patient lived in a rural setting? If the patient had a physical disability that limited his ability to leave his apartment?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Barnett, T., & Whiteside, A. (2006). AIDS in the twenty-first century: Disease and globalization (2nd ed.). New York, NY: Palgrave Macmillan. British Columbia Centre for Excellence in HIV/AIDS. (2011). Therapeutic guidelines: Antiretroviral therapy for HIV-1 infected adults. Vancouver, BC: Author. Burton, D. R. (2005). Neutralizing antibodies and HIV vaccine design. Paper presented at the 14th Annual Canadian Conference on HIV/ AIDS Research, Vancouver, BC. Canadian AIDS Society, & Health Canada. (2002). A guide to HIV/AIDS epidemiological and surveillance terms. Ottawa, ON: Authors. Canadian AIDS Treatment Information Exchange. (2009). A practical guide to complementary therapies for people living with HIV (rev. ed.). Toronto, ON: Author. Canadian Blood Services. (2006). Nucleic acid amplification testing (NAT) for hepatitis C. Retrieved from http://www.blood.ca/centreapps/internet/ uw_v502_mainengine.nsf/9749ca80b75a038585256aa20060d703/ a3e062d9062260bd85256abe00510bf2?OpenDocument Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author. Retrieved from http://cna-aiic.ca/CNA/practice/ ethics/code/default_e.aspx DeVita, V. T., Jr., Hellman, S., & Rosenberg, S. (Eds.). (1997). AIDS: Etiology, diagnosis, treatment, and prevention (4th ed.). Philadelphia, PA: Lippincott—Raven Publishers. Dudek, S. G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Goff, S. (2004). Introduction to retroviruses. In G. Wormser (Ed.), AIDS and other manifestations of HIV disease. San Diego, CA: Elsevier. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Heckman, T., Kochman, A., & Sikkema, K. (2004). Depressive symptoms in older adults living with HIV disease: Application of the Chronic Illness Quality of Life model. In C. Emlet, (Ed.), HIV/AIDS and older adults: Challenges for individuals, families, and communities. New York, NY: Springer.

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Immunologic Function

Holzemer, W., Corless, I., Nokes, K., et al. (2004). Predictors of selfreported adherence in persons living with HIV disease. In J. Laurence (Ed.), Medication adherence in HIV/AIDS. Larchmont, NY: Mary Ann Liebert. Horowitz, H., & Wormser, G. (2004). Care of the adult patient with HIV disease. In G. Wormser (Ed.), AIDS and other manifestations of HIV disease. San Diego, CA: Elsevier. Hu, D., Pieniazek, D., & Mastro, T. (2004). The genetic diversity and global molecular epidemiology of HIV. In G. Wormser (Ed.), AIDS and other manifestations of HIV disease. San Diego, CA: Elsevier. International Partnership for Microbicides. (2014). The Promise of ARVBased Microbicides. Silver Spring, MD: Author. Retrieved from http:// www.ipmglobal.org/why-microbicides/arv-based-microbicides-andhow-they-work/promise-arv-based-microbicides Public Health Agency of Canada. (2010a). Population-specific HIV/AIDS status report: Aboriginal peoples. Ottawa, ON: Author. Public Health Agency of Canada. (2010b). HIV/AIDS epi updates, July 2010. Ottawa, ON: Author. Public Health Agency of Canada. (2012a). Population-specific HIV/AIDS status report: Women. Ottawa, ON: Author. UNAIDS. (2013). Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva, CH: Author.

JOURNALS AND ELECTRONIC DOCUMENTS *Anastasi, J., Capili, B., Kim, G., et al. (2006). Symptom management of HIV-related diarrhea by using normal foods: A randomized controlled clinical trial. Journal of the Association of Nurses in AIDS Care, 17(2), 47–57. *Andrade, S., & Anderson, E. (2008). The lived experience of a mindbody intervention for people living with HIV. Journal of the Association of Nurses in AIDS Care, 19(3), 192–199. *Bova, C., Jaffarian, C., Himlan, P., et al. (2008). The symptom experience of HIV/HCV-coinfected adults. Journal of the Association of Nurses in AIDS Care, 19(3), 170–180. Calza, L., Manfredi, R., Pocaterrra, D., et al. (2008). Risk of premature atherosclerosis and ischemic heart disease associated with HIV infection and antiretroviral therapy. Journal of Infection, 57(1), 16–32. Canadian Association of Nurses in AIDS Care. (2012). Caring for clients who are at risk for and living with HIV/AIDS: Best practice guidelines. Vancouver, BC: Author. Retrieved from http://www.catie.ca/sites/default/ files/Best%20Practice%20Guidelines%20Final%20April%202012.pdf Canadian Association of Nurses in AIDS Care. (2013). Core competencies for HIV/AIDS nursing education at the undergraduate level. Vancouver, BC: Author. Retrieved from http://www.canac.org/English/Resources_ Publications.html#CANAC Canadian International Development Agency. (2011). Minister Oda announces continued support for the Global Fund. Retrieved from http://www.acdi-cida.gc.ca/acdi-cida/ACDI-CIDA.nsf/eng/ CAR-128134420-PYR Centers for Disease Control and Prevention. (2005). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for Postexposure Prophylaxis. MMWR–Morbidity and Mortality Weekly Report, 54(RR-9), 1–17. Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR–Morbidity and Mortality Weekly Report, 55(RR-14), 1–17. Centers for Disease Control and Prevention. (2008). Estimates of new HIV infections in the United States. CDC HIV/AIDS Facts. www.cdc. gov/hiv/topics/surveillance/resources/factsheets/pdf/incidence.pdf Centers for Disease Control, & U.S. Department of Health and Human Services. (1992). 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR–Morbidity and Mortality Weekly Report, 41(RR-17), 1–19. Coates, T. (2008). The US HIV epidemic: Why is prevention failing? HIV/AIDS annual update 2008. Postgraduate Institute for Medicine. Clinical Care Options HIV. www.clinicaloptions.com/ccohiv2008, 179–198. Cooper, D., Steigbiegel, R., Gatell, J., et al. (2008). Subgroup and resistance analyses of raltegravir for resistant HIV-1 infection. New England Journal of Medicine, 359(4), 355–365. De Ruiter, A., Mercey, D., Anderson, J., et al. (2008) British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women 2008. HIV Medicine, 9, 452–502.

Furlotte, C., Schwartz, K., Koornstra, J. J., et al. (2012). Got a room for me? Housing experiences of older adults living with HIV/AIDS in Ottawa. Canadian Journal on Aging, 31(1), 37–48. Gilmour, J., Harrison, C., Cohen, M. H., et al. (2011). Pediatric use of complementary and alternative medicine: Legal, ethical, and clinical issues in decision-making. Pediatrics, 128, S149–S154. Government of Canada. (2012). The Canadian HIV vaccine initiative. Ottawa, ON: Author. Retrieved from http://www.chvi-icvv.gc.ca/indexeng.html Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents. (2009). Recommendations of the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the HIV Medicine Association of the Infectious Diseases Society of America (HIVMA/IDSA). MMWR– Morbidity and Mortality Weekly Report, 58(RR-4), 1–207 Available from http://AIDSinfo.nih.gov Hall, H. I., Song, R., Rhodes, P., et al. (2008). Estimation of HIV incidence in the United States. Journal of the American Medical Association, 300(5), 520–529. *Harrowing, J. N. (2009). The impact of HIV education on the lives of Ugandan nurses and nurse-midwives. Advances in Nursing Science, 32(2), E94–E108. *Harrowing, J. N. (2011). Compassion practice by Ugandan nurses who provide HIV care. Online Journal of Issues in Nursing, 16(1). *Harrowing, J. N., & Mill, J. (2010). Moral distress among Ugandan nurses providing HIV care: A critical ethnography. International Journal of Nursing Studies, 47(6), 723–731. Horton, R., & Das, P. (2008). Putting prevention at the forefront of HIV/ AIDS. Lancet, 372(9637), 421–422. Kuritzkes, D. (2008). New findings on resistance to NRTIs, NNRTIs, and PIs. HIV/AIDS annual update 2008. Postgraduate Institute for Medicine. Clinical Care Options HIV. www.clinicaloptions.com/ccohiv2008, 33–47. Levine, A. (2008). Non-AIDS defining cancers in the era of HAART. HIV/ AIDS annual update 2008. Postgraduate Institute for Medicine. Clinical Care Options HIV. www.clinicaloptions.com/ccohiv2008, 113–142. Lunny, C., & Shearer, B. D. (2011). A systematic review and comparison of HIV contact tracing laws in Canada. Health Policy, 103, 111–123. *McCall, J., & Pauly, B. (2012). Providing a safe place: Adopting a culturally safe perspective in the care of Aboriginal women living with HIV/AIDS. Canadian Journal of Nursing Research, 44(2), 130–145. McConnell, J. (2008). Leading edge: Does HIV/AIDS still require an exceptional response? Lancet Infectious Diseases, 8(8), 457. Meintjes, G., Lawn, S., Scano, F., et al. (2008). Tuberculosis-associated immune reconstitution inflammatory syndrome: Case definitions for use in resource-limited settings. Lancet Infectious Diseases, 8(8), 516–523. Merson, M. H. (2006). The HIV-AIDS pandemic at 25: The global response. New England Journal of Medicine, 354(23), 2414–2417. Merson, M., O’Malley, J., Serwadda, D., et al. (2008). The history and challenge of HIV prevention. Lancet Infectious Diseases, 8(8), 7–20. *Mill, J., Austin, W., Chaw-Kant, J., et al. (2007). The influence of stigma on access to health services by persons with HIV illness. Edmonton, AB: University of Alberta. *Mill, J., Harrowing, J. N., Rae, T., et al. (2013). Stigma in AIDS nursing care in sub-Saharan Africa and the Caribbean. Qualitative Health Research, 23(8), 1066–1078. *Mill, J., Lambert, D. T., Larkin, K., et al. (2008). Challenging lifestyles: Aboriginal men and women living with HIV. Pimatisiwin, 5(2), 151–173. Moyle, G., Gatell, J., Perno, C., et al. (2008). Potential for new antiretroviral to address unmet needs in the management of HIV infection. AIDS Patient Care and STDs, 22(6), 459–471. National Institutes of Health, Centers for Disease Control and Prevention, and HIV Medicine Association of the Infectious Diseases Society of America. (2008). Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. http://aidsinfo. nih.gov/contentfiles/Adult_OI.pdf *Nicholas, P., Voss, J., Corless, I., et al. (2007). Unhealthy behaviours for self-management of HIV-related peripheral neuropathy. AIDS Care, 19(10), 1266–1273. *Nokes, K., Rivero-Mendez, M., Valencia, C., et al. (2006). Sociodemographic and other characteristics in persons 50 years and older with HIV/AIDS in five countries. Global Ageing: Issues and Action, 4(2), 5–13. O’Brien, K. K., Wilkins, A., Zack, E., et al. (2011). Developing clinical practice guidelines in HIV rehabilitation: Process recommendations and guiding principles. AIDS Education and Prevention, 23(5), 457–468.

CHAPTER 53 O’Byrne, P. (2012). HIV prevention in the context of care: HIV testing and public health practice. Public Health Nursing, 29(2), 175–182. Padian, N., Buve, A., Balkus, J., et al. (2008). Biomedical interventions to prevent HIV infection: Evidence, challenges, and way forward. Lancet, 372(9638), 585–599. Panel of Antiretroviral Guidelines for Adults and Adolescents (Guidelines). Guidelines for the use of antiretroviral agents on HIV-1-infected adults and adolescents. Department of Health and Human Services. January 29, 2008;1–128. Available at http://www.aidsinfo.nih.gov/ ContentFiles/AdultandAdolescentGL.pdf Pauly, B., Goldstone, I., McCall, J., et al. (2007). The ethical, legal, and social context of harm reduction. Canadian Nurse, 103(8), 19–23. Public Health Agency of Canada. (2012b). Routine practices and additional precautions assessment and educational tools. Ottawa, ON: Author. Retrieved from http://publications.gc.ca/site/archivee-archived. html?url=http://publications.gc.ca/collections/collection_2013/ aspc-phac/HP40-65-2012-eng.pdf Public Health Agency of Canada. (2013a). Canadian guidelines on sexually transmitted infections. Ottawa, ON: Author. Retrieved from http:// www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-8-eng.php Public Health Agency of Canada. (2013b). Human immunodeficiency virus: Hiv screening and testing guide. Ottawa, ON: Author. Retrieved from http://hiv.ubccpd.ca/hiv-screening-and-testing-guide-publichealth-agency-of-canada/ Relf, M. V., Mekwa, J., Chasokela, C., et al. (2011). Essential nursing competencies related to HIV and AIDS. Journal of the Association of Nurses in AIDS Care, 22, e5–e40. *Richter, M. S., Mill, J., Muller, C. E., et al. (2012). Nurses’ engagement in AIDS policy development. International Nursing Review, 1–7. Senior, K. (2008). Back to basics for HIV vaccine research. Lancet Infectious Diseases, 8(8), 467. Shippy, A., & Karpiak, S. (2005). Perceptions of support among older adults with HIV. Research on Aging, 27(3), 290–306. Siegel, J. D, Rhinehart, E., Jackson, M., et al. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html Small, W., Moore, D., Shoveller, J., et al. (2012). Perceptions of risk and safety within injection settings: Injection drug users’ reasons for attending a supervised injecting facility in Vancouver, Canada. Health, Risk, and Society, 14(4), 307–324. *Vollestad, J., Sivertsen, B., & Nielsen, G.H. (2011). Mindfulness-based stress reduction for patients with anxiety disorders: Evaluation in a randomized controlled trial. Behaviour Research and Therapy, 49(4), 281–288. Wood, R. A., Wood, E., Lai, C., et al. (2008). Nurse-delivered safer injection education among a cohort of injection drug users: Evidence from the evaluation of Vancouver’s supervised injection facility. International Journal of Drug Policy, 19(3), 183–188. Zack, J., & Park, S. (2008). Eradication of HIV: Possible or still a pipe dream? HIV/AIDS annual update 2008. Postgraduate Institute for Medicine. Clinical Care Options HIV. www.clinicaloptions.com/ ccohiv2008, 17–32.

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RESOURCES AIDS Action: www.aidsaction.org AIDS Education and Training Centers (ETCs) Program (regional, national, and international training opportunities): www.aidsetc.org Antiretroviral medication information Web sites: www.AIDSmeds.com: www.projectinform.org; www.sfaf.org; http://hivinsite.ucsf.edu; www. amfAR.org; www.natap.org; www.thebody.com (many of these sites are coordinated by people living with HIV/AIDS British Columbia Centre for Excellence in HIV/AIDS: http://www.cfenet. ubc.ca/index.php# Canadian Aboriginal AIDS Network: http://www.caan.ca/ Canadian AIDS Society: http://www.cdnaids.ca/ Canadian AIDS Treatment Information Exchange: http://www.catie.ca/ Canadian Association for HIV Research: http://www.cahr-acrv.ca Canadian Association of Nurses in AIDS Care: http://www.canac.org Canadian Blood Services: http://www.blood.ca/ Canadian Harm Reduction Network: http://www.canadianharmreduction. com/ Canadian HIV/AIDS Information Centre: http://www.aidssida.cpha.ca/ Canadian HIV/AIDS Legal Network: http://www.aidslaw.ca/ Canadian HIV Trials Network: http://www.hivnet.ubc.ca/e/home/ Canadian Hospice Palliative Care Association: http://www.chpca.net/ Canadian Institutes of Health Research: http://www.cihr-irsc.gc.ca/ Canadian International Development Agency: http://www.acdi-cida.gc. ca/index.htm Canadian Nurses Association: http://cna-aiic.ca/cna/ Canadian Public Health Association: http://www.cpha.ca/ Centers for Disease Control and Prevention (2008): HIV/AIDS Prevention Research Synthesis Project: www.cdc.gov/hiv/topics/research/prs/ evidence-based-interventions.htm; www.cdc.gov Gay Men’s Health Crisis Network: www.gmhc.org Hemophilia and AIDS/HIV Network for the Dissemination of Information: www.hemophilia.org HIV Community-Based Research Network: http://cbr.cbrc.net/ International AIDS Vaccine Initiative: www.iavi.org; e-mail: pubs@iavi. org International Council of Nurses: http://www.icn.ch/ International Development Research Centre: http://www.idrc.ca/ International Partnership for Microbicides: www.ipm-microbicides.org Joint United Nations Programme on HIV/AIDS: http://www.unaids.org/ en/default.asp Public Health Agency of Canada, Centre for Infectious Disease Prevention and Control: http://www.stephenlewis foundation.org/ United Nations Association in Canada: http://www.unac.org/en/index. asp U.S. Department of Health and Human Services AIDSInfo Drug Database: http://aidsinfo.nih.gov/DrugsNew/Default.aspx?MenuItem= Drugs World Health Organization: http://www.who.int/en/

CHAPTER

54 Assessment and Management of Patients With Allergic Disorders Adapted by Saman Maleki Vareki, Hossein Khalili, and Paul Jeffrey

Learning Objectives On completion of this chapter, the learner will be able to: 1. Explain the physiologic events involved with allergic reactions. 2. Describe the types of hypersensitivity. 3. Describe the management of patients with allergic disorders. 4. Describe measures to prevent and manage anaphylaxis. 5. Use the nursing process as a framework for care of the patient with allergic rhinitis. 6. Discuss the different allergic disorders according to type.

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The human body is menaced by a host of potential invaders—allergens as well as microbial organisms—that constantly threaten its defenses. After penetrating those defenses, these allergens and organisms, if allowed to continue unimpeded, disrupt the body’s enzyme systems and destroy its vital tissues. To protect against these agents, the body is equipped with an elaborate defense system. The epithelial cells coating the skin and making up the lining of the respiratory, gastrointestinal, and genitourinary tracts provide the first line of defense against microbial invaders. The structure and continuity of these surfaces and the resistance to penetration are initial deterrents to invaders. One of the most effective defense mechanisms is the body’s capacity to equip itself rapidly with weapons (antibodies) individually designed to meet each new invader, namely specific antigens. Antibodies react with antigens in a variety of ways: (a) coating the antigens’ surfaces if they are particular substances, (b) neutralizing the antigens if they are toxins, and (c) precipitating the antigens out of solution if they are dissolved. The antibodies prepare the antigens so that the phagocytic cells of the blood and the tissues can dispose of them. However, despite being usually protective, in some cases the immune system produces inappropriate or exaggerated responses to specific antigens, and the result is an allergic or hypersensitivity disorder.

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ALLERGIC ASSESSMENT Physiologic Overview An allergic reaction is a manifestation of tissue injury resulting from interaction between an antigen and an antibody. Allergy is an inappropriate and often harmful response of the immune system to usually harmless substances called allergens (e.g., dust, pollen, weeds, dander). Chemical mediators released in allergic reactions may produce symptoms that range from mild to life-threatening. In allergic reactions, the body encounters antigens, usually proteins that the body’s defenses recognize as foreign, and a series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body. When lymphocytes respond to the antigens, antibodies (protein substances that protect against antigens) are produced. Antibodies combine with antigens in a special way, which has been described as keys fitting into a lock. Antigens (the keys) fit only certain antibodies (the locks). Hence, the term specificity refers to the specific reaction of an antibody to an antigen. There are many variations and complexities in these patterns.

Glossary allergen: substance that causes manifestations of allergy allergy: inappropriate and often harmful immune response to substances that are usually harmless anaphylaxis: clinical response to an immediate immunologic reaction between a specific antigen and antibody angioneurotic edema: condition characterized by urticaria and diffuse swelling of the deeper layers of the skin antibody: protein substance developed by the body in response to and interacting with a specific antigen antigen: substance that induces the production of antibodies antihistamine: medication that opposes the action of histamine atopic dermatitis: type I hypersensitivity involving inflammation of the skin evidenced by itching, redness, and a variety of skin lesions: term often used to describe immunoglobulin E–mediated diseases (i.e., atopic dermatitis, asthma, and allergic rhinitis) with a genetic component B lymphocyte: cells that are important in producing circulating antibodies bradykinin: a substance that stimulates nerve fibres and causes pain eosinophil: granular leukocyte epitope: immunologically active site on an antigen; a single antigen can have several different epitopes that elicit responses from different antibodies

erythema: diffuse redness of the skin hapten: incomplete antigen histamine: substance in the body that causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle hypersensitivity: abnormal heightened reaction to a stimulus of any kind immunoglobulins: a family of closely related proteins capable of acting as antibodies leukotrienes: a group of chemical mediators that initiate the inflammatory response lymphokines: substances released by sensitized lymphocytes when they contact specific antigens mast cell: connective tissue cells that contain heparin and histamine in their granules prostaglandins: unsaturated fatty acids that have a wide assortment of biologic activity pruritus: the symptom of itching, an uncomfortable sensation leading to the urge to rub or scratch the skin to obtain relief rhinitis: inflammation of the nasal mucosa serotonin: chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor T lymphocyte: cells that can cause graft rejection, kill foreign cells, or suppress production of antibodies urticaria: a pruritic skin eruption of the upper dermis, usually transient, characterized by wheals (hives) of various shapes and sizes

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Immunologic Function

Function of Immunoglobulins Antibodies that are formed by lymphocytes and plasma cells in response to an immunogenic stimulus constitute a group of serum proteins called immunoglobulins. Grouped into five classes (IgE, IgD, IgG, IgM, and IgA), immunoglobulins can be found in the lymph nodes, tonsils, appendix, and Peyer’s patches of the intestinal tract, or circulating in the blood and lymph. These antibodies are capable of binding with a wide variety of antigens (Abbas, Lichtman, & Pillai, 2012). Immunoglobulins of the IgE class are involved in allergic disorders and some parasitic infections. IgE-producing cells are located in the respiratory and intestinal mucosa. Two or more IgE molecules bind together to an allergen and trigger mast cells or basophils to release chemical mediators, such as histamine; serotonin; kinins; slow-reacting substance of anaphylaxis (SRS-A); and the neutrophil factor, which produces allergic skin reactions, asthma, and hay fever. Atopy refers to IgE-mediated diseases such as allergic rhinitis that have a genetic component.

Role of B Cells B cells, or B lymphocytes, are programmed to produce one specific antibody. On encountering a specific antigen, B cells stimulate production of plasma cells, the site of antibody production. The result is the outpouring of antibodies for the purpose of destroying and removing the antigens.

Role of T Cells T cells, or T lymphocytes, assist the B cells in producing antibodies. T cells secrete substances known as lymphokines that encourage cell growth, promote cell activation, direct the flow of cell activity, destroy target cells, and stimulate the macrophages. Macrophages present the antigens to the T cells and initiate the immune response. They also digest antigens and assist in removing cells and other debris. Unlike a specific antibody, a T cell does not bind free antigens. T-cells are divided into five major categories based on their function in the immune process. T-cells can be classified as T helper cells (TH), regulatory T cells (TREG), cytotoxic T cells (TC), memory T cells, and lastly natural killer T cells

(NKT). Most of these have a unique function in the allergic response.

Function of Antigens Antigens are divided into two groups: complete protein antigens and low-molecular-weight substances. Complete protein antigens, such as animal dander, pollen, and horse serum, stimulate a complete humoural response. (Refer to Chapter 51 for a discussion of humoural immunity.) Lowmolecular-weight substances, such as medications, function as haptens (incomplete antigens), binding to tissue or serum proteins to produce a carrier complex that initiates an antibody response. In an allergic reaction, the production of antibodies requires active communication between macrophages, T cells, and B cells. When the allergen is absorbed through the respiratory tract, gastrointestinal tract, or skin, allergen sensitization occurs. Macrophages process the antigen and present it to the appropriate T cells. These cells mature into allergen-specific secreting plasma cells that synthesize and secrete antigen-specific antibody.

Function of Chemical Mediators Mast cells, which are located in the skin and mucous membranes, play a major role in IgE-mediated immediate hypersensitivity. When mast cells are stimulated by antigens, powerful chemical mediators are released causing a sequence of physiologic events that results in symptoms of immediate hypersensitivity (Fig. 54-1). There are two types of chemical mediators: primary and secondary. Primary mediators are preformed and are found in mast cells or basophils. Secondary mediators are inactive precursors that are formed or released in response to primary mediators. Table 54-1 summarizes the actions of primary and secondary chemical mediators.

Primary Mediators Histamine Histamine, which is released by mast cells, plays an important role in the immune response. Its effects are greatest

Allergen

FIGURE 54-1. Allergen triggers

IgE B cell

Mediators Mast cell

SYMPTOMS

B cell to make IgE antibody, which attaches to the mast cell. When that allergen reappears, it binds to the IgE and triggers the mast cell to release its chemicals. Courtesy of U.S. Department of Health and Human Services, National Institutes of Health.

CHAPTER 54

TABLE 54-1

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Chemical Mediators of Hypersensitivity

Mediators Primary Mediators (Preformed and found in mast cells or basophils) Histamine (preformed in mast cells)

Eosinophil chemotactic factor of anaphylaxis (ECF-A) (preformed in mast cells) Platelet-activating factor (PAF) (requires synthesis by mast cells, neutrophils, and macrophages) Prostaglandins (chemically derived from arachidonic acid; require synthesis by cells) Basophil kallikrein (preformed in mast cells) Secondary Mediators (Inactive precursors formed or released in response to primary mediators) Bradykinin (derived from precursor kininogen) Serotonin (preformed in platelets) Heparin (preformed in mast cells) Leukotrienes (derived from arachidonic acid and activated by mast cell degranulation) C, D, and E or slow-reacting substance of anaphylaxis (SRS-A)

within about 15 minutes after antigen contact, include erythema; localized edema in the form of wheals; pruritus; contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm; dilation of small venules and constriction of larger vessels; and increased secretion of gastric and mucosal cells, resulting in diarrhea. Histamine action results from stimulation of histamine-1 (H1) and histamine-2 (H2) receptors. H1 receptors are found predominantly on bronchiolar and vascular smooth muscle cells. H2 receptors are found on gastric parietal cells. Certain medications are categorized by their action at these receptors. Diphenhydramine (Benadryl) is an example of an antihistamine, a medication that displays an affinity for H1 receptors.

Eosinophil Chemotactic Factor of Anaphylaxis Eosinophil chemotactic factor of anaphylaxis affects movement of eosinophils (granular leukocytes) to the site of allergens. It is performed in the mast cells and is released from disrupted mast cells.

Platelet-activating Factor Platelet-activating factor is responsible for initiating platelet aggregation and leukocyte infiltration at sites of immediate hypersensitivity reactions. It also causes bronchoconstriction and increased vascular permeability (Simandyl, 2010).

Prostaglandins Prostaglandins produce smooth muscle contraction as well as vasodilation and increased capillary permeability (Simandyl, 2010). The fever and pain that occur with inflammation in allergic responses are caused in part by the prostaglandins.

Action

Vasodilation Smooth muscle contraction, increased vascular permeability, increased mucus secretions Attracts eosinophils Smooth muscle contraction Incites platelets to aggregate and release serotonin and histamine D and F series → bronchoconstriction E series → bronchodilation D, E, and F series → vasodilation Frees bradykinin, which causes bronchoconstriction, vasodilation, and nerve stimulation

Smooth muscle contraction, increased vascular permeability, stimulates pain receptors, increased mucus production Smooth muscle contraction, increased vascular permeability Anticoagulant Smooth muscle contraction, increased vascular permeability

Secondary Mediators Leukotrienes Leukotrienes are chemical mediators that initiate the inflammatory response. Many manifestations of inflammation can be attributed in part to leukotrienes. In addition, leukotrienes cause smooth muscle contraction, bronchial constriction, mucus secretion in the airways, and the typical wheal-and-flare reactions of the skin. Compared with histamine, leukotrienes are 100 to 1,000 times more potent in causing bronchospasm.

Bradykinin Bradykinin is a substance that has the ability to cause increased vascular permeability, vasodilation, hypotension, and contraction of many types of smooth muscle, such as the bronchi. Increased permeability of the capillaries results in edema. Bradykinin stimulates nerve cell fibres and produces pain.

Serotonin Serotonin acts as a potent vasoconstrictor, causing contraction of bronchial smooth muscle.

Hypersensitivity Although the immune system defends the host against infections and foreign antigens, immune responses can themselves cause tissue injury and disease. Hypersensitivity is a reflection of excessive or aberrant immune response to any type of stimulus (Abbas et al., 2012). It usually does not occur with the first exposure to an allergen. Rather, the reaction follows a re-exposure after

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Type I

Mast cell

Antigen

IgE antibody Release of vasoactive amines and other mediators Type I. An anaphylactic reaction is characterized by vasodilation, increased capillary permeability, smooth muscle contraction, and eosinophilia. Systemic reactions may involve laryngeal stridor, angioedema, hypotension, and bronchial, GI, or uterine spasm; local reactions are characterized by hives. Examples of type I reactions include extrinsic asthma, allergic rhinitis, systemic anaphylaxis, and reactions to insect stings.

Type II Antigen Complement

Phagocytosis

RBC IgG or IgM antibody Lysis of RBC

Type II. A cytotoxic reaction, which involves the binding of either the IgG or IgM antibody to a cellbound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia. FIGURE 54-2. Four types of hypersensitivity reactions. (Ig, immunoglobulin; PMN, polymorphonuclear;

RBC, red blood cell.)

sensitization, or buildup of antibodies, in a predisposed individual. To promote understanding of the immunopathogenesis of disease, hypersensitivity reactions have been classified into four specific types of reactions (Fig. 54-2). Most allergic reactions are either type I or type IV hypersensitivity reactions.

Anaphylactic (Type I) Hypersensitivity The most severe hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type I or anaphylactic hypersensitivity is an

immediate reaction beginning within minutes of exposure to an antigen. This reaction is mediated by IgE antibodies rather than IgG or IgM antibodies. It typically occurs on re-exposure to a specific antigen and requires the release of proinflammatory mediators. Primary chemical mediators are responsible for the symptoms of type I hypersensitivity because of their effects on the skin, lungs, and gastrointestinal tract. If chemical mediators continue to be released, a delayed reaction may occur and may last for up to 24 hours. Clinical symptoms are determined by the amount of the allergen, the amount of mediator released, the sensitivity of the target organ, and the route of allergen entry. Type I hypersensitivity reactions may include both local and systemic anaphylaxis. Examples include allergic rhinitis, asthma, and severe allergic response in people sensitized to penicillin or latex.

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Type III

Complement

Antigen– antibody complex

PMN leukocyte

Infiltration of PMN leukocytes Damage to adjacent cells Lysosomal enzymes

Type III. An immune complex reaction is marked by acute inflammation resulting from formation and deposition of immune complexes. The joints and kidneys are particularly susceptible to this kind of reaction, which is associated with systemic lupus erythematosus, serum sickness, nephritis, and rheumatoid arthritis. Some signs and symptoms include urticaria, joint pain, fever, rash, and adenopathy (swollen glands).

Type IV

Antigen presenting cell

Antigen

Active immune response resulting in tissue damage

MHC

Sensitized T cell Type IV. A delayed, or cellular, reaction occurs 1 to 3 days after exposure to an antigen. The reaction, which results in tissue damage, involves activity by lymphokines, macrophages, and lysozymes. Erythema and itching are common; a few examples include contact dermatitis, graft-versus-host disease, Hashimoto’s thyroiditis, and sarcoidosis. FIGURE 54-2.

Cytotoxic (Type II) Hypersensitivity Type II, or cytotoxic, hypersensitivity occurs when the immune system mistakenly identifies a normal constituent of the body as foreign. This reaction may be a result of a cross-reacting antibody, possibly leading to cell and tissue damage. Type II hypersensitivity involves the binding of either IgG or IgM antibody to the cell-bound antigen. Type II hypersensitivity reactions are associated with several disorders. For example, in myasthenia gravis, the body mistakenly generates antibodies against normal nerve-ending receptors. In Goodpasture syndrome, it generates antibodies against lung and renal tissue, producing lung damage and renal failure. A type II hypersensitivity reaction resulting in red blood cell destruction is associated with drug-induced immune hemolytic anemia,

Continued.

Rh-hemolytic disease of the newborn, and incompatibility reactions in blood transfusions (see Chapter 34).

Immune Complex (Type III) Hypersensitivity Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. These complexes are then cleared from the circulation by phagocytic action. If these type III complexes are deposited in tissues or vascular endothelium, two factors contribute to injury: the increased amount of circulating complexes and the presence of vasoactive amines. As a result, there is an increase in vascular permeability and tissue injury. The joints and kidneys are particularly susceptible to this type of injury. Type III hypersensitivity is

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associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and some types of bacterial endocarditis. These are discussed elsewhere in this text.

episodes, smears obtained from nasal secretions, conjunctival secretions, and sputum of allergic patients usually reveal eosinophils, indicating an active allergic response.

Delayed-Type (Type IV) Hypersensitivity

Total Serum Immunoglobulin E Levels

Type IV, or delayed-type hypersensitivity, also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. It is mediated by sensitized T cells and macrophages rather than antibodies. An example of a type IV hypersensitivity reaction is contact dermatitis resulting from exposure to allergens such as cosmetics, adhesive tape, topical agents (e.g., povidone-iodine), medication additives, and plant toxins. Symptoms include itching, erythema, and raised lesions.

ASSESSMENT Health History A comprehensive allergy history and a thorough physical examination provide useful data for the diagnosis and management of patients with allergic disorders. An assessment form is useful for obtaining and organizing this information (Chart 54-1). The degree of difficulty and discomfort experienced by the patient because of allergic symptoms and the degree of improvement in those symptoms with and without treatment are assessed and documented. The relationship of symptoms to exposure to possible allergens is noted.

DIAGNOSTIC EVALUATION Diagnostic evaluation of the patient with allergic disorders commonly includes blood tests, smears of body secretions, skin tests, and the radioallergosorbent test (RAST). Results of laboratory blood studies provide supportive data for various diagnostic possibilities; however, they are not the major criteria for the diagnosis of allergic disease.

Complete Blood Count With Differential The white blood cell (WBC) count is usually normal except with infection. Eosinophils, which are granular leukocytes, usually make up 1% to 3% of the total number of WBCs. A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.

Eosinophil Count An actual count of eosinophils can be obtained from blood samples or smears of secretions. During symptomatic

High total serum IgE levels support the diagnosis of allergic disease. However, an acceptable IgE level does not exclude the diagnosis of an allergic disorder. IgE levels are not as sensitive as the paper radioimmunosorbent test (PRIST) or the enzyme-linked immunosorbent assay (ELISA), also referred to as enzyme immunoessay (EIA).

Skin Tests Skin testing entails the intradermal injection or superficial application (epicutaneous) of solutions at several sites. Depending on the suspected cause of allergic signs and symptoms, several different solutions may be applied at separate sites. These solutions contain individual antigens representing an assortment of allergens most likely to be implicated in the patient’s disease. Positive (wheal-andflare) reactions are clinically significant when correlated with the history, physical findings, and results of other laboratory tests. The results of skin tests complement the data obtained from the history. They indicate which of several antigens are most likely to provoke symptoms and provide some clue to the intensity of the patient’s sensitization. The dosage of the antigen (allergen) injected is also important. Most patients are hypersensitive to more than one allergen. Under testing conditions, they may not react (although they usually do) to the specific allergens that induce their attacks. In cases of doubt about the validity of the skin tests, a RAST or a provocative challenge test may be performed. If a skin test is indicated, there is a reasonable suspicion that a specific allergen is producing symptoms in a patient with allergies. However, several precautionary steps must be observed before skin testing with allergens is performed: • Testing is not performed during periods of bronchospasm. • Epicutaneous tests (scratch or prick tests) are performed before other testing methods in an effort to minimize the risk of systemic reaction. • Emergency equipment must be readily available to treat anaphylaxis.

Types of Skin Tests The methods of skin testing include prick skin tests, scratch tests, and intradermal skin testing (Fig. 54-3). After negative prick or scratch tests, intradermal skin testing is performed with allergens that are suggested by the patient’s history to be problematic. The back is the most suitable area of the body for skin testing because it permits the performance of many tests. A multitest applicator with multiple test heads is a commercially available for simultaneous

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CHART 54-1

Allergy Assessment Form Name ____________ Age _________________Sex ______________ Date _______________ I. Chief concern: II. Present illness: III. Collateral allergic symptoms: Eyes: Pruritus Burning Lacrimation Swelling Injection Discharge Ears: Pruritus Fullness Popping Frequent infections Nose: Sneezing Rhinorrhea Obstruction Pruritus Mouth breathing Purulent discharge Throat: Soreness Postnasal discharge Palatal pruritus Mucus in the morning Chest: Cough Pain Wheezing Sputum Dyspnea Colour Rest Amount Exertion Skin: Dermatitis Eczema Urticaria IV. Family allergies: V. Previous allergic treatment or testing: Prior skin testing: Medications: Antihistamines Improved Unimproved Bronchodilators Improved Unimproved Nose drops Improved Unimproved Hyposensitization Improved Unimproved Duration Antigens Reactions Antibiotics Improved Unimproved Corticosteroids Improved Unimproved VI. Physical agents and habits: Bothered by: Tobacco for _____ years Alcohol Air conditioning Cigarettes _____ packs/day Heat Muggy weather Cigars _____ per day Cold Weather changes Pipes _____ per day Perfumes Chemicals Never smoked Paints Hair spray Bothered by smoke Insecticides Newspapers Cosmetics Latex VII. When symptoms occur: Time and circumstances of 1st episode: Prior health: Course of illness over decades: progressing regressing Time of year: Exact dates: Perennial Seasonal Seasonally exacerbated Monthly variations (menses, occupation): Time of week (weekends vs. weekdays): Time of day or night: After insect stings: VIII. Where symptoms occur: Living where at onset: Living where since onset: Effect of vacation or major geographic change: Symptoms better indoors? Or outdoors?: Effect of school/work: Effect of staying elsewhere nearby: Effect of hospitalization: Effect of specific environments: continued >

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CHART 54-1 Allergy

Assessment Form, continued

Do symptoms occur around: old leaves hay lakeside barns summer homes damp basement dry attic lawn mowing animals other Do symptoms occur after eating: cheese mushrooms beer melons bananas fish nuts citrus fruits other foods (list) Home: city rural house age apartment basement damp dry heating system pets (how long) dog cat other Bedroom: Type Age Living room: Type Pillow Rug Mattress Matting Blankets Furniture Quilts Furniture Anywhere in home symptoms are worse: IX. What does patient think makes symptoms worse? X. Under what circumstances is patient free of symptoms? XI. Summary and additional comments:

administration of antigens by multiple punctures at different sites. A negative response on a skin test cannot be interpreted as an absence of sensitivity to an allergen. Such a response may occur with insufficient sensitivity of the test or with use of an inappropriate allergen in testing. Therefore, it is essential to observe the patient undergoing skin testing for an allergic reaction even if the previous response was negative.

Age

Interpretation of Skin Test Results Familiarity with and consistent use of a grading system are essential. The grading system used should be identified on a skin test record for later interpretation. A positive reaction, evidenced by the appearance of an urticarial wheal (round, reddened skin elevation) (Fig. 54-4), localized erythema (diffuse redness) in the area of inoculation or contact, or pseudopodia (irregular projection at the end of a wheal) with associated erythema is considered indicative of sensitivity to the corresponding antigen. False-positive results may occur because of improper preparation or administration of allergen solutions.

!

NURSING ALERT

Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and are usually withheld 48 to 96 hours before testing, depending on the duration of their activity. False-positive skin tests may result from improper preparation or administration of allergen solutions. FIGURE 54-3. Intradermal testing. A 0.5-mL or 1-mL sterile syringe

with a 26/27-gauge intradermal needle is used to inject 0.02 to 0.03 mL of intradermal allergen. The needle is inserted with the bevel facing upward and the syringe parallel to the skin. The skin is penetrated superficially, and a small amount of the allergen solution is injected to create a bleb (raised area) approximately 5 mm in diameter. A separate sterile syringe and needle are used for each injection. From Taylor, C., Lillis, C., & LeMone, P. (2005). Fundamentals of nursing: The art and science of nursing care (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Interpretation of positive or negative skin tests must be based on the history, physical examination, and other laboratory test results. The following guidelines are used for the interpretation of skin test results: • Skin tests are more reliable for diagnosing atopic sensitivity in patients with allergic rhinoconjunctivitis than in patients with asthma. • Positive skin tests correlate highly with food allergy.

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Negative wheal

1+ wheal Reaction Guide

2+ wheal 4+ 3+ 2+ 1+

FIGURE 54-4. Interpretation of reactions: Negative, wheal soft with minimal erythema; 1+, wheal present (5 to 8 mm) with associated erythema; 2+, wheal (7 to 10 mm) with associated erythema; 3+, wheal (9 to 15 mm), slight pseudopodia possible with associated erythema; 4+, wheal (12 mm+) with pseudopodia and diffuse erythema.

• The use of skin tests to diagnose immediate hypersensitivity to medications is limited because metabolites of medications, not the medications themselves, are usually responsible for causing hypersensitivity.

Provocative Testing Provocative testing involves the direct administration of the suspected allergen to the sensitive tissue, such as the conjunctiva, nasal or bronchial mucosa, or gastrointestinal tract (by ingestion of the allergen), with observation of target organ response. This type of testing is helpful in identifying clinically significant allergens in patients with a large number of positive tests. Major disadvantages of this type of testing are the limitation of one antigen per session and the risk of producing severe symptoms, particularly bronchospasm, in patients with asthma.

Radioallergosorbent Test (RAST) RAST is a radioimmunoassay that measures allergenspecific IgE. A sample of the patient’s serum is exposed to a variety of suspected allergen particle complexes. If antibodies are present, they will combine with radiolabelled allergens. Test results are compared with control values. In addition to detecting an allergen, RAST indicates the quantity of allergen necessary to evoke an allergic reaction. Values are reported on a scale from 0 to 5. Values of 2 or greater are considered significant. The major advantages of RAST over other tests include decreased risk of systemic reaction, stability of antigens, and lack of dependence on skin reactivity modified by medications. The major disadvantages include the limited allergen selection, reduced sensitivity compared with intradermal skin tests, lack of immediate results, and higher cost.

3+ wheal

0.5 1.0 1.5 2.0 3.0 cm 4.0

4+ wheal

ALLERGIC DISORDERS There are two types of IgE-mediated allergic reactions: atopic and nonatopic disorders. Although the underlying immunologic reactions of the two types of disorders are the same, the predisposing factors and manifestations are different. The atopic disorders are characterized by a hereditary predisposition and production of a local reaction to IgE antibodies, which manifests in one or more of the following three atopic disorders: allergic rhinitis, asthma, and atopic dermatitis/eczema. The nonatopic disorders lack the genetic component and organ specificity of the atopic disorders (Simandyl, 2010). Latex allergy (see later discussion) may be a type I or type IV hypersensitivity reaction, although true latex allergy is considered to be a type I hypersensitivity reaction (Cabanes, Igea, & de La Hoz, 2012). Contact dermatitis is considered to be a type IV hypersensitivity reaction.

Anaphylaxis Anaphylaxis is a clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and an antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe, life-threatening allergic reaction. In Canada, it is estimated that 1% to 2% of Canadians are at risk of an anaphylactic reaction (Allergy Asthma Information Association [AAIA] Canada, 2014).

Pathophysiology Anaphylaxis is “the most severe systematic allergic reaction” (Barkman & Pooler, 2010, p. 604). It is caused by the interaction of a foreign antigen with specific IgE antibodies found on the surface membrane of mast cells and peripheral blood basophils. The subsequent release of

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CHART 54-2

Nonallergenic Anaphylaxis (Anaphylactoid Reaction) Closely resembling anaphylaxis is an anaphylactoid reaction that is caused by the release of mast cell and basophil mediators triggered by non–IgE-mediated events. This nonallergenic anaphylaxis reaction may occur with medications, food, exercise, or cytotoxic antibody transfusions. The reaction may be local or systemic. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Although possibly severe, nonallergenic anaphylaxis reactions are rarely fatal. Systemic reactions occur within about 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems. For the most part, the treatment of nonallergenic anaphylaxis reaction is identical to that of anaphylaxis (Johansson, Hourihane, Bousquet, et al., 2005).

histamine and other bioactive mediators causes activation of platelets, eosinophils, and neutrophils. Histamine, prostaglandins, and inflammatory leukotrienes are potent vasoactive mediators that are implicated in the vascular permeability changes, flushing, urticaria, angioedema, hypotension, and bronchoconstriction that characterize anaphylaxis (Kounis, Soufras, & Hahalis, 2013). Smooth muscle spasm, bronchospasm, mucosal edema and inflammation, and increased capillary permeability result. These systemic changes characteristically produce clinical manifestations within seconds or minutes of antigen exposure(Simandyl, 2010). Closely related to anaphylaxis is a nonallergenic anaphylaxis (anaphylactoid) reaction, which is described in Chart 54-2. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex (Chart 54-3). Foods that are common causes of anaphylaxis CHART 54-3

Common Causes of Anaphylaxis Foods Peanuts, tree nuts (e.g., walnuts, pecans, cashews, almonds), shellfish (e.g., shrimp, lobster, crab), fish, milk, eggs, soy, wheat

Medications Antibiotics, especially penicillin and sulfa antibiotics, allopurinol, radiocontrast agents, anesthetic agents (lidocaine, procaine), vaccines, hormones (insulin, vasopressin, adrenocorticotropic hormone [ACTH], aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs])

Other Pharmaceutical/Biologic Agents Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin), antigens used in skin testing

Insect Stings Bees, wasps, hornets, yellow jackets, ants (including fire ants)

Latex Medical and nonmedical products containing latex

include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Many medications have been implicated in anaphylaxis. Those that are most frequently reported include antibiotics (e.g., penicillin), radiocontrast agents, intravenous (IV) anesthetics, aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs), and opioids. Antibiotics and radiocontrast agents cause the most serious anaphylactic reactions, producing reactions in about 1 of every 5,000 exposures. Penicillin is the most common cause of anaphylaxis. While the actual prevalence of penicillin allergy in the general population is unknown, the incidence of selfreported penicillin allergy ranges from 1% to 10%. It has been reported that 80% to 90% of those patients with selfreported penicillin allergy have no evidence of IgE antibodies to penicillin on skin testing (Solensky, 2012). The diagnosis of risk of anaphylaxis is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended (Peters, Gurrin, Dharmage, et al., 2013).

Clinical Manifestations Anaphylactic reactions produce a clinical syndrome that affects multiple organ systems. Reactions may be categorized as mild, moderate, or severe. The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. The severity of previous reactions does not determine the severity of subsequent reactions, which could be, the same or more or less severe. The severity depends on the degree of allergy and the dose of allergen (Kounis et al., 2013). Mild systemic reactions consist of peripheral tingling and a sensation of warmth, possibly accompanied by sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. Onset of symptoms begins within the first 2 hours of exposure. Moderate systemic reactions may include flushing, warmth, anxiety, and itching in addition to any of the milder symptoms. More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, and wheezing. The onset of symptoms is the same as for a mild reaction. Severe systemic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

Prevention Strict avoidance of potential allergens is an important preventive measure for the patient at risk for anaphylaxis. Patients at risk for anaphylaxis from insect stings should avoid areas populated by insects and should use appropriate clothing, insect repellent, and caution to avoid further stings. If avoidance of exposure to allergens is impossible, the patient is instructed to carry and administer epinephrine

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based on controlled anaphylaxis, with a gradual release of mediators. Patients who undergo desensitization are cautioned that there should be no lapses in therapy, because this may lead to the reappearance of the allergic reaction when the medication is resumed.

Medical Management

FIGURE 54-5. The EpiPen and EpiPen Jr. autoinjectors are commercially available first-aid devices that administer premeasured doses of epinephrine. An EpiPen training device is available for patients to practice correct self-injection technique. Courtesy of Dey Pharmaceuticals, Napa, CA.

to prevent an anaphylactic reaction in the event of exposure to the allergen. People who are sensitive to insect bites and stings, those who have experienced food or medication reactions, and those who have experienced idiopathic or exercise-induced anaphylactic reactions should always carry an emergency kit that contains epinephrine. The EpiPen from Dey Pharmaceuticals (Napa, CA) is a commercially available first aid device that delivers premeasured doses of 0.30 mg (EpiPen) or 0.15 mg (EpiPen Jr.) of epinephrine (Fig. 54-5). The autoinjection system requires no preparation, and the self-administration technique is uncomplicated. The patients must be given an opportunity to demonstrate the correct technique for use; an EpiPen training device can be used for teaching correct technique. Verbal and written information about the emergency kit, as well as strategies to avoid exposure to threatening allergens, must also be provided. Screening for allergies before a medication is prescribed or first administered is an important preventive measure. A careful history of any sensitivity to suspected antigens must be obtained before administering any medication, particularly in parenteral form, because this route is associated with the most severe anaphylaxis. Nurses caring for patients in any setting (hospital, home, outpatient diagnostic testing sites, long-term care facilities) must assess patients’ risks for anaphylactic reactions. Patients are asked about previous exposure to contrast agents used for diagnostic tests and any allergic reactions as well as reactions to any medications, foods, insect stings, and latex. People who are predisposed to anaphylaxis should wear some form of identification, such as a medical alert bracelet, which names allergies to medications, food, and other substances. People who are allergic to insect venom may require venom immunotherapy, which is used as a control measure and not a cure. Immunotherapy administered after an insect sting is very effective in reducing the risk of anaphylaxis from future stings (Pesek & Lockey, 2013). Insulinallergic patients with diabetes and those who are allergic to penicillin may require desensitization. Desensitization is

Management depends on the severity of the reaction. Initially, respiratory and cardiovascular functions are evaluated. If the patient is in cardiac arrest, cardiopulmonary resuscitation is instituted. Oxygen is provided in high concentrations during cardiopulmonary resuscitation or if the patient is cyanotic, dyspneic, or wheezing. Epinephrine, in a 1:1,000 dilution, is administered subcutaneously in the upper extremity or thigh and may be followed by a continuous IV infusion. Most adverse events associated with administration of epinephrine (Adrenaline) occur when the dose is excessive or it is given intravenously. Patients at risk for adverse effects include older patients and those with hypertension, arteriopathies, or known ischemic heart disease (Laemmle-Ruff, O’Hehir, Ackland, et al., 2012). Antihistamines and corticosteroids may also be given to prevent recurrences of the reaction and to treat urticaria and angioedema (Lang, 2014). IV fluids (e.g., normal saline solution), volume expanders, and vasopressor agents are administered to maintain blood pressure and usual hemodynamic status. In patients with episodes of bronchospasm or a history of bronchial asthma or chronic obstructive pulmonary disease, aminophylline and corticosteroids may also be administered to improve airway patency and function. If hypotension is unresponsive to vasopressors, glucagon may be given IV for its acute inotropic and chronotropic effects. Patients who have experienced anaphylactic reactions and received epinephrine should be transported to the local emergency department for observation and monitoring because of the risk for a “rebound” reaction 4 to 10 hours after the initial allergic reaction. Patients with severe reactions are monitored closely for 12 to 14 hours in a facility that can provide emergency care, if needed. Because of the potential for recurrence, patients with even mild reactions must be informed about this risk (Sicherer & Leung, 2013).

Nursing Management If a patient is experiencing an allergic response, the nurse’s initial action is to assess the patient for signs and symptoms of anaphylaxis. The nurse assesses the airway, breathing pattern, and vital signs. The patient is observed for signs of increasing edema and respiratory distress. Prompt notification of the physician and preparation for initiation of emergency measures (intubation, administration of emergency medications, insertion of IV lines, fluid administration, oxygen administration) are important to reduce the severity of the reaction and to restore cardiovascular function. The nurse documents the interventions used and the patient’s vital signs and response to treatment. The patient who has recovered from anaphylaxis needs an explanation of what occurred, instruction about avoiding future exposure to antigens, and how to administere emergency medications to treat anaphylaxis. The patient must also be instructed about antigens that

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should be avoided and about other strategies to prevent recurrence of anaphylaxis. All patients who have experienced an anaphylactic reaction should receive a prescription for preloaded syringes of epinephrine. The nurse instructs the patient and family in their use and has the patient and family demonstrate correct administration (Chart 54-4).

Allergic Rhinitis Allergic rhinitis (hay fever, seasonal allergic rhinitis) is the most common form of respiratory allergy presumed to be mediated by an immediate (type I hypersensitivity) immunologic reaction, and it is among the top 10 reasons for visits to primary care physicians (Braido, Sclifò, & Ferrando, 2014). It affects about 20% to 25% of the Canadian population (Kim, 2008). The symptoms are similar to those of viral rhinitis but are usually more persistent and demonstrate seasonal variation; rhinitis is considered to be the allergic form if the symptoms are caused by an allergenspecific IgE-mediated immunologic response. However, a sizable proportion of patients with rhinitis have mixed rhinitis, or coexisting allergic and nonallergic rhinitis (Braido et al., 2014). The proportion of patients with the allergic form of rhinitis increases with age. It often occurs with other conditions, such as allergic conjunctivitis, sinusitis, and asthma. If symptoms are severe, allergic rhinitis may interfere with sleep, leisure, and school or work activities (Braido et al., 2014). If left untreated, many complications may result, such as allergic asthma; chronic nasal obstruction; chronic otitis media with hearing loss; anosmia (absence of the sense of smell); and, in children, orofacial dental deformities. Early diagnosis and adequate treatment are essential to reduce complications and relieve symptoms. Because allergic rhinitis is induced by airborne pollens or molds, it is characterized by the following seasonal occurrences: • Early spring: Snow mold, tree pollen (oak, elm, poplar) • Early summer: Rose pollen (rose fever), Grass pollen (Timothy, red-top) • Early fall: Weed pollen (ragweed) Each year attacks begin and end at about the same time. Airborne mold spores require warm, damp weather. Although there is no rigid seasonal pattern, these spores appear in early spring (snow molds in particular), are rampant during the summer, and taper off and disappear by the first frost in areas that experience dramatic seasonal temperature variation. In temperate areas that do not experience freezing temperatures, these allergens, especially mold, can persist throughout the year.

Pathophysiology Sensitization begins by ingestion or inhalation of an antigen. On re-exposure, the nasal mucosa reacts by the slowing of ciliary action, edema formation, and leukocyte (primarily eosinophil) infiltration. Histamine is the major mediator of allergic reactions in the nasal mucosa. Tissue edema results from vasodilation and increased capillary permeability.

CHART 54-4

Patient Education Self-Administration of Epinephrine Practice this technique using a training device. 1. After removing the EpiPen autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointing downward. Form fist around the unit with the black tip down and with your other hand, remove the grey safety release cap.

2. Hold black tip near outer thigh. with the device perpendicular (90-degree angle) to the thigh, swing and jab firmly into outer thigh until a click is heard.

3. Hold firmly against the thigh for approximately 10 seconds. Remove the unit from the thigh and massage injection area for 10 seconds. Call 911 and seek immediate medical attention. Carefully place the used EpiPen, needle-end first, into the device storage tube without bending the needle. Screw on the storage tube completely, and take with you to the hospital emergency room.

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Assessment and Management of Patients With Allergic Disorders

Clinical Manifestations Typical signs and symptoms of allergic rhinitis include sneezing and nasal congestion; clear, watery nasal discharge; and nasal itching. Itching of the throat and soft palate is common. Drainage of nasal mucus into the pharynx results in multiple attempts to clear the throat and results in a dry cough or hoarseness. Headache, pain over the paranasal sinuses, and epistaxis can accompany allergic rhinitis. The symptoms of this chronic condition depend on environmental exposure and intrinsic host responsiveness. Allergic rhinitis can affect quality of life by also producing fatigue, loss of sleep, and poor concentration (Braido et al., 2014).

Assessment and Diagnostic Findings Diagnosis of seasonal allergic rhinitis is based on history, physical examination, and diagnostic test results. Diagnostic tests include nasal smears, peripheral blood counts, total serum IgE, epicutaneous and intradermal testing, RAST, food elimination and challenge, and nasal provocation tests. Results indicative of allergy as the cause of rhinitis include increased IgE and eosinophil levels and positive reactions on allergen testing. False-positive and false-negative responses to these tests, particularly skin testing and provocation tests, may occur.

Medical Management The goal of therapy is to provide relief from symptoms. Therapy may include one or all of the following interventions: avoidance therapy, pharmacotherapy, and immunotherapy. Verbal instructions must be reinforced by written information. Knowledge of general concepts regarding assessment and therapy in allergic diseases is important so that patients can learn to manage certain conditions as well as prevent severe reactions and illnesses.

Avoidance Therapy In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Simple measures and environmental controls are often effective in decreasing symptoms. Examples include the use of air conditioners, air cleaners, humidifiers and dehumidifiers; removal of dust-catching furnishings, carpets, and window coverings; removal of pets from the home or bedroom; the use of pillow and mattress covers that are impermeable to dust mites; and a smoke-free environment (Morris, 2010). Because multiple allergens are often implicated, multiple measures to avoid exposure to allergens are often necessary (Rank, Wollan, Li, et al., 2010). High-efficiency particulate air (HEPA) purifiers and vacuum cleaner filters may also be used to reduce allergens in the environment. Research has shown that multiple avoidance strategies tailored to a person’s risk factors can reduce the severity of symptoms, the number of work or school days missed because of symptoms, and the number of unscheduled health care visits for treatment (Izquierdo-Domínguez, Valero, & Mullol, 2013). In many cases, it is impossible to

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avoid exposure to all environmental allergens, so pharmacologic therapy or immunotherapy is needed.

Pharmacologic Therapy ANTIHISTAMINES. Antihistamines, now classified as H1receptor antagonists (or H1-blockers), are used in managing mild allergic disorders. H1-blockers bind selectively to H1 receptors, preventing the actions of histamines at these sites. They do not prevent the release of histamine from mast cells or basophils. The H1 antagonists have no effect on H2 receptors, but they do have the ability to bind to nonhistaminic receptors. The ability of certain antihistamines to bind to and block muscarinic receptors underlines several of the prominent anticholinergic side effects of these medications. Oral antihistamines, which are readily absorbed, are most effective when given at the first occurrence of symptoms because they prevent the development of new symptoms. The effectiveness of these medications is limited to certain patients with hay fever, vasomotor rhinitis, urticaria (hives), and mild asthma. They are rarely effective in other conditions or in any severe conditions. Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although histamine H1 antagonists are less sedating than earlier antihistamines (Church & Church, 2011). Additional side effects include nervousness, tremors, dizziness, dry mouth, palpitations, anorexia, nausea, and vomiting. Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children less than 2 years of age, with caution for children less than 6 years of age, older people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, and prostatic hyperplasia). Newer antihistamines are called second-generation or nonsedating H1 receptor antagonists. Unlike first-generation H1 receptor antagonists, they do not cross the blood–brain barrier and do not bind to cholinergic, serotoninergic, or alpha-adrenergic receptors (Church & Church, 2011). They bind to peripheral rather than central nervous system H1 receptors, causing less sedation. Examples of these medications are loratadine (Claritin), fexofenadine (Allegra), and cetirizine (Zyrtec). These are summarized in Table 54-2. Antihistamines may also be combined with decongestants to reduce the nasal congestion associated with allergies. Some of these combination products are available as over-the-counter (nonprescription) medications; examples are desloratadine/pseudoephedrine (Claritin-D) and cetirizine/pseudoephedrine (Zyrtec-D). Decongestants can cause an increase in blood pressure; therefore, patients with a history of hypertension should be cautioned about the long-term use of any medication containing decongestants. ADRENERGIC AGENTS. Adrenergic agents, vasoconstrictors of mucosal vessels, are used topically (nasal and ophthalmic formulations) in addition to the oral route. The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid

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TABLE 54-2 H1 Antihistamine

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Immunologic Function

Selected H1 Antihistamines Contraindications

First-Generation H1 Antihistamines (Sedating) Diphenhydramine Allergy to any antihistamines (Benadryl) Third trimester of pregnancy Lactation Use cautiously with narrow-angle glaucoma, asthma, stenosing peptic ulcer, BPH or bladder neck obstruction, pregnancy, older patients, hypertension Chlorpheniramine (Chlor-Trimeton)

Hydroxyzine (Atarax)

Allergy to any antihistamines Third trimester of pregnancy Lactation Use cautiously with narrow-angle glaucoma, asthma, stenosing peptic ulcer, BPH or bladder neck obstruction, pregnancy, older patients, hypertension Allergy to hydroxyzine or cetirizine (Zyrtec), pregnancy, lactation, hypertension

Second-Generation H1 Antihistamines (Nonsedating) Cetirizine (Zyrtec) Allergy to any antihistamines Narrow-angle glaucoma Asthma Stenosing peptic ulcer BPH or bladder neck obstruction Lactation Hypertension Desloratadine Allergy to loratadine (Alavert, (Clarinex) Claritin) Lactation Use cautiously with renal or hepatic impairment pregnancy, hypertension Loratadine Allergy to any antihistamines (Alavert, Claritin) Narrow-angle glaucoma Asthma Stenosing peptic ulcer BPH or bladder neck obstruction, hypertension Fexofenadine (Allegra)

Allergy to any antihistamines Pregnancy Lactation Use with caution with hepatic or renal impairment, in older patients, and with hypertension

Major Side Effects

Nursing Implications and Patient Teaching

Drowsiness, confusion, dizziness, dry mouth, nausea, vomiting, photosensitivity, urinary retention

Administer with food if gastrointestinal upset occurs. Caution patients to avoid alcohol, driving, or engaging in any hazardous activities until CNS response to medication is stabilized. Suggest sucking on sugarless lozenges or ice chips for relief of dry mouth. Encourage use of sunscreen and hat while outdoors. Assess for urinary retention; monitor urinary output. Caution patients to avoid alcohol, driving, or engaging in any hazardous activities until CNS response to medication is stabilized. Suggest sucking on sugarless lozenges or ice chips for relief of dry mouth. Recommend use of humidifier.

Drowsiness, sedation, and dizziness, although less than other sedating agents; confusion, dry mouth, nausea, vomiting, urinary retention, epigastric distress, thickening of bronchial secretions Drowsiness, dry mouth, involuntary motor activity, including tremor and seizures

Caution patients to avoid alcohol, driving, or engaging in any hazardous activities until CNS response to medication is stabilized. Suggest sucking on sugarless lozenges or ice chips for relief of dry mouth. Instruct patients to report tremors.

Dry nasal mucosa, thickening of bronchial secretions

Can be taken without regard to meals. Instruct patients to use caution if driving or performing tasks that require alertness. Recommend use of humidifier.

Somnolence, nervousness, dizziness, fatigue, dry mouth

Can be taken without regard to meals. Suggest sucking on sugarless lozenges or ice chips for relief of dry mouth. Recommend use of humidifier.

Headache, nervousness, dizziness, depression, edema, increased appetite

Instruct patients to take on empty stomach (1 h before or 2 h after meals or food). Instruct patients to avoid alcohol and to use caution if driving or performing tasks that require alertness. Suggest sucking on sugarless lozenges or ice chips for relief of dry mouth. Recommend use of humidifier. Should not be administered within 15 min of ingestion of antacids. Instruct patients to use caution if driving or performing tasks that require alertness. Recommend use of humidifier.

Fatigue, drowsiness, GI upset

BPH, benign prostatic hyperplasia; CNS, central nervous system.

rebound congestion. Adrenergic nasal decongestants are applied topically to the nasal mucosa for the relief of nasal congestion. They activate the alpha-adrenergic receptor sites on the smooth muscle of the nasal mucosal blood vessels, reducing local blood flow, fluid exudation, and mucosal edema. Topical ophthalmic drops are used for symptomatic relief of eye irritations caused by allergies. Potential side effects include hypertension, dysrhythmias, palpitations, central nervous system stimulation, irritabil-

ity, tremor, and tachyphylaxis (acceleration of hemodynamic status). MAST CELL STABILIZERS. Intranasal cromolyn sodium (NasalCrom) is a spray that acts by stabilizing the mast cell membrane, thus reducing the release of histamine and other mediators of the allergic response. In addition, it inhibits macrophages, eosinophils, monocytes, and platelets involved in the immune response (Hepworth, Daniłowicz-Luebert, Rausch, et al., 2012). Cromolyn

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Assessment and Management of Patients With Allergic Disorders

interrupts the physiologic response to nasal antigens, and is used prophylactically (before exposure to allergens) to prevent the onset of symptoms and to treat symptoms once they occur. It is also used therapeutically in chronic allergic rhinitis. This spray is as effective as antihistamines but is less effective than intranasal corticosteroids in the treatment of seasonal allergic rhinitis. The patient must be informed that the beneficial effects of the medication may take a week or so to occur. The medication is of no benefit in the treatment of nonallergic rhinitis. Adverse effects (e.g., sneezing, local stinging, and burning sensations) are usually mild. CORTICOSTEROIDS. Intranasal corticosteroids are indicated in more severe cases of allergic and perennial rhinitis that cannot be controlled by more conventional medications such as decongestants, antihistamines, and intranasal cromolyn. Examples of these medications include beclomethasone (Beconase, Vancenase), budesonide (Rhinocort), dexamethasone (Decadron Phosphate Turbinaire), flunisolide (Nasalide), fluticasone (Cutivate, Flonase), and triamcinolone (Nasacort). Because of their anti-inflammatory actions, corticosteroids are equally effective in preventing or suppressing the major symptoms of allergic rhinitis. These medications are administered by metered-spray devices. If the nasal passages are blocked, a topical decongestant may be used to clear the passages before the administration of the intranasal corticosteroid. Patients must be made aware that full benefit may not be achieved for several days to 2 weeks. Adverse effects of intranasal corticosteroids are mild and include drying of the nasal mucosa and burning and itching sensations caused by the vehicle used to administer the medication. Systemic effects are more likely with dexamethasone. Recommended use of this medication is limited to 30 days. Beclomethasone, budesonide, flunisolide, fluticasone, and triamcinolone are deactivated rapidly after absorption, so they do not achieve significant blood levels. Because corticosteroids suppress host defenses, they must be used with caution in patients with tuberculosis or untreated bacterial infections of the lungs. Patients on corticosteroids are at risk for infection and for suppression of typical manifestations of inflammation because host defenses are compromised. Inhaled corticosteroids do not affect the immune system to the same degree as systemic corticosteroids (i.e., oral corticosteroids). As corticosteroids are inhaled into the upper respiratory tract, tuberculosis or untreated bacterial infections of the lungs may become apparent and progress. Whenever possible, patients with tuberculosis or other bacterial infections of the lungs should avoid inhaled corticosteroids. Oral and parenteral corticosteroids are used when conventional therapy has failed and symptoms are severe and of short duration. They can control symptoms of allergic reactions such as hay fever, medication-induced allergies, and allergic reactions to insect stings. Because the response to corticosteroids is delayed, these agents have little or no value in acute therapy for severe reactions such as anaphylaxis. Patients who receive corticosteroids must be cautioned to not stop taking the medication suddenly or without specific instructions from the physician. The patient is also instructed about the side effects, which include fluid retention, weight gain, hypertension, gastric irritation, glucose intolerance, and adrenal suppression.

TABLE 54-3 Leukotriene Modifier

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Leukotriene Modifiers Available Formulations

Leukotriene-Receptor Antagonists (LTRAs) Zafirlukast Tablets: 10 mg; (Accolate) 20 mg Montelukast Tablets: 10 mg Chewable tablets: (Singulair) 4 mg; 5 mg Granules: 4 mg/ packet Leukotriene-Receptor Inhibitors (LTRIs) Zileuton (Zyflo Tables: 600 mg CR) extended release

Frequency of Dosing Taken twice a day Taken once a day in PM

Taken twice a day within 1 h after morning and evening meals

Further discussion of corticosteroids is provided in Chapter 43. LEUKOTRIENE MODIFIERS. As previously discussed, leukotrienes have many effects on the inflammatory cycle. Leukotriene modifiers, such as zileuton (Zyflo), zafirlukast (Accolate), and montelukast (Singulair), block the synthesis or action of leukotrienes and prevent the signs and symptoms associated with asthma (Table 54-3). Leukotriene modifiers are for long-term use, and patients should be advised to take their medication daily. Patients take appropriate “rescue” medications for symptom exacerbation but continue to take the leukotriene modifier on a daily basis. The 2007 National Asthma Education and Prevention Program (NAEPP) suggests using a leukotriene modifier in conjunction with an inhaled corticosteroid for mild persistent asthma.

Immunotherapy Allergen desensitization (allergen immunotherapy, hyposensitization) is primarily used to treat IgE-mediated diseases by injections of allergen extracts. Immunotherapy, also referred to as allergy vaccine therapy, involves the administration of gradually increasing quantities of specific allergens to the patient until a dose is reached that is effective in reducing disease severity from natural exposure (Frew, 2010). This type of therapy provides an adjunct to symptomatic pharmacologic therapy and can be used when allergen avoidance is not possible. Specific immunotherapy has been used in the treatment of allergic disorders for about 100 years. Goals of immunotherapy include reducing the level of circulating IgE, increasing the level of blocking antibody IgG, and reducing mediator cell sensitivity. Immunotherapy has been most effective for ragweed pollen; however, treatment for grass, tree pollen, cat dander, and house dust mite allergens has also been effective. Indications and contraindications for immunotherapy are presented in Chart 54-5. Correlation of a positive skin test with a positive allergy history is an indication for immunotherapy if the allergen cannot be avoided. The benefit of immunotherapy has been fairly well established in instances of allergic rhinitis and bronchial asthma that are clearly due to sensitivity to one of the common pollens, molds, or household dust.

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Immunologic Function

!

CHART 54-5

Immunotherapy: Indications and Contraindications Indications

NURSING ALERT

Because the injection of an allergen may induce systemic reactions, such injections are given only in a setting (i.e., physician’s office, clinic) where epinephrine is immediately available.

• Allergic rhinitis, conjunctivitis, or allergic asthma • History of a systemic reaction to Hymenoptera and specific IgE antibodies to Hymenoptera venom

• Desire to avoid the long-term use, potential adverse effects, or costs of medications

• Lack of control of symptoms by avoidance measures or use of medications

Contraindications • Use of beta-blocker or angiotensin-converting inhibitor

(ACE) therapy, which may mask early signs of anaphylaxis

• Presence of significant pulmonary or cardiac disease or organ failure

• Inability of the patient to recognize or report signs and symptoms of a systemic reaction

• Nonadherence of the patient to other therapeutic regi-

mens and nonlikelihood that patient will adhere to immunization schedule (often weekly for an indefinite period) • Inability to monitor the patient for at least 30 minutes after administration of immunotherapy • Absence of equipment or adequate personnel to respond to allergic reaction if one occurs

Because of the risk for anaphylaxis, injections should not be given by a lay person or by the patient. The patient must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. If a large, local swelling develops at the injection site, the next dose should not be increased, as this may be a warning sign of a possible systemic reaction. Therapeutic failure is evident when a patient does not experience a decrease of symptoms within 12 to 24 months, fails to develop increased tolerance to known allergens, and cannot decrease the use of medications to reduce symptoms. Potential causes of treatment failure include misdiagnosis of allergies, inadequate doses of allergen, newly developed allergies, and inadequate environmental controls.

!!"## Unlike antiallergy medication, allergen immunotherapy has the potential to alter the allergic disease course after 3 to 5 years of therapy. Because it may prevent progression or development of asthma or multiple or additional allergies, it is also considered to be a potential preventive measure (Compalati, Braido, & Canonica, 2014). The patient needs to understand what to expect and the importance of continuing therapy for several years before immunotherapy is accomplished. When skin tests are performed, the results are correlated with symptoms; treatment is based on the patient’s needs rather than just on the results of skin tests. The most common method of treatment is the serial injection of one or more antigens that are selected in each particular case on the basis of skin tests. This method provides a simple and efficient technique for identifying IgE antibodies to specific antigens. Specific treatment consists of injecting extracts of the allergens that cause symptoms in a particular patient. Injections begin with very small amounts and are gradually increased, usually at weekly intervals, until a maximum tolerated dose is attained. Maintenance booster injections are given at 2- to 4-week intervals, frequently for a period of several years, before maximum benefit is achieved, although some patients will note early improvement in their symptoms. Long-term benefit seems to be related to the cumulative dose of vaccine given over time (Frew, 2010). Immunotherapy should not be initiated during pregnancy; for patients who have been receiving immunotherapy before pregnancy, the dosage should not be increased during pregnancy. Although severe systemic reactions occur in less than 1% of patients receiving immunotherapy (Frew, 2010), the risk for systemic and potentially fatal anaphylaxis exists. It tends to occur most frequently at the induction or “up-dosing” phase. Therefore, the patient must be monitored after administration of immunotherapy.

Nursing Process

The Patient With Allergic Rhinitis Assessment The examination and history of the patient with allergic rhinitis reveal sneezing, often in paroxysms, thin and watery nasal discharge, itching eyes and nose, lacrimation, and occasionally headache. The health history includes a personal and family history of allergy. The allergy assessment identifies the nature of antigens, seasonal changes in symptoms, and medication history. The nurse also obtains subjective data about how the patient feels just before symptoms become obvious, such as the occurrence of pruritus, breathing issues, and tingling sensations. In addition to these symptoms, hoarseness, wheezing, hives, rash, erythema, and edema are noted. Any relationship between emotional concerns or stress and the triggering of allergy symptoms is assessed.

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Ineffective breathing pattern related to allergic reaction

CHAPTER 54

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Assessment and Management of Patients With Allergic Disorders

• Deficient knowledge about allergy and the recommended modifications in lifestyle and self-care practices • Ineffective individual coping with chronicity of condition and need for environmental modifications

Collaborative Problems/ Potential Complications Based on assessment data, potential complications may include the following: • Anaphylaxis • Impaired breathing • Nonadherence to the therapeutic regimen

Planning and Goals The goals for the patient may include restoration of regular breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications.

Nursing Interventions Improving Breathing Pattern The patient is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. The patient is instructed to reduce exposure to people with upper respiratory tract infections (URIs). If a URI occurs, the patient is encouraged to take deep breaths and cough frequently to ensure adequate gas exchange and prevent atelectasis. The patient is instructed to seek medical attention because allergy symptoms along with a URI may compromise adequate lung function. Adherence to medication schedules and other treatment regimens is encouraged and reinforced.

Promoting Understanding of Allergy and Allergy Control Instruction includes strategies to minimize exposure to allergens, and explanations about desensitization procedures, and correct use of medications. The nurse informs and reminds the patient of the importance of keeping appointments for desensitization procedures, as dosages are usually adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment. Patients also need to understand that medications for allergy control should be used only when the allergy is apparent. This is usually on a seasonal basis. Continued use of medications when not required can cause an increased tolerance to the medication, with the result that the medication will not be effective when needed.

Coping With a Chronic Disorder Although allergic reactions are infrequently lifethreatening, they require constant vigilance to avoid

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allergens and modification of the lifestyle or environment to prevent recurrence of symptoms. Allergic symptoms are often present year-round and create discomfort and inconvenience for the patient. Although patients may not feel ill during allergy seasons, they often do not feel well either. The need to be alert for possible allergens in the environment may be tiresome, placing a burden on the patient’s ability to lead a normal life. Stress related to these difficulties may in turn increase the frequency or severity of symptoms. To assist the patient in adjusting to these modifications, the nurse needs an appreciation of the difficulties encountered by the patient. The patient is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively.

Monitoring and Managing Potential Complications ANAPHYLAXIS AND IMPAIRED BREATHING.

Respiratory and cardiovascular functioning can be significantly altered during allergic reactions by the reaction itself or by the medications used to treat reactions. The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties or unexpected lung sounds. The pulse rate and rhythm and blood pressure are monitored to assess cardiovascular status regularly or any time the patient reports symptoms such as itching or difficulty breathing. In the event of signs and symptoms suggestive of anaphylaxis, emergency medications and equipment must be available for immediate use. NONADHERENCE TO THERAPEUTIC REGIMEN.

Knowing about the treatment regimen does not ensure adherence. Having the patient identify potential barriers and explore acceptable solutions for effective management of the condition (e.g., installing tile or wood floors rather than carpet, not gardening in the spring) can increase adherence to the treatment regimen.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient is instructed about strategies to minimize exposure to allergens, the actions and adverse effects of medications, and the correct use of medications. The patient should know the name, dose, frequency, actions, and side effects of all medications taken. Teaching about strategies to control allergic symptoms is based on the needs of the patient as determined by the results of tests, the severity of symptoms, and the motivation of the patient and family to deal with the condition. Suggestions for patients who are sensitive to dust and mold in the home are given in Chart 54-6. Additional nursing interventions for allergy management are presented in Chart 54-7. If the patient is to undergo immunotherapy, the nurse reinforces the physician’s explanation regarding

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Immunologic Function

CHART 54-6

HOME CARE CHECKLIST •

Allergy Management

Patient

Family/ Caregiver

• Verbalize how to maintain a dust-free environment by removing drapes, curtains, and

✔

✔

• Identify rationale for washing the floor and dusting and vacuuming daily.

✔

✔

• Identify rationale for replacing stuffed furniture with wood pieces that can easily be dusted.

✔

✔

• State rationale for wearing a mask whenever cleaning is being done.

✔

✔

• Identify rationale for avoiding use of tufted bedspreads, stuffed toys, and feather pillows

✔

✔

• State rationale for avoiding the use of any clothing that causes itching.

✔

✔

• Verbalize ways to reduce dust in the house as a whole by using steam or hot water for

✔

✔

• Verbalize ways to reduce exposure to pollens or molds by identifying seasons of the year

✔

✔

• State rationale for seeking air-conditioned areas at the height of the allergy season.

✔

✔

• State rationale for avoiding sprays and perfumes.

✔

✔

• State rationale for use of hypoallergenic cosmetics.

✔

✔

• State rationale for taking prescribed medications as ordered.

✔

✔

• Identify specific foods that may cause allergic symptoms. (Examples of foods that can cause

✔

✔

• Develop a list of foods to avoid.

✔

✔

At the completion of the home care learning sessions, the patient, family member, or caregiver will be able to: venetian blinds and replacing them with pull shades; covering the mattress with a hypoallergenic cover that can be zipped; and removing rugs and replacing them with wood flooring or linoleum.

and replacing them with washable cotton material.

heating rather than air and using air filters or air-conditioning.

when pollen counts are high; wearing a mask at times of increased exposure (windy days and when grass is being cut); and avoiding contact with weeds, dry leaves, and freshly cut grass.

allergic reactions are fish, nuts, eggs, and chocolate.)

the purpose and procedure. Instructions are given regarding the series of injections, which are usually given initially every week and then at 2- to 4-week intervals. These instructions include remaining in the physician’s office or the clinic for at least 30 minutes after the injection so that emergency treatment can be given if the patient has a reaction, avoiding rubbing or scratching the injection site, and continuing with the series for the period of time required. In addition, the patient and family are informed about emergency treatment of severe allergic symptoms. Because antihistamines may produce drowsiness, the patient is cautioned about this and other side effects of the particular medication. Operating machinery, driving a car, and performing activities requiring intense concentration should be postponed. The patient is also informed about the dangers of drinking alcohol when taking these medications, as they tend to exaggerate the effects of alcohol. The patient must be aware of the effects caused by overuse of the sympathomimetic agents in nose drops or sprays. A condition referred to as rhinitis medicamentosa may result (Fig. 54-6). After topical

application of the medication, a rebound period occurs in which the nasal mucous membranes become more edematous and congested than they were before the medication was used. Such a reaction encourages the use of more medication, and a cyclic pattern results. The topical agent must be discontinued immediately and completely to correct this situation. CONTINUING CARE. Follow-up telephone calls to the patient are often reassuring to the patient Nasal congestion

Topical application of sympathomimetic drugs

Rebound reaction

Relief FIGURE 54-6. Rhinitis medicamentosa. This cyclic pattern results from

overuse of sympathomimetic nose drops or sprays.

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Assessment and Management of Patients With Allergic Disorders

CHART 54-7

Selected Nursing Strategies for Allergy Management • Identify the patient’s known allergens (e.g., medications, foods, insects, environmental allergens).

• Describe the patient’s typical allergic reaction and its severity.

• Document the patient’s allergies (e.g., medications, • • • • • • • • • •

foods, insects, and environmental allergens) in the patient’s medical record. Post allergy alerts appropriately. Encourage the patient to wear a medical alert band and to carry information about allergies at all times. Monitor the patient closely after administration of new medications and exposure to new foods, contrast agents, latex, and other allergens. Investigate potential for allergic reactions with all new medications through consultation with the pharmacist. Instruct the patient to question all medications and new foods. Identify early manifestations of allergic reactions. Administer emergency treatment for allergic reactions. Monitor the patient’s response and status for 12–24 hours after a severe allergic reaction. Instruct the patient and family about emergency home management of allergic reaction. Instruct the patient and family about avoidance measures to reduce risk of exposure to allergens.

and family and provide an opportunity for the nurse to answer any questions. The patient is reminded to keep follow-up appointments and is informed about the importance of continuing with the treatment. The importance of participating in health promotion activities and health screening is also emphasized.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Exhibits regular breathing patterns a. Demonstrates lungs clear on auscultation b. Exhibits absence of adventitious breath sounds (crackles, rhonchi, wheezing) c. Has an acceptable respiratory rate and pattern d. Reports no respiratory distress (shortness of breath, difficulty on inspiration or expiration) 2. Demonstrates knowledge about allergy and strategies to control symptoms a. Identifies causative allergens, if known b. States methods of avoiding allergens and controlling indoor and outdoor precipitating factors c. Removes from environment items that retain dust d. Wears a dampened mask if dust or mold may be a problem e. Avoids smoke-filled rooms and dust-filled or freshly sprayed areas

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f. Uses air conditioning for a major part of the day when allergens are high g. Takes antihistamines as prescribed; participates in hyposensitization program, if applicable h. Describes name, purpose, side effects, and method of administration of prescribed medications i. Identifies when to seek immediate medical attention for severe allergic responses j. Describes activities that are possible, including ways to participate in activities without activating the allergies 3. Experiences relief of discomfort while adapting to the inconveniences of an allergy a. Relates the emotional aspects of allergic response b. Demonstrates use of measures to cope positively with allergy 4. Demonstrates absence of complications a. Exhibits vital signs within appropriate limits b. Reports no symptoms or episodes of anaphylaxis (urticaria, itching, peripheral tingling, fullness in the mouth and throat, flushing, difficulty swallowing, coughing, wheezing, or difficulty breathing) c. Demonstrates correct procedure to selfadminister emergency medications to treat severe allergic reaction d. Correctly states medication names, dose and frequency of administration, and medication actions e. Correctly identifies side effects and untoward signs and symptoms to report to physician f. Discusses acceptable lifestyle changes and solutions for identified potential barriers to adherence to treatment and medication regimen

Contact Dermatitis Contact dermatitis (dermatitis venenata), a type IV delayed hypersensitivity reaction, is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens. There are four basic types: allergic, irritant, phototoxic, and photoallergic (Table 54-4). Eighty percent of cases are due to excessive exposure to or additive effects of irritants (e.g., soaps, detergents, organic solvents). Skin sensitivity may develop after brief or prolonged periods of exposure, and the clinical picture may appear hours or weeks after the sensitized skin has been exposed.

Clinical Manifestations Symptoms include itching, burning, erythema, skin lesions (vesicles), and edema, followed by weeping, crusting, and finally drying and peeling of the skin. In severe responses, hemorrhagic bullae may develop. Repeated reactions may be accompanied by thickening of the skin and pigmentary changes. Secondary invasion by bacteria may develop in skin abraded by rubbing or scratching.

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TABLE 54-4

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Immunologic Function

Types, Testing, and Treatment of Contact Dermatitis

Type

Etiology

Clinical Presentation

Diagnostic Testing

Treatment

Allergic

Results from contact of skin and allergenic substance. Has a sensitization period of 10 to 14 days.

Vasodilation and perivascular infiltrates on the dermis Intracellular edema Usually seen on dorsal aspects of hand

Patch testing (contraindicated in acute, widespread dermatitis)

Avoidance of offending material Burow’s solution or cool water compress Systemic corticosteroids (prednisone) for 7 to 10 days Topical corticosteroids for mild cases Oral antihistamines to relieve pruritus

Irritant

Results from contact with a substance that chemically or physically damages the skin on a nonimmunologic basis. Occurs after first exposure to irritant or repeated exposures to milder irritants over an extended time.

Dryness lasting days to months Vesiculation, fissures, cracks Hands and lower arms most common areas

Clinical picture Appropriate negative patch tests

Identification and removal of source of irritation Application of hydrophilic cream or petrolatum to soothe and protect Topical corticosteroids and compresses for weeping lesions Antibiotics for infection and oral antihistamines for pruritus

Phototoxic

Resembles the irritant type but requires sun and a chemical in combination to damage the epidermis

Similar to irritant dermatitis

Photopatch test

Same as for allergic and irritant dermatitis

Photoallergic

Resembles allergic dermatitis but requires light exposure in addition to allergen contact to produce immunologic reactivity.

Similar to allergic dermatitis

Photopatch test

Same as for allergic and irritant dermatitis

Usually, there are no systemic symptoms unless the eruption is widespread.

Assessment and Diagnostic Findings The location of the skin eruption and the history of exposure aid in determining the condition. However, in cases of obscure irritants or an unobservant patient, diagnosis can be extremely difficult, often involving many trial-anderror procedures before the cause is determined. Patch tests on the skin with suspected offending agents may clarify the diagnosis. The patch test most commonly used is the Thin-layer Rapid Use Epicutaneous (TRUE) test.

Atopic Dermatitis Atopic dermatitis is a type I immediate hypersensitivity disorder characterized by inflammation and hyperreactivity of the skin. Other terms used to describe this skin disorder include atopic eczema, atopic dermatitis/eczema, and atopic dermatitis/eczema syndrome (AEDS). In a revised classification system developed to clarify terminology, AEDS includes both allergic and nonallergic disorders. The term atopic dermatitis is currently the most commonly used of these terms and is used in the following discussion. Atopic dermatitis affects 15% to 20% of children and 1% to 3% of adults in developed countries (Silverberg, 2014). Most patients have significant elevations of serum

IgE and peripheral eosinophilia. Pruritus and hyperirritability of the skin are the most consistent features of atopic dermatitis and are related to large amounts of histamine in the skin. Excessive dryness of the skin with resultant itching is related to changes in lipid content, sebaceous gland activity, and sweating. In response to stroking of the skin, immediate redness appears on the skin. Pallor follows in 15 to 30 seconds and persists for 1 to 3 minutes. Lesions develop secondary to the trauma of scratching and appear in areas of increased sweating and hypervascularity. Atopic dermatitis is chronic, with remissions and exacerbations. This condition has a tendency to recur, with remission from adolescence to 20 years of age. It is important to note that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis (Simandyl, 2010). It is the result of interactions between susceptibility genes, the environment, defective function of the skin barrier, and immunologic responses.

Medical Management Treatment of patients with atopic dermatitis must be individualized. Guidelines for treatment include decreasing itching and scratching by wearing cotton fabrics; washing with a mild detergent; humidifying dry heat in winter; maintaining room temperature at 20.0 to 22.2°C; using antihistamines such as diphenhydramine (Benadryl); and avoiding animals, dust, sprays, and perfumes. Keeping the skin moisturized with daily baths to hydrate the skin and the use of topical skin moisturizers is encouraged. Topical corticosteroids are used to prevent inflammation, and any

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Assessment and Management of Patients With Allergic Disorders

infection is treated with antibiotics to eliminate Staphylococcus aureus when indicated. Use of immunosuppressive agents, such as cyclosporine (Neoral, Sandimmune), tacrolimus (Prograf, Protopic), and pimecrolimus (Elidel), may be effective in inhibiting T cells and mast cells involved in atopic dermatitis (Silverberg, 2014). More research is needed to assess the effectiveness and the adverse side effects of medications used to treat atopic dermatitis (Silverberg, 2014).

Nursing Management Patients who experience atopic dermatitis and their families require assistance and support from the nurse to cope with the disorder. The symptoms are often disturbing to the patient and disruptive to the family. The appearance of the skin may affect the patient’s self-esteem and his or her willingness to interact with others. Teaching and counselling about strategies to incorporate preventive measures and treatments into the lifestyle of the family may be helpful. Patients and family members need to be aware of signs of secondary infection and of the need to seek treatment if infection occurs. The nurse also teaches the patient and family about the side effects of medications used in treatment.

Dermatitis Medicamentosa (Drug Reactions) Dermatitis medicamentosa, a type I hypersensitivity disorder, is the term applied to skin rashes associated with certain medications. Although people react differently to each medication, certain medications tend to induce eruptions of similar types. Rashes are among the most common adverse reactions to medications and occur in approximately 2% to 3% of hospitalized patients. In general, drug reactions appear suddenly; have a particularly vivid colour; manifest with characteristics that are more intense than the somewhat similar eruptions of infectious origin; and, with the exception of bromide and the iodide rashes, disappear rapidly after the medication is withdrawn. Rashes may be accompanied by systemic or generalized symptoms. On discovery of a medication allergy, patients are warned that they have a hypersensitivity to a particular medication and are advised not to take it again. Patients should carry information identifying the hypersensitivity with them at all times. Skin eruptions related to medication therapy suggest more serious hypersensitivities. Frequent assessment and prompt reporting of the appearance of any eruptions are important so that early treatment can be initiated. Some cutaneous drug reactions may be associated with a clinical complex that involves other organs. These are known as complex drug reactions. Patients who suspect that a new rash may be caused by a drug allergy (newly prescribed medications, especially antibiotics such as penicillin or sulfa medications) should stop taking the medication immediately and contact their prescribing clinician, who will determine whether the medication and the rash are related.

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Urticaria and Angioneurotic Edema Urticaria (hives) is a type I hypersensitive allergic reaction of the skin characterized by the sudden appearance of pinkish, edematous elevations that vary in size, shape and itch, and cause local discomfort. They may involve any part of the body, including the mucous membranes (especially those of the mouth), the larynx (occasionally with serious respiratory complications), and the gastrointestinal tract. Each hive remains for a few minutes to several hours before disappearing. For hours or days, clusters of these lesions may come, go, and return episodically. If this sequence continues for longer than 6 weeks, the condition is called chronic urticaria. Angioneurotic edema involves the deeper layers of the skin, resulting in more diffuse swelling rather than the discrete lesions characteristic of hives. On occasion, this reaction covers the entire back. The skin over the reaction may appear normal but often has a reddish hue. The skin does not pit on pressure, as does ordinary edema. The regions most often involved are the lips, eyelids, cheeks, hands, feet, genitalia, and tongue; the mucous membranes of the larynx, the bronchi, and the gastrointestinal canal may also be affected, particularly in the hereditary type (see Hereditary Angioedema section). Swellings may appear suddenly; in a few seconds or minutes; or slowly, in 1 or 2 hours. In the latter case, their appearance is often preceded by itching or burning sensations. Seldom does more than a single swelling appear at one time, although one may develop while another is disappearing. Infrequently, swelling recurs in the same region. Patient lesions usually last 24 to 36 hours. On rare occasions, swelling may recur with remarkable regularity at intervals of 3 to 4 weeks. Several frequently prescribed medications, such as angiotensin-converting enzyme (ACE) inhibitors and penicillin, may cause angioedema. The nurse needs to be aware of all medications the patient is taking and be alert to the potential of angioedema as a side effect.

Hereditary Angioedema Hereditary angioedema, although not an immunologic disorder in the usual sense, is included because of its resemblance to allergic angioedema and because of the potential seriousness of the condition. Symptoms are due to edema of the skin, the respiratory tract, or the digestive tract. Attacks may be precipitated by trauma or may seem to occur spontaneously.

Clinical Manifestations When skin is involved, the swelling is usually diffuse, does not itch, and is usually not accompanied by urticaria. Gastrointestinal edema may cause abdominal pain severe enough to suggest the need for surgery. Typically, attacks last 1 to 4 days and are harmless; however, attacks can occasionally affect the subcutaneous and submucosal tissues in the region of the upper airway and can be associated with

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Immunologic Function

respiratory obstruction and asphyxiation. This disorder is inherited as an autosomal dominant trait. Approximately 85% of patients with this disorder have one nonproductive gene, and the remaining 15% have a gene mutation (Altman & Naimi, 2014).

Medical Management Attacks usually subside within 3 to 4 days, but during this time the patient must be observed carefully for signs of laryngeal obstruction, which may necessitate tracheostomy as a life-saving measure. Epinephrine, antihistamines, and corticosteroids are usually used in treatment, but their success is limited.

Food Allergy

(Burks, 2008; Bush, 2008). Women who are pregnant or breast feeding need to be aware of a family history of allergy (mother, father, or a sibling of the unborn infant with asthma, eczema, hay fever, or other allergy) should avoid peanuts and peanut-containing foods during pregnancy as a precaution (Burks, 2008; Cappellano, 2008). One of the dangers of food allergens is that they may be hidden in other foods and not apparent to those susceptible to the allergen. For example, peanuts and peanut butter are often used in salad dressings and in Asian, African, and Mexican cooking and may result in severe allergic reactions, including anaphylaxis. Previous contamination of equipment with allergens (e.g., peanuts) during preparation of another food product (e.g., chocolate cake) is enough to produce anaphylaxis in people with severe allergy.

Clinical Manifestations

IgE-mediated food allergy, a type I hypersensitivity reaction, occurs in 6% to .8% of children and about 2% of the adult population (Zukiewicz-Sobczak, Wróblewska, Adamczuk, et al., 2013); it is thought to occur in people who have a genetic predisposition combined with exposure to allergens early in life through the gastrointestinal or respiratory tract or nasal mucosa (Sicherer & Sampson, 2014). Researchers have also identified a second type of food allergy, a non–IgE-mediated food allergy syndrome in which T cells play a major role (Perry & Pesek, 2013). Almost any food can cause allergic symptoms. Any food can contain an allergen that results in anaphylaxis. The most common offenders are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, and sunflower seeds), nuts, berries, egg white, buckwheat, milk, and chocolate. Peanut and tree nut (e.g., cashew, walnut) allergies are responsible for most severe food allergy reactions (Hsu, Missmer, Young, et al., 2013). In more than 70% of children with peanut allergy, symptoms develop at their first known exposure, suggesting unknown exposure through breast milk or another source

Clinical symptoms are classic allergic symptoms (urticaria, dermatitis, wheezing, cough, laryngeal edema, angioedema) and gastrointestinal symptoms (itching; swelling of lips, tongue, and palate; abdominal pain; nausea; cramps; vomiting; and diarrhea).

Assessment and Diagnostic Findings A careful diagnostic workup is required in any patient with a suspected food hypersensitivity. Included are a detailed allergy history, a physical examination, and pertinent diagnostic tests. Skin testing is used to identify the source of symptoms and is useful in identifying specific foods as causative agents.

Medical Management Therapy for food hypersensitivity includes elimination of the food responsible for the hypersensitivity (Chart 54-8). Pharmacologic therapy is necessary in patients who cannot

CHART 54-8

HOME CARE CHECKLIST •

Managing Food Allergies

Patient

Family/ Caregiver

• Verbalize understanding of the need to maintain an allergen-free diet.

✔

✔

• Demonstrate reading of food labels to identify hidden allergens in food.

✔

✔

• Identify ways to manage an allergen-free diet when eating away from home.

✔

✔

• State the need to wear a medical alert medallion or bracelet.

✔

✔

• List symptoms of food allergy.

✔

✔

• Demonstrate emergency administration of epinephrine.

✔

✔

• State the importance of replacing epinephrine when outdated.

✔

✔

• State the importance of prompt treatment of allergic reactions and health care follow-up.

✔

✔

At the completion of the home care learning session, the patient, family, or caregiver will be able to:

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Assessment and Management of Patients With Allergic Disorders

avoid exposure to offending foods and in patients with multiple food sensitivities not responsive to avoidance measures. Medication therapy involves the use of H1-blockers, antihistamines, adrenergic agents, corticosteroids, and cromolyn sodium. Another essential aspect of management is teaching patients and family members how to recognize and manage the early stages of an acute anaphylactic reaction. Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the patient carefully avoids the offending food. However, peanut allergy has been reported to persist throughout adulthood in some people (Z˙ukiewicz-Sobczak et al., 2013).

Nursing Management In addition to participating in management of the allergic reaction, the nurse focuses on preventing future exposure of the patient to the food allergen. If a severe allergic or anaphylactic reaction to food allergens has occurred, the nurse must instruct the patient and family about strategies to prevent its recurrence. The patient is instructed about the importance of carefully assessing food prepared by others for obvious as well as hidden sources of food allergens and of avoiding locations and facilities where those allergens are likely to be present. This includes careful reading of food labels and monitoring the preparation of food by others to be sure that exposure to even minute amounts of allergenic foods is avoided. The patient and family must be knowledgeable about early signs and symptoms of allergic reactions and must be proficient in emergency administration of epinephrine if a reaction occurs. The nurse also advises the patient to wear a medical alert bracelet or to carry identification and emergency equipment at all times. Patients’ food allergies should be noted on their medical records because there may be risk of allergic reactions not only to food but also to some medications containing similar substances (Sicherer & Sampson, 2014).

Latex Allergy Latex allergy, the allergic reaction to natural rubber proteins, has been implicated in rhinitis, conjunctivitis, contact dermatitis, urticaria, asthma, and anaphylaxis. Shortly after 1987, when hospitals and outpatient facilities mandated the use of powdered latex gloves to prevent transmission of infections, some health care workers began to experience numerous adverse reactions (Bernstein, 2006). From 1989 until the mid-1990s, the number of cases steadily increased (Chaari, Sakly, Amri, et al., 2010). However, since that time, the prevalence has been steadily declining, possibly because of the use of nonpowdered latex and latexfree gloves (Rolland & O’Hehir, 2008). Natural rubber latex is derived from the sap of the rubber tree (Hevea brasiliensis). The conversion of the liquid rubber latex into a finished product entails the addition of more than 200 chemicals. The proteins in the natural rubber latex (Hevea proteins) or the various chemicals that are used in the manufacturing process are thought to be the source of the allergic reactions. Not all objects

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composed of latex have the same ability to stimulate an allergic response. For example, the antigenicity of latex gloves can vary widely depending on the manufacturing method used. Populations at risk include health care workers, patients with atopic allergies, multiple surgeries or dental procedures, people working in factories manufacturing latex products, females, and patients with spina bifida (daily catheterization). Because more food handlers, hair dressers, auto mechanics, and police often wear latex gloves, they may also be at risk for latex allergy. It is estimated that 1% to 6% of the general population has an allergy to latex and that as many as 8% to 12% of health care workers are sensitized (Chaari et al., 2010; Rolland & O’Hehir, 2008; Porth, 2010). Patients are at risk for anaphylactic reactions due to contact with latex during medical treatments, especially surgical procedures. Food that has been handled by individuals wearing latex gloves may stimulate an allergic response. Cross-reactions have been reported in people who are allergic to certain food products, such as kiwis, bananas, pineapples, mangos, passion fruits, avocados, and chestnuts (Ameratunga, Ameratunga, Crooks, et al., 2008). Routes of exposure to latex products can be cutaneous, percutaneous, mucosal, parenteral, and aerosol. Allergic reactions are more likely with parenteral or mucous membrane exposure but can also occur with cutaneous contact or inhalation (Rolland & O’Hehir, 2008). The most frequent source of exposure is cutaneous, which usually involves the wearing of natural latex gloves. The powder used to facilitate putting on latex gloves can become a carrier of latex proteins from the gloves; when the gloves are put on or removed, the particles become airborne and can be inhaled or settle on skin, mucous membranes, or clothing. Mucosal exposure can occur from the use of latex condoms, catheters, airways, and nipples. Parenteral exposure can occur from IV lines or hemodialysis equipment. In addition to latex-derived medical devices, many household items also contain latex. Examples of medical and household items containing latex and a list of alternative products are found in Table 54-5. It is estimated that over 40,000 medical devices and nonmedical products contain latex. Although nonlatex gloves and other items have a low potential to stimulate an allergic response, chemical additives used in their manufacture have been associated with allergic symptoms (Bernstein, 2006).

Clinical Manifestations Several different types of reactions to latex are possible (Table 54-6). Irritant contact dermatitis, a nonimmunologic response, may be due to mechanical skin irritation or an alkaline pH associated with latex gloves. Common symptoms of irritant dermatitis include erythema and pruritus. These symptoms can be eliminated by changing glove brands or using powder-free gloves. Use of hand lotion before donning latex gloves may worsen the symptoms because lotions may leach latex proteins from the gloves, increasing skin exposure and the risk of developing true allergic reactions (Bernstein, 2006). Delayed hypersensitivity to latex, a type IV allergic reaction mediated by T cells in the immune system, is localized

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TABLE 54-5

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Selected Products Containing Natural Rubber Latex and Latex-Free Alternatives

Products Containing Latex Hospital Environment Ace bandage (brown) Adhesive bandages, Band-Aid dressing, Telfa Anesthesia equipment Blood pressure cuff, tubing, and bladder

Examples of Latex-safe Alternativesa Ace bandage, white, all cotton Cotton pads and plastic or silk tape, Active Strip (3M), Duoderm

Catheters Catheter leg bag straps Crutch axillary pads and hand grips, tips Electrocardiogram (ECG) pads Elastic compression stockings Gloves Intravenous (IV) catheters IV rubber injection ports Levin tube Medication vials Penrose drains Prepackaged enema kits Pulse oximeters Resuscitation bags Stethoscope tubing Syringes—single use (Monoject, B & D) Suction tubing Tapes Thermometer probes Tourniquets Theraband

Neoprene anesthesia kit (King) Clean Cuff, single-use nylon or vinyl blood pressure cuffs or wrap with stockinette or apply over clothing All-silicone or vinyl catheters Velcro straps Cover with cloth, tape Baxter, Red Dot 3M ECG pads Kendall SCD stockings with stockinette Dermaprene, Neoprene, polymer, or vinyl gloves Jelko, Deseret IV catheters Cover Y sites and ports; do not puncture. Use three-way stopcocks on plastic tubing. Salem sump tube Remove rubber stopper Jackson-Pratt, Zimmer hemovac drains Theravac, Fleet Ready-to-use Nonin oximeters Laerdal, Puritan Bennett, certain Ambu PVC tubing; cover with latex-free stockinette Terumo syringes, Abbott PCA Abboject PVC (Davol, Laerdal) Dermicel, Micropore Diatec probe covers X-Tourn straps (Avcor) New Thera-band Exercisers, plastic tubing

Home Environment Balloons Diapers, incontinence pads Condoms, diaphragms Feminine hygiene pad Wheelchair cushions

Mylar balloons Huggies, Always, some Attends Polyurethane products, Durex/Avanti and Reality products (female condom) Kimberly-Clark products ROHO cushions, Sof Care bed/chair cushions

a

Confirmation is essential to verify that all items are latex-free before using, especially if risk of latex allergy is present.

to the area of exposure and is characterized by symptoms of contact dermatitis, including vesicular skin lesions, papules, pruritus, edema, erythema, and crusting and thickening of the skin. These symptoms usually appear on the back of the hands. This reaction is thought to be caused by chemicals that are used in the manufacturing of latex products. It is the most common allergic reaction to latex. Although not usually life-threatening, delayed hypersensitivity reactions often require major changes in the patient’s home and work environment to avoid further exposure. People who are sensitized to latex are at increased risk for development of type I allergic reactions (Bernstein, 2006). Immediate hypersensitivity, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. Clinical manifestations have a rapid onset and can include urticaria, wheezing, dyspnea, laryngeal edema, bronchospasm, tachycardia, angioedema, hypotension, and cardiac arrest. Localized itching, erythema, or local urticaria within minutes after exposure to latex are often the initial symptoms. Symptoms of subsequent reactions can include generalized urticaria, angioedema, rhinitis, conjunctivitis,

asthma, and anaphylactic shock minutes after dermal or mucosal exposure to latex. An increasing number of patients who are allergic to latex experience severe reactions characterized by generalized urticaria, bronchospasm, and hypotension.

Assessment and Diagnostic Findings The diagnosis of latex allergy is based on the history and diagnostic test results (Kounis et al., 2013). Sensitization is detected by skin testing, RAST, ELISA, or level of Hevea latex-specific IgE antibody in the serum. Testing for the chemicals found in the rubber production that makes latex is performed using the patch test. Skin patch testing is the preferred method for patients with contact allergies. The TRUE test and other skin tests should be performed only by clinicians who have expertise in their administration and interpretation and who have the necessary equipment available to treat local or systemic allergic reactions to the reagent. Nasal challenge and dipstick tests may be useful in the future as screening tests for latex allergy.

CHAPTER 54

TABLE 54-6

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Assessment and Management of Patients With Allergic Disorders

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Types of Reactions to Latex

Type of Reaction

Cause

Signs/Symptoms

Treatment

Irritant contact dermatitis

Damage to skin because of irritation and loss of epidermoid skin layer; not an allergic reaction. Can be caused by excessive use of soaps and cleansers, multiple handwashings, inadequate hand drying, mechanical irritation (e.g., sweating, rubbing inside powdered gloves), exposure to chemicals added during the manufacturing of gloves, and alkaline pH of powdered gloves. Reaction may occur with first exposure, is usually benign, and is not life-threatening.

Acute: redness, edema, burning, discomfort, itching Chronic: dry, thickened, cracked skin

Referral for diagnostic testing Avoidance of exposure to irritant Thorough washing and drying of hands Use of powder-free gloves with more frequent changes of gloves Changing glove types Use of water- or silicone-based moisturizing creams, lotions, or topical barrier agents Avoidance of oil- or petroleum-based skin agents with latex products, because they cause breakdown of the latex product

Allergic contact dermatitis

Delayed hypersensitivity (type IV) reaction. Usually affects only area in contact with latex; reaction is usually to chemical additives used in the manufacturing process rather than to latex itself. Cause of reaction is T cell–mediated sensitization to additives of latex. Reaction is not life-threatening and is far more common than a type I reaction. Slow onset; occurs 18–24 h after exposure. Resolves within 3–4 days after exposure. More severe reactions may occur with subsequent exposures.

Pruritus, erythema, swelling, crusty thickened skin, blisters, other skin lesions

Referral for diagnosis (patch tests) and treatment Thorough washing and drying of hands Use of water- or silicone-based moisturizing creams, lotions, or topical barrier agents Avoidance of oil- or petroleum-based products unless they are latex compatible Avoidance of identified causative agent, because continued exposure to latex products in presence of breaks in skin may contribute to latex protein sensitization

Latex allergy

Type I IgE-mediated immediate hypersensitivity to plant proteins in natural rubber latex. In sensitized people, antilatex IgE antibody stimulates mast cell proliferation and basophil histamine release. Exposure can be through contact with the skin, mucous membranes, or internal tissues, or through inhalation of traces of powder from latex gloves. Severe reactions usually occur shortly after parenteral or mucous membrane exposure. People with any type I reaction to latex are at high risk for anaphylaxis. Local swelling, redness, edema, itching, and systemic reactions, including anaphylaxis, occur within minutes after exposure.

Rhinitis, flushing, conjunctivitis, urticaria, laryngeal edema, bronchospasm, asthma, severe vasodilation angioedema, anaphylaxis, cardiovascular collapse, death

Immediate treatment of reaction with epinephrine, fluids, vasopressors, and corticosteroids, and airway and ventilator support, with close monitoring for recurrence for next 12–14 h Prompt referral for diagnostic evaluation Treatment and diagnostic evaluation in latexfree environment Assessment of all patients for symptoms of latex allergy Teaching of patients and family members about the disorder and about the importance of preventing future reactions by avoiding latex (e.g., wearing medical alert bracelet, carrying EpiPen)

Medical Management The best treatment available for latex allergy is the avoidance of latex-based products, but this is often difficult because of their widespread use. Patients who have experienced an anaphylactic reaction to latex should be instructed to wear medical identification. Antihistamines and an emergency kit containing epinephrine should be provided to these patients, along with instructions about emergency management of latex allergy symptoms. Patients must be counselled to notify all health care workers as well as local paramedic and ambulance companies about their allergy. Warning labels can be attached to car windows to alert police and paramedics about the driver’s or passenger’s latex allergy in case of a motor vehicle crash. Individuals with latex allergy should be provided with a list of alternative products and referred to local support groups; they are also urged to carry their own supply of nonlatex gloves. People with type I latex sensitivity may be unable to continue to work if a latex-free work environment is not possible. This may occur with surgeons, dentists, operating room personnel, or intensive care nurses. Occupational implications for employees with type IV latex

sensitivity are usually easier to manage by changing to nonlatex gloves and avoiding direct contact with latexbased medical equipment. Although latex-specific immunotherapy has been attempted, this method of treatment remains experimental.

Nursing Management The nurse can assume a pivotal role in the management of latex allergies in both patients and staff. All patients should be asked about latex allergy, although special attention should be given to those at particularly high risk (e.g., patients with spina bifida, patients who have undergone multiple dental or surgical procedures). Every time an invasive procedure must be performed, the nurse should consider the possibility of latex allergies. Nurses working in operating rooms, intensive care units, endoscopy and day surgery units, and emergency departments need to pay particular attention to latex allergy. Refer to Chapter 19 for a latex allergy assessment form. Although the type I reaction is the most significant of the reactions to latex, care must be taken in the presence of irritant contact dermatitis and delayed hypersensitivity

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reaction to avoid further exposure of the person to latex. Patients with latex allergy are advised to notify their health care providers and to wear a medical information bracelet. Patients must be knowledgeable about what products contain latex and what products are safe, nonlatex alternatives. They must also become knowledgeable about signs and symptoms of latex allergy and emergency treatment and self-injection of epinephrine in case of an allergic reaction. Nurses can be instrumental in establishing and participating in multidisciplinary committees to address latex allergy and to promote a latex-free environment. Latex allergy protocols and education of staff about latex allergy and precautions are important strategies to reduce this growing problem and to ensure assessment and prompt treatment of affected people.

Critical Thinking Exercises 1 A 23-year-old college student has developed symptoms of severe seafood allergy. She is to receive instructions about self-administration of epinephrine if she experiences anaphylaxis. Develop a teaching plan for her and identify outcomes to measure the effectiveness of your teaching. Given her allergy to seafood, what other teaching or counselling is needed? 2

A 35-year-old woman has developed symptoms of asthma thought to be an allergic response to the two dogs and two cats her new roommate has brought with her into the apartment. Develop an evidence-based plan for strategies to reduce or eliminate the patient’s allergen exposure. Describe the strength of the evidence and criteria used to assess its strength. What instructional strategies and outcome measures will you use to educate her about avoidance strategies and to assess the effectiveness of their use?

3 An 18-year-old man is scheduled for removal of his wisdom teeth in the dentist’s office. He reports that he has severe seasonal and bee sting allergies. He also experienced an episode of hives and itching during a dental procedure in the past. He reports that he has had to use emergency epinephrine on several occasions in the past because of severe allergic reactions caused by bee stings. What precautions are needed preprocedure, during the procedure, and postprocedure for this patient to prevent the potential occurrence of a severe allergic reaction? What interventions and nursing management would be indicated if he developed a severe allergic reaction?

REFERENCES AND SELECTED READINGS BOOKS Abbas, A. K., Lichtman, A. H., & Pillai, S. (2012). Basic immunology: Functions and disorders of the immune system (4th ed.). Philadelphia, PA: Elsevier Health Sciences. Adkinson, N. F., Busse, W. W., Bochner, B. S., et al. (Eds.). (2009). Middleton’s allergy: Principles and practice (7th ed.). Philadelphia, PA: Elsevier. Barkman, A., & Pooler, C. (2010). Heart failure and circulatory shock. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology:

Concepts of altered health states (1st Canadian ed., pp. 583–612). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams, & Wilkins. Porth, C. M. (2010). Disorders of the immune response. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 385–410). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams, & Wilkins. Simandyl, G. (2010). Disorders of skin integrity and function. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1488–1531). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams, & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS Admani, S., & Jacob, S. E. (2014). Allergic contact dermatitis in children: Review of the past decade. Current Allergy and Asthma Reports, 14(4), 1–11. Allergy/Asthma Information Association [AAIA] Canada. (2014). Anaphylaxis facts. Retrieved from http://www.aaia.ca/en/anaphylaxis_ facts.htm Altman, K. A., & Naimi, D. R. (2014). Hereditary angioedema: A brief review of new developments. Current Medical Research and Opinion, 30(5), 923–930. Ameratunga, R., Ameratunga, S., Crooks, C., et al. (2008). Latex glove use by food handlers: The case for nonlatex gloves. Journal of Food Protection, 71(11), 2334–2338. Bernstein, J. (2006). Allergic occupational disease among healthcare workers: Latex allergy and beyond. American Academy of Allergy, Asthma and Immunology 62nd Annual Meeting: March 3–7, 2006. Miami, FL. www.medscape.com/viewarticle/530091 Boothpur, R., Hardinger, K. L., Skelton, R. M., et al. (2010). Serum sickness after treatment with rabbit antithymocyte globulin in kidney transplant recipients with previous rabbit exposure. American Journal of Kidney Diseases, 55(1), 141–143. Braido, F., Sclifò, F., Ferrando, M., et al. (2014). New therapies for allergic rhinitis. Current Allergy and Asthma Reports, 14(4), 1–8. Burks, A. (2008). Peanut allergy. Lancet, 371(3), 1538–1546. Bush, R. K. (2008). Approach to patients with symptoms of food allergy. American Journal of Medicine, 121(5), 376–378. Cabanes, N., Igea, J. M., de La Hoz, et al. (2012). Latex allergy: Position paper. Journal of Investigational Allergology and Clinical Immunology, 22(5), 313–330. Cappellano, K. L. (2008). Food allergy and intolerances: The nuts and bolts of detection and management. Nutrition Today, 43(1), 11–14. Chaari, N., Sakly, A., Amri, C., et al., (2010). Occupational allergy in healthcare workers. Recent Patents on Inflammation and Allergy Drug Discovery, 4(1), 65–74. Church, D. S., & Church, M. K. (2011). Pharmacology of antihistamines. The World Allergy Organization Journal, 4(Suppl 3), S22. Compalati, E., Braido, F., & Canonica, G. W. (2014). An update on allergen immunotherapy and asthma. Current Opinion in Pulmonary Medicine, 20(1), 109–117. Frew, A. J. (2010). Allergen immunotherapy. Journal of Allergy and Clinical Immunology, 125(2), S306–S313. Hepworth, M. R., Daniłowicz-Luebert, E., Rausch, S., et al. (2012). Mast cells orchestrate type 2 immunity to helminths through regulation of tissue-derived cytokines. Proceedings of the National Academy of Sciences, 109 (17), 6644–6649. Hsu, J. T., Missmer, S. A., Young, M. C., et al. (2013). Prenatal food allergen exposures and odds of childhood peanut, tree nut, or sesame seed sensitization. Annals of Allergy, Asthma and Immunology, 111(5), 391–396. Izquierdo-Domínguez, A., Valero, A. L., & Mullol, J. (2013). Comparative analysis of allergic rhinitis in children and adults. Current Allergy and Asthma Reports, 13(2), 142–151. Johanson, S. G. O., Houriane, O. B., Bouquet, J. et al. (2005). Revised nomencalture for global use. Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. Allergy and Clinical Immunology International Journal of the World Allergy Organization, 17(1), 4–8. Kim, H. (2008). Allergic Rhinitis. Retrieved from http://www.aaia.ca/en/ allergic_rhinitis.htm Kounis, N. G., Soufras, G. D., & Hahalis, G. (2013). Anaphylactic shock: Kounis hypersensitivity-associated syndrome seems to be the primary cause. North American Journal of Medical Sciences, 5(11), 631.

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Laemmle-Ruff, I., O’Hehir, R., Ackland, M., et al. (2012). Anaphylaxis: Identification, management and prevention. Australian Family Physician, 42(1), 38. Lang, D. M. (2014). Evidence-based diagnosis and treatment of chronic urticaria/angioedema. In Allergy and Asthma Proceedings, 35(1), 10–16. Morris, D. O. (2010). Human allergy to environmental pet danders: A public health perspective. Veterinary Dermatology, 21(5), 441–449. Perry, T. T., & Pesek, R. D. (2013). Clinical manifestations of food allergy. Pediatric Annals, 42(6), 96–101. Pesek, R. D., & Lockey, R. F. (2013). Management of insect sting hypersensitivity: An update. Allergy, Asthma and immunology Research, 5(3), 129–137. Peters, R. L., Gurrin, L. C., Dharmage, S. C., et al. (2013). The natural history of IgE-mediated food allergy: Can skin prick tests and serumspecific IgE predict the resolution of food allergy? International Journal of Environmental Research and Public Health, 10(10), 5039–5061. Rank, M. A., Wollan, P., Li, J. T., et al. (2010). Trigger recognition and management in poorly controlled asthmatics. In Allergy and Asthma Proceedings: The Official Journal of Regional and State Allergy Societies, 31(6), 99. Rolland, J. M., & O’Hehir, R. E. (2008). Latex allergy: A model for therapy. Clinical and Experimental Allergy, 38 (6), 898–912. Sicherer, S. H., & Leung, D. Y. (2013). Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2012. Journal of Allergy and Clinical Immunology, 131(1), 55–66.

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Sicherer, S. H., & Sampson, H. A. (2014). Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment. Journal of Allergy and Clinical Immunology, 133(2), 291–307. Silverberg, J. I. (2014). Atopic dermatitis: An evidence-based treatment update. American journal of clinical dermatology, 1–16. Solensky, R. (2012). Allergy to β-lactam antibiotics. Journal of Allergy and Clinical Immunology, 130(6), 1442–1442.e5. Tukenmez Demirci, G., Kivanc Altunay, I., Atis, G., et al. (2012). Allergic contact dermatitis mimicking angioedema due to paraphenylendiamine hypersensitivity: A case report. Cutaneous and Ocular Toxicology, 31(3), 250–252. Z˙ukiewicz-Sobczak, W. A., Wróblewska, P., Adamczuk, P., et al. (2013). Causes, symptoms and prevention of food allergy. Postepy Dermatologii i Alergologii, 30(2), 113–116.

RESOURCES Anaphylaxis Canada, http://www.anaphylaxis.ca. Asthma Society of Canada, http://www.asthma.ca. Canadian Allergy, Asthma and Immunology Foundation, http:/www. allergyfoundation.ca. Canadian Society of Allergy and Clinical Immunology, http://csaci.ca.

CHAPTER

55 Assessment and Management of Patients With Rheumatic Disorders Adapted by Hossein Khalili and Saman Maleki Vareki

Learning Objectives On completion of this chapter, the learner will be able to: 1. Explain the pathophysiology of rheumatic diseases. 2. Describe the assessment and diagnostic findings seen in patients with a suspected diagnosis of rheumatic disease or disorder. 3. Discuss appropriate nursing interventions based on nursing diagnoses and collaborative problems that commonly occur with rheumatic disorders. 4. Apply the nursing process as a framework for the care of the patient with a rheumatic disease, such as connective tissue disease or osteoarthritis. 5. Describe the systemic effects of a connective tissue disease. 6. Devise a teaching plan for the patient with newly diagnosed rheumatic disease. 7. Identify modifications in interventions to accommodate changes in patients’ functional ability that may occur with disease progression.

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CHAPTER 55

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Assessment and Management of Patients With Rheumatic Disorders

Rheumatic diseases include common disorders such as osteoarthritis (OA) and less common conditions such as systemic lupus erythematosus (SLE) and scleroderma. These conditions can be life-threatening, or they can be minor illnesses. The problems caused by the rheumatic diseases include not only the obvious limitations in mobility and activities of daily living but also the more subtle systemic effects that can lead to organ failure and death or result in problems such as pain, fatigue, altered self-image, and sleep disturbances. The rheumatic disease may be the patient’s primary health problem or a secondary diagnosis. An understanding of rheumatic diseases and their effects on a patient’s function and well-being is essential to developing an appropriate plan of nursing care.

RHEUMATIC DISEASES Commonly called arthritis (inflammation of a joint) and thought of as one condition, the rheumatic diseases are more than 100 different types of disorders that primarily affect skeletal muscles, bones, cartilage, ligaments, tendons, and joints in males and females of all ages (Hannon, Pooler, & Porth, 2010). Some disorders are more likely to occur at a particular time of life or to affect one gender more than the other. The onset of these conditions may be acute or insidious, with a course possibly marked by periods of remission (a period when disease symptoms are reduced or absent) and exacerbation (a period when symptoms occur or increase). Treatment can be simple, aimed at localized relief, or it can be complex, directed toward relief of systemic effects. Permanent changes and disability may result from these disorders. Nurses need to understand the classification of rheumatic diseases. One basic system is to classify disease as either monoarticular (affecting a single joint) or polyarticular (affecting multiple joints), and then to further classify it as either inflammatory or noninflammatory. Conditions that may secondarily affect the musculoskeletal structure are also included, illustrating the diversity of the rheumatic diseases.

Pathophysiology The joint is the area most commonly affected in rheumatic diseases. Despite the diversity of rheumatic diseases, from localized involvement of one joint to systemic, multisystem disorders, they all involve some degree of inflammation and degeneration, which may occur simultaneously. Inflamma-

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tion is manifested in the joints as synovitis. In inflammatory rheumatic diseases, the primary process is inflammation caused by the immune response. Degeneration occurs as a secondary process, resulting from the effect of pannus (proliferation of newly formed synovial tissue infiltrated with inflammatory cells). Conversely, in degenerative rheumatic diseases, inflammation occurs as a secondary process. This synovitis is usually milder, is more likely to be seen in advanced disease, and represents a reactive process.

Inflammation Inflammation is a series of related steps. In response to the triggering event, (e.g., trauma, increased stress), the antigen stimulus activates monocytes and T lymphocytes (also called T cells). Next, the immunoglobulin antibodies form immune complexes with antigens. Phagocytosis of the immune complexes is initiated, generating an inflammatory reaction (joint effusion, pain, and edema) (Fig. 55-1). During the next step, the immune response deviates from normal. Phagocytosis produces chemicals such as leukotrienes and prostaglandins. Leukotrienes contribute to the inflammatory process by attracting other white blood cells to the area. Prostaglandins act as modifiers to inflammation. In some cases, they increase inflammation; in other cases, they decrease it. Leukotrienes and prostaglandins produce enzymes such as collagenase that break down collagen, a vital part of a normal joint. The release of these enzymes in the joint causes edema, proliferation of synovial membrane and pannus formation, destruction of cartilage, and erosion of bone. The immunologic inflammatory process begins when antigens are presented to T lymphocytes, leading to a proliferation of T and B cells. B cells are a source of antibodyforming cells, or plasma cells. In response to specific antigens, plasma cells produce and release antibodies. Antibodies combine with corresponding antigens to form pairs, or immune complexes. The immune complexes build up and are deposited in synovial tissue or other organs in the body, triggering the inflammatory reaction that can ultimately damage the involved tissue. The systemic nature of the rheumatic diseases is reflected in the resultant widespread inflammatory process. Although focused in the joints, inflammation also involves other areas. The blood vessels (vasculitis and arteritis), lungs, heart, and kidneys may also be affected by the inflammation. In the joints, this inflammatory response is manifested as pannus extending throughout the joint space and, if persistent, eroding the articular cartilage, causing secondary degenerative changes to the joint.

Glossary ankylosis: fixation or immobility of a joint arthritis: inflammation of a joint arthroplasty: replacement of a joint osteoarthritis: degenerative joint disease osteophyte: a bony outgrowth or protuberance; bone spur pannus: proliferation of newly formed synovial tissue infiltrated with inflammatory cells

rheumatic diseases: numerous disorders affecting skeletal muscles, bones, cartilage, ligaments, tendons, and joints rheumatoid arthritis: autoimmune disease of unknown origin subchondral bone: bony plate that supports the articular cartilage tophi: accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage

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Immunologic Function

Physiology/Pathophysiology Presentation of antigen to T cells

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

Warmth, swelling, 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

Degeneration Although the cause of degeneration of the articular cartilage is poorly understood, the process is known to be metabolically active and therefore is more accurately called “degradation.” One theory of degradation is that genetic or hormonal influences, mechanical factors, and prior joint damage cause cartilage failure. Degradation of cartilage ensues, and increased mechanical stress on bone ends causes stiffening of bone tissue. Another theory is that bone stiffening occurs and results in increased mechanical stress on cartilage, which in turn initiates the processes of degradation. (See Chapter 67 for more information on the structure and function of the articular system.)

Clinical Manifestations The most common symptom in the rheumatic diseases that causes a person to seek medical attention is pain. Other common symptoms include joint swelling, limited movement, stiffness, weakness, and fatigue.

Assessment and Diagnostic Findings Assessment begins with a general health history, which includes the onset of symptoms and how they evolved, family history, past health history, and any other contributing factors. Because many of the rheumatic diseases are

FIGURE 55-1. Pathophysiology and

associated physical signs of rheumatoid arthritis. ROM, range of motion.

chronic conditions, the health history should also include information about the patient’s perception of the problem, previous treatments and their effectiveness, the patient’s support systems, and the patient’s current knowledge base and the source of that information. A complete health history is followed by a complete physical assessment (see Chapter 5). Assessment for rheumatic diseases combines the physical examination with a functional assessment. Inspection of the patient’s general appearance occurs during initial contact. Gait, posture, and general musculoskeletal size and structure are observed. Gross deformities and abnormalities in movement are noted. The symmetry, size, and contour of other connective tissues, such as the skin and adipose tissue, are also noted and recorded. Chart 55-1 outlines the important areas for consideration during the physical assessment. The functional assessment is a combination of history (what the patient reports that he or she can and cannot do) and examination (observation of activities: the patient demonstrates what he or she can and cannot do, such as dressing and getting in and out of a chair). Observation also includes the adaptations and adjustments the patient may have made (sometimes without awareness); for example, with shoulder or elbow involvement, the person may bend over to reach a fork, rather than raising the fork to the mouth. The history and physical assessment data are supplemented by supportive or confirming diagnostic test findings. In some instances, tests are used to monitor the course of the disease. For example, the erythrocyte sedimentation rate (ESR) reflects inflammatory activity and, indirectly, the progression or remission of disease.

CHART 55-1

Assessing for Rheumatic Disorders In addition to the head-to-toe assessment or systems review, the following are important areas of consideration to be noted when performing the complete physical assessment of a patient with a known or suspected rheumatic disorder. Manifestation Skin (inquire and inspect) Rash, lesions Increased bruising Erythema Thinning Warmth Photosensitivity Hair (inquire and inspect) Alopecia or thinning Eye (inquire and inspect) Dryness, grittiness Decreased acuity or blindness Cataracts Decreased peripheral vision Conjunctivitis, uveitis Ear (inquire) Tinnitus Decreased acuity Mouth (inquire and inspect) Buccal, sublingual lesions Altered sense of taste Dryness Dysphagia Difficulty chewing Chest (inspect and inquire) Pleuritic pain Decreased chest expansion Activity intolerance (dyspnea) Cardiovascular system (inquire, inspect, palpate) Blanching of fingers on exposure to cold Peripheral pulses Abdomen (inquire and palpate) Altered bowel habits Nausea, vomiting, bloating, and pain Weight change (measure) Genitalia (inquire and inspect) Dryness, itching Abnormal menses Altered sexual performance Hygiene Urethritis, dysuria Lesions Neurologic (inquire and inspect) Paresthesias of extremities; abnormal reflex pattern Headaches Musculoskeletal (inspect and palpate) Joint redness, warmth, swelling, tenderness, deformity— location of first joint involved, pattern of progression, symmetry, acute versus chronic nature Joint range of motion Surrounding tissue findings Muscle atrophy, subcutaneous nodules, popliteal cyst Muscle strength (grip)

Significance Associated with lupus erythematosus (LE), vasculitis, adverse effect of medication Associated with several rheumatic diseases and adverse effect of medication Sign of inflammation Adverse effect of medication Sign of inflammation Associated with systemic lupus erythematosus (SLE), dermatomyositis, adverse effect of medication Associated with rheumatic diseases or adverse effect of medication Associated with Sjögren’s syndrome (commonly occurring with rheumatoid arthritis [RA] and LE) Associated with temporal arteritis, medication complications Adverse effect of medication Adverse effect of medication Associated with ankylosing spondylitis and Reiter’s syndrome Adverse effect of medication Adverse effect of medication Associated with vasculitis, dermatomyositis, adverse effect of medication Adverse effect of medication Associated with Sjögren’s syndrome Associated with myositis Associated with decreased range of motion of jaw Associated with RA and SLE Associated with ankylosing spondylitis Associated with pulmonary hypertension in scleroderma Associated with Raynaud’s phenomenon Deficit may indicate vascular involvement or edema associated with medication effect or rheumatic diseases, especially SLE or scleroderma Associated with scleroderma, spondylosis, ulcerative colitis, decreased physical mobility, medication effect Adverse effect of medication Associated with RA (decreased), adverse effect of medication (increased or decreased) Associated with Sjögren’s syndrome Adverse effect of medication Fear of pain (or of pain caused by partner) and limitation of motion may affect sexual mobility Poor hygiene may be related to limitations in activities of daily living Associated with ankylosing spondylitis and Reiter’s syndrome Associated with vasculitis Nerve compressions associated with carpal tunnel syndrome, spinal stenosis, etc. Associated with temporal arteritis, adverse effect of medication Signs of inflammation

Decreased range of motion may indicate severity or progression of disease Extra-articular manifestations Muscle strength decreases with increased disease activity

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TABLE 55-1

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Immunologic Function

Common Blood Studies for Rheumatic Diseases

Test 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 h

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

Normal Value

Significance

0.6–1.2 mg/dL (50–110 µmol/L)

Increase may indicate renal damage in SLE, scleroderma, and polyarteritis.

Westergren = Men, 0–15 mm/h, Women, 0–25 mm/h Wintrobe = Men, 0–9 mm/h Women, 0–15 mm/h

Increase is usually seen in inflammatory connective tissue diseases. An increase indicates rising inflammation, resulting in clustering of RBCs, which makes them heavier than normal. The higher the ESR, the greater the inflammatory activity.

Men: 42–52% Women: 35–47%

Decrease can be seen in chronic inflammation (anemia of chronic disease); also, blood loss through bowel due to medication.

Men: average 4.8 million/µL Women: average 4.3 million/µL

Decrease can be seen in RA, SLE.

5,000–10,000 cells/mm3

Decrease may be seen in SLE.

Nonreactive 2.5–8.0 mg/dL (0.15–0.50 mmol/L)

False-positive results are sometimes found with SLE. Increase is seen with gout.

Negative A few healthy adults have a positive ANA

Positive test is associated with SLE, RA, scleroderma, Raynaud’s disease, Sjögren’s syndrome, necrotizing arteritis. The higher the titer, the greater the inflammation. The pattern of immunofluorescence (speckled, homogeneous, or nucleolar) helps determine the diagnosis.

Negative

High titre is seen in SLE; increases in titre may indicate an increase in disease activity.

C3: 55–120 mg/dL (550–1,200 mg/L) C4: 11–40 mg/dL (110–400 mg/L)

Decrease may be seen in RA and SLE. Decrease indicates autoimmune and inflammatory activity.

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UNIT 11

TABLE 55-3

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Immunologic Function

Medications Used in Rheumatic Diseases (Continued)

Medication

Action, Use, and Indication

Nursing Considerations

Tumour necrosis factor (TNF) blocking agents: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi)

Action: biologic response modifier that binds to TNF, a cytokine involved in inflammatory and immune responses. Used in moderate to severe RA unresponsive to methotrexate. Can be used alone or with methotrexate or other DMARDs. Humira is administered every 1–2 wk, and Enbrel is administered twice a week

Interleukin-1 receptor antagonist: anakinra (Kineret)

Action: human interleukin-1 (IL-1) receptor antagonist; blocks IL-1 receptors, decreasing inflammatory and immunologic responses. Used in moderate to severe RA unresponsive to methotrexate. Can be used alone or with methotrexate or DMARDs other than TNF blocking agents

Patient should be tested for tuberculosis before beginning this medication. Teach patient subcutaneous self-injection of adalimumab (Humira) or etanercept (Enbrel). Infliximab (Remicade) is administered by IV line over 2 h or more. Medication must be refrigerated. Monitor for injection site reactions. Educate patient about increased risk for infection and to withhold medication if fever occurs Administered daily by subcutaneous injection. Teach patient subcutaneous self-injection to be administered daily. Medication must be refrigerated. Monitor for injection site reactions. Educate patient about increased risk of infection and to withhold medication if fever occurs

Corticosteroids Prednisone, prednisolone, hydrocortisone

Topical Analgesics Capsaicin (Zostrix)

Action: anti-inflammatory 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 Intra-articular injections useful for joints unresponsive to NSAIDs

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

Action: analgesic

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

GI, gastrointestinal; CNS, central nervous system; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; WBCs, white blood cells; CBC, complete blood count; TNF, tumour necrosis factor.

TABLE 55-4

Exercise to Promote Mobility

Type of Exercise

Purpose

Recommended Performance

Precautions

Range of motion

Maintain flexibility and joint motion

Isometric exercise

Improve muscle tone, static endurance, and strength; prepare for dynamic and weight-bearing exercises Maintain or increase dynamic strength and endurance; increase muscle power; enhance synovial blood flow; promote strength of bone and cartilage Improve cardiovascular fitness and endurance Water supports or resists movement; warm water may provide muscle relaxation

Active or active/self-assisted at least daily Perform at 70% of maximal voluntary contraction daily

Reduce number of repetitions when inflammation is present Monitor blood pressure: isometric exercises may increase blood pressure and decrease blood flow to muscles

Start with repetitions against gravity and add progressive resistance; perform 2–3 d/wk

May increase biomechanical stress on unstable or misaligned joints

Perform 3–5 d/wk for 20–30 min of moderate intensity exercise Provides buoyant medium for performance of dynamic or aerobic exercise

Progress slowly as activity tolerance and fitness improve Heated swimming pool; deep water to minimize joint compression; nonslip footwear for safety and comfort; receive appropriate instruction in a program designed for people with arthritis

Dynamic exercise

Aerobic exercise Pool exercise

Adapted from Firestein, G. S., Panayi, G. S., & Willheim, F. A. (2006). Rheumatoid arthritis. Oxford, UK: Oxford University Press.

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Assessment and Management of Patients With Rheumatic Disorders

establishing a set time to sleep and a regular wake-up time, creating a quiet sleep environment with a comfortable room temperature, avoiding factors that interfere with sleep (e.g., use of alcohol and caffeine), using relaxation exercises, and getting out of bed and engaging in another activity (e.g., reading) if unable to sleep (Bulechek, Butcher, & Dochterman, 2008).

Nursing Management The plan of nursing care in Chart 55-2 details the nursing diagnoses, interventions, and expected outcomes for the patient older with a rheumatic disorder.

DIFFUSE CONNECTIVE TISSUE DISEASES Diffuse connective tissue disease refers to a group of systematic disorders that are chronic in nature and are 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 rheumatoid arthritis (RA), SLE, scleroderma, polymyositis, and polymyalgia rheumatica.

Rheumatoid Arthritis RA is an autoimmune disease of unknown origin that affects 1% of the population worldwide, with a female-tomale ratio between 2:1 and 4:1 (Khanna, Arnold, Pencharz, et al., 2006). In Canada, the incidence rate is approximately 1% of Canadian adults, with a female-to-male ratio of 2:1 (Health Canada, 2010).

Pathophysiology In RA, the autoimmune reaction (see Fig. 55-1) 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 fibres 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 symptoms. Palpation of the joints reveals spongy or boggy tissue. Often fluid can be aspirated from the inflamed joint. Characteristically, the pattern of joint involvement begins in the small joints of the hands, wrists, and feet

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(Stephen, Skillen, Day, et al., 2010). As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are affected. 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 in the morning. 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 by immobilizing them. Immobilization for extended periods can lead to contractures, creating soft tissue deformity. Deformities of the hands and feet are common in RA (see Chapter 67). The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when one 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 stress-induced vasospasm causing episodes of digital blanching or cyanosis). Rheumatoid nodules may be noted in patients with more advanced RA, and they develop at some time in the course of the disease in about 25% of patients. 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 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 about three fourths of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. The ESR is significantly elevated in RA. The red blood cell count and C4 complement component are decreased. C-reactive protein and antinuclear antibody (ANA) test results may also be positive (Karpoff & Labus, 2008) (Chart 55-3). Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. X-rays show bony erosions and narrowed joint spaces. X-rays of the hands and feet should be performed at baseline (text continued on page 1747)

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UNIT 11

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Immunologic Function

Plan of Nursing Care NURSING INTERVENTIONS

Chart 55-2. Care of the Patient With a Rheumatic Disorder

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, 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 unproven 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 nonpharmacologic 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.

• Identifies factors that exacerbate or influence pain response

• Identifies and uses pain management strategies

• Verbalizes decrease in pain • Reports signs and symptoms of side • • • •

5. Knowledge of rheumatic pain and appropriate treatment may help patient avoid unsafe, ineffective therapies. 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 pain is a more reliable indicator than objective measurements such as change in vital signs, body movement, and facial expression.

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 unproven self-treatment methods Identifies changes in quality or intensity of pain

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 activity 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. 2. Facilitate development of appropriate activity/rest schedule.

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. 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. 2. Alternating rest and activity conserves energy while allowing most productivity.

• 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

• • • • •

(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 well-paced, therapeutic activity schedule Adheres to therapeutic program Follows a planned conditioning program

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Plan of Nursing Care

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Chart 55-2. Care of the Patient With a Rheumatic Disorder, Continued

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

3. Encourage adherence to the treatment program. 4. Refer to and encourage a conditioning program.

3. Overall control of disease activity can decrease the amount of fatigue. 4. Deconditioning resulting from lack of mobility, understanding, and disease activity contributes to fatigue. 5. A nutritious diet can help counteract fatigue.

• Consumes a nutritious diet consisting

5. Encourage adequate nutrition, including source of iron from food and supplements.

of appropriate food groups and recommended daily allowance of vitamins and minerals

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 self-concept 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 self-care needs, incorporating joint protection, energy conservation, and work simplification concepts. a. Provide appropriate assistive devices. b. Reinforce correct and safe use of assistive devices.

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 selfcare 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 self-care needs

• Identifies and uses other health care

resources for meeting self-care needs

continued >

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Plan of Nursing Care

Chart 55-2. Care of the Patient With a Rheumatic Disorder, Continued

NURSING INTERVENTIONS

RATIONALE

c. Allow patient to control timing of self-care 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.

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.

EXPECTED 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 behaviours 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: Absence or resolution of complications 1. Perform periodic clinical assessment and laboratory evaluation. 2. Instruct in correct self-administration, potential 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 potential 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.

• 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

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NURSING RESEARCH PROFILE

Chart 55-3. Managing Symptoms in Rheumatoid Arthritis Sousa, K. H., Ryu, E., Kwok, O., et al. (2007). Development of a model to measure symptom status in persons living with rheumatoid arthritis. Nursing Research, 56(6), 434–440. Purpose Rheumatoid arthritis (RA) is a chronic, progressive, inflammatory disease of unknown etiology that causes disability as well as morbidity and mortality. RA has a constellation of symptoms (e.g., blurred vision, pain, dizziness) that affect quality of life. The purpose of this study was to develop and validate a structured model to measure symptom status in patients with RA. Design This study was a secondary analysis of symptom checklists available from 901 women enrolled in the Arthritis, Rheumatism, and Aging Medical Information System. The symptom checklists contained a list of 31 symptoms, and participants were asked to check off all symptoms they had

to help establish the diagnosis of RA and then every 3 years to monitor the progression of the disease (Khanna et al., 2006).

Medical Management Early Rheumatoid Arthritis Patients with RA should receive aggressive and early treatment (Khanna et al., 2006). Treatment includes education, a balance of rest and exercise, and referral to appropriate community agencies (such as the Arthritis Foundation) 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. Several cyclo-oxygenase 2 (COX-2) enzyme blockers, another class of NSAIDs, have been approved for treatment of RA. Cyclo-oxygenase is an enzyme that is involved in the inflammatory process. COX-2 medications block the enzyme involved in inflammation (COX-2) while leaving intact the enzyme involved in protecting the stomach lining (COX-1). As a result, COX-2 enzyme blockers are less likely to cause gastric irritation and ulceration than other NSAIDs; however, they are associated with increased risk of cardiovascular disease and must be used with caution (Karch, 2013). A window of opportunity for symptom control and improved disease management occurs within the first 2 years after disease onset. Therefore, it is recommended that treatment with the DMARDs (antimalarials, gold, penicillamine, or sulfasalazine) begin within 3 months of disease onset. If symptoms are aggressive (i.e., early bony erosions as seen on x-rays), methotrexate may be considered. Methotrexate (Rheumatrex) is currently the standard treatment of RA because of its success in preventing both joint destruction and long-term disability (Schmajuk, et al., 2007).

experienced in the previous 6 months. Factor analysis was used to develop the model to measure symptoms. Findings Results of the factor analysis supported a two-factor model for the measurement of symptom status. The factors were (1) RA pain symptoms and (2) general symptoms. The two factors were found to be significantly different from each other, and the RA pain symptoms factor had a stronger impact on functional health than general symptoms. Nursing Implications The first aspect of effective symptom management for patients with RA is nursing assessment. This study provides a model and validated structure for such an assessment. For example, the symptoms that form the RA pain cluster could serve as a baseline assessment for nurses to identify goals and interventions to help improve the functional health and quality of life of patients with RA.

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 (De Keyser, 2011). Research using tumour necrosis factor-alpha (TNF-a) inhibitors in combination with other medications have shown that patients demonstrate significant improvement. Examples of biologic response modifiers that are currently available are etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), and anakinra (Kineret). Etanercept, infliximab, adalimumab, and golimumab inhibit the function of TNF-α, a key cytokine known to play a role in the disease process in RA (Hannon et al., 2010), whereas anakinra inhibits the function of interleukin-1, another cytokine that contributes to the destruction of the joint. Research in this area is ongoing. Additional analgesia may be prescribed for periods of extreme pain. Opioid analgesic agents are avoided because of the potential for continuing need for pain relief. Nonpharmacologic pain management techniques (e.g., relaxation techniques, heat and cold applications) are taught.

Moderate, Erosive Rheumatoid Arthritis 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 musclestrengthening 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 (Neoral), an immunosuppressant, may be added to enhance the diseasemodifying effect of methotrexate.

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Persistent, Erosive Rheumatoid Arthritis

Nursing Management

For persistent, erosive RA, reconstructive surgery and corticosteroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures and the threat of loss of independence is eminent. Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing of 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 DMARDs (e.g., methotrexate) to begin taking effect. Low-dose corticosteroid therapy is prescribed for the shortest time necessary to minimize side effects (Khanna et al., 2006). Single large joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid.

Nursing care of the patient with RA follows the basic plan of care presented earlier (see Chart 55-2). The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility (Sousa, Ryu, Kwok, et al., 2007). The patient with newly diagnosed RA needs information about the disease to make daily self-management decisions and to cope with having a chronic disease.

Advanced, Unremitting Rheumatoid Arthritis For advanced, unremitting RA, immunosuppressive agents are prescribed because of their ability to affect the production of antibodies at the cellular level. These include highdose methotrexate (Rheumatrex), cyclophosphamide (Cytoxan), azathioprine (Imuran), and leflunomide (Arava). However, these medications are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances, and rashes. For most patients with 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. Health Canada has approved a medical device for use in treating patients with more severe and long-standing RA who have had no response to or are intolerant of DMARDs. The device, a protein A immunoadsorption column (Prosorba), is used in 12 weekly 2-hour apheresis treatments to bind immunoglobulin G (IgG) (e.g., circulating immune complex). In this unique population of patients, a significant improvement using the American College of Rheumatology criteria for improvement has been demonstrated (Eustice & Eustice, 2008). 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 patient who is extremely anorexic, small, frequent feedings with increased protein supplements may be prescribed. Supplemental vitamins and minerals may also be prescribed as needed (Klippel, Stone, Crofford, et al., 2008). Certain medications (i.e., 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 counselled about eating a healthy, calorie-restricted diet.

Monitoring and Managing Potential Complications Medications used for treating RA may cause serious and adverse effects. These medication-induced complications may include bone marrow suppression, anemia, gastrointestinal disturbances, and rashes. The primary health care provider bases the prescribed medication regimen on clinical findings and past medical history, and then with the help of the nurse, monitors for side effects using periodic clinical assessments and laboratory testing. The nurse, who can be available for consultation between physician visits, works to help the patient recognize and deal with these side effects (see Table 55-3). The medication may need to be stopped or the dose reduced. If the patient experiences an increase in symptoms while the complication is being resolved or a new medication is being initiated, the nurse’s counselling 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 RA 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 potential side effects of medications, strategies to maintain independence and function, and patient safety in the home (Chart 55-4). The patient and family are encouraged to verbalize their concerns and ask questions. Because RA 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. One alternative therapy, an expensive one, used by many patients with RA is elk antler velvet. The velvet from elk antlers is harvested, ground, and put into capsules. In one randomized clinical trial of 168 patients with early stages of RA, researchers found that elk velvet has no clinical efficacy in the symptom management of the disease (Allen, Oberle, Grace, et al., 2008). Pain, fatigue, and depression can interfere with the patient’s ability to learn and should be addressed before teaching is initiated. Various educational strategies may then be used, depending on the patient’s previous knowledge base, interest level, degree of comfort, social

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CHART 55-4

HOME CARE CHECKLIST •

The Patient With Rheumatoid Arthritis

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• Explain the nature of the disease and principles of disease management.

✔

✔

• Describe the medication regimen (name of medications, dosage, schedule of administration,

✔

✔

• 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.

✔

precautions, potential side effects, and desired effects).

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, potential side effects, selfadministration, 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 older or frail, has RA that limits function significantly, and lives alone may need referral for home care. The impact of RA on everyday life is not always evident when the patient is seen in the hospital or in 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 RA. During home visits, the nurse has the opportunity to assess the home environment and its adequacy for patient safety and management of the disorder. Adherence to 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, a patient who also has diabetes and requires insulin may be unable to fill the syringe accurately or unable to

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 adherence are identified, and appropriate referrals are 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 RA. Referrals to physical and occupational therapists may be made as problems are identified and limitations increase. A home care nurse may visit the home to make sure the patient can function as independently as possible despite mobility problems and can safely manage treatments, including pharmacotherapy. The patient and family should be informed about support services such as Meals on Wheels and local Arthritis Foundation chapters. Because many of the medications used to suppress inflammation are injectable, the nurse may administer the medication to the patient or teach self-injection. 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. Patients should know which type of rheumatic disease they have, not just that they have “arthritis” or “arthritis of the knee.” The importance of attending follow-up appointments is emphasized to the patient and family, and they should be reminded about the importance of participating in other health promotion activities and health screening. Patients with chronic disorders such as RA often focus on the chronic disease and neglect general health issues.

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Systemic Lupus Erythematosus The overall prevalence of SLE is estimated to be 1 per 1,000 Canadians. It occurs ten times more frequently in women than in men. SLE usually develops in individuals in either their 20s or 30s. SLE is more common in certain ethnic groups, particularly in blacks, Asians, Caucasians, and Aboriginal Canadians (Barnabe, Joseph, Belisle, et al., 2012; Pons-Estel, Alarcón, Scofield, et al., 2010; Wandstrat, Carr-Johnson, Branch, et al., 2006).

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 factors, hormonal factors (as evidenced by the usual onset during the childbearing years), and environmental factors (e.g., 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. Specifically, B cells and T cells both contribute to the immune response in SLE (Sang, Zheng, & Morel, 2013; Suen & Chiang, 2012). B cells are instrumental in promoting the onset and flares of the disease (Sang et al., 2013).

Clinical 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. The onset of disease may be insidious or acute. 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 (occurring in more than 50% of patients with SLE) is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks (Stephen et al., 2010) (Fig. 55-2). In some cases of discoid lupus erythematosus, only skin involvement occurs. In some patients with SLE, the initial skin involvement is 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, 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.

FIGURE 55-2. The characteristic butterfly rash of systemic lupus

erythematosus.

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 (see Chapter 32). 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 behaviour patterns or cognitive ability.

Assessment and Diagnostic Findings Diagnosis of SLE is based on a complete history, physical examination, and blood tests. Typically, assessment reveals classic symptoms, including fever, fatigue, weight loss, and possibly arthritis, pleurisy, and pericarditis. Interactions with the patient and family may provide further evidence of systemic involvement. 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.

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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. The neurologic assessment is directed at identifying and describing any central nervous system changes. The patient and family members are asked about any behavioural 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 ANAs (Wandstrat et al., 2006). Other diagnostic immunologic tests support but do not confirm the diagnosis.

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 can 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. 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. 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 (IV) 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. The NSAIDs used for minor clinical manifestations are often used along

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with corticosteroids in an effort to minimize corticosteroid requirements. Immunosuppressive agents (alkylating agents and purine analogues) are used because of their effect on immune function. These medications are generally reserved for patients who have serious forms of SLE that have not responded to conservative therapies. B-cell depleting therapies are the newest treatment for SLE. Monoclonal antibodies, rituximab (Rituxan), and epratuzumab (humanized anit-CD22 antibody) have shown good therapeutic results in clinical trials (Ding & Gordon, 2013).

Nursing Management Nursing care of the patient with SLE is based on the fundamental plan presented earlier in the chapter (see Chart 55-2). The most common nursing diagnoses 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 with sensitivity to the psychological reactions of the patient. The patient may benefit from participation in support groups, which can provide 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 of 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 of cardiovascular disease, including hypertension and atherosclerosis. The nurse instructs the patient about the importance of continuing prescribed medications and addresses the changes and potential side effects that are likely to occur with their use. The patient is reminded of the importance of monitoring because of the increased risk of systemic involvement, including renal and cardiovascular effects.

Scleroderma Scleroderma (“hard skin”) is a relatively rare disease that is poorly understood; the cause is unknown. The incidence of scleroderma (also known as systemic sclerosis) is 50 to 300 cases per million per year (Gabrielli, Avvedimento, & Krie, 2009). Like other diffuse connective tissue diseases, it has a variable course with remissions and exacerbations. Its prognosis is not as optimistic as that of SLE.

Pathophysiology Scleroderma commonly begins with skin involvement. Mononuclear cells cluster on the skin and stimulate lymphokines to stimulate procollagen. Insoluble collagen is

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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 et al., 2008).

Clinical Manifestations 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 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 dysfunction, sclerodactyly (scleroderma of the digits), and telangiectasia (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 colour 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 most patients with scleroderma. Blood tests may detect ANAs, indicating a connective tissue disorder and possibly distinguishing the subgroup (diffuse or limited) of scleroderma. A positive ANA test result is common in patients with scleroderma.

Medical Management Treatment of scleroderma depends on the clinical manifestations. All patients require counselling, during which real-

istic 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 (Siebold, 2005).

Nursing Management The nursing care of the patient with scleroderma is based on the fundamental plan of nursing care presented earlier (see Chart 55-2). The most common nursing diagnoses of the patient with scleroderma are impaired skin integrity; self-care deficits; imbalanced nutrition, less than body requirements; and disturbed body image. The patient with advanced disease may also have 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.

Polymyositis Polymyositis is a group of diseases that are termed idiopathic inflammatory myopathies (Klippel et al., 2008). They are rare conditions, with an incidence estimated at 5 to 10 cases per million adults per year.

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 ranges from sudden with rapid progression to very slow and insidious. 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.

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Assessment and Diagnostic Findings A complete history and physical examination help exclude other muscle-related disorders. As with other diffuse connective tissue disorders, no single 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. Plasmapheresis, lymphapheresis, and total-body irradiation have been used if there is no response to corticosteroids and immunosuppressive medications. The antimalarial agent hydroxychloroquine (Plaquenil) may be effective for skin rashes. Physical therapy is initiated slowly, with range-of-motion exercises to maintain joint mobility, followed by gradual strengthening exercises (Klippel et al., 2008).

Nursing Management Nursing care is based on the fundamental plan of nursing care presented earlier (see Chart 55-2). The most frequent nursing diagnoses for the patient with polymyositis are impaired physical mobility, fatigue, self-care deficit, and insufficient knowledge of self-management 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 the 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.

Polymyalgia Rheumatica Pathophysiology 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. Polymyalgia rheumatica and giant cell arteritis are found almost exclusively in people older than 50 years of age. Polymyalgia rheumatica has an annual incidence rate of 52 cases per 100,000 people older than 50 years. Giant cell arteritis varies by geographic location and has the highest incidence in Scandinavian countries (Klippel et al., 2008).

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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 usually occurs in people 50 years of age and older, it may be confused with, or dismissed 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 the condition is left untreated. Polymyalgia rheumatica and giant cell arteritis typically have a self-limited course, lasting several months to several years (Klippel et al., 2008).

Assessment and Diagnostic Findings 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 The treatment for patients with polymyalgia rheumatica (without giant cell arteritis) is moderate doses of corticosteroids (Klippel et al., 2008). NSAIDs are sometimes used for mild disease. The treatment for patients with giant cell arteritis is rapid initiation of and strict adherence to a regimen of corticosteroids. This is essential to avoid the complication of blindness. Aspirin is a useful adjunctive treatment that also helps reduce the risk of visual loss (Klippel et al., 2008).

Nursing Management Nursing care of the patient with polymyalgia rheumatica is based on the fundamental plan of nursing care presented earlier (see Chart 55-2). 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 and the physician’s prescription. Nursing implications are related to

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helping the patient prevent and monitor side effects of medications (e.g., infections, diabetes mellitus, gastrointestinal problems, and depression) and adjust to those side effects that cannot be prevented (e.g., increased appetite and altered body image).

!

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.

The loss of bone mass with corticosteroid use increases the risk of osteoporosis in this already at-risk population. Interventions to promote bone health, such as adequate dietary calcium and vitamin D, measurement of bone mineral density, weight-bearing exercise, smoking cessation, and reduction of alcohol consumption if indicated, should be emphasized.

DEGENERATIVE JOINT DISEASE (OSTEOARTHRITIS) Osteoarthritis (OA), also known as degenerative joint disease or osteoarthrosis (even though inflammation may be present), is the most common and most 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 older 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, because the ability of the articular cartilage to resist microfracture with repetitive low loads diminishes with age. OA often begins in the third decade of life and peaks between the fifth and sixth decades. OA affects more than 10% of Canadian adults (Health Canada, 2010). By the age of 40 years, 90% of the population have degenerative joint changes in their weight-bearing joints, even though clinical symptoms are usually absent. Prevalence of OA is between 50% and 80% in the older (Ganz, Chang, Roth, et al., 2006).

Pathophysiology OA may be thought of as the end result of many factors that, when combined, predispose the patient 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. Understanding of OA has been greatly expanded beyond what previously was thought of as simply “wear

and tear” related to aging. The basic degenerative process in the joint exemplified in OA is presented in Figure 55-3. 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. Risk factors for OA include increased age, obesity, previous joint damage, repetitive use (occupational or recreational), anatomic deformity, and genetic susceptibility. Being overweight or obese also increases symptoms associated with the disease (Klippel et al., 2008). Research has shown that a weight loss of 10% improves function by 28% in people with OA affecting the knee (Messier, Mihalko, Legault, et al., 2013).

Clinical Manifestations The primary clinical manifestations of OA are pain, stiffness, and functional impairment. The pain is caused by an inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes (bone spurs), trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm (Fig. 55-4). Stiffness, which is most commonly experienced in the morning or after awakening, usually lasts less than 30 minutes and decreases with movement. Functional impairment results from 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% of patients with changes seen on x-ray 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 the joint space. In addition, reactive changes occur at the joint margins and on the subchondral bone in the form of osteophytes 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

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Physiology/Pathophysiology Mechanical injury

Genetic and hormonal factors

Other

Previous joint damage

Chondrocyte response

Release of cytokines

Stimulation, production, and release of proteolytic enzymes, metalloproteases, collagenase

Resulting damage predisposes to further damage FIGURE 55-3. Pathophysiology of osteoarthritis.

undertaken early enough. These include weight reduction, prevention of injuries, perinatal screening for congenital hip disease, and ergonomic modifications. Conservative treatment measures include patient education, the use of heat, weight reduction, joint rest and avoidance of joint overuse, orthotic devices (e.g., splints,

braces) to support inflamed joints, isometric and postural exercises, and aerobic exercise. Other miscellaneous physical modalities, such as massage, yoga, pulsed electromagnetic fields, transcutaneous electrical nerve stimulation (TENS), and music therapy, have unproven value in the treatment of OA. Occupational and physical therapy can help the patient adopt self-management strategies. Patients with arthritis often use complementary and alternative therapies, many of which are not traditionally taught in medical schools and are not traditionally available in hospitals. These may include herbal and dietary supplements, other special diets, acupuncture, acupressure, wearing copper bracelets or magnets, and participation in T’ai chi. Research is under way to determine the effectiveness of many of these treatments (Macfarlane, Paudyal, Doherty, et al., 2012).

Pharmacologic Therapy FIGURE 55-4. Joint space narrowing and osteophytes (bone spurs) are

characteristic of degenerative changes in joints.

Pharmacologic management of OA is directed toward symptom management and pain control. Selection of medication is based on the patient’s needs, the stage of

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disease, and the risk of side effects. Medications are used in conjunction with nonpharmacologic strategies. 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 enzyme blockers. However, COX-2 enzyme blockers must be used with caution because of the associated risk of cardiovascular disease. Other medications that may be considered are the opioids and intra-articular corticosteroids. Topical analgesic agents such as capsaicin (Capsin, Zostrix) and methylsalicylate are also used (Klippel et al., 2008). Other therapeutic approaches include glucosamine and chondroitin. Although it has been suggested that these substances modify cartilage structure, studies have not shown them to be effective (Henrotin & Lambert, 2013). Viscosupplementation, the injection of gel-like substances (hyaluronates), into a joint (intra-articular) is thought to supplement the viscous properties of synovial fluid. Five hyaluronates are currently approved by the FDA for joint injection in OA (Eustice & Eustice, 2006).

Surgical Management In moderate to severe OA, when pain is severe or because of loss of function, surgical intervention may be used. The procedures most commonly used are osteotomy (to alter the distribution of weight within the joint) and arthroplasty. In arthroplasty, diseased joint components are replaced (see Chapter 68).

Nursing Management Nursing management of the patient with OA includes both pharmacologic and nonpharmacologic approaches. Nonpharmacologic interventions are used first and continued with pharmacologic agents. Pain management and optimal functional ability are major goals of nursing intervention. The patient’s understanding of the disease process and symptom pattern is critical to a plan of care. Because patients with OA usually are older, they may have other health problems. Commonly they are overweight, and they may have a sedentary lifestyle. Weight loss and exercise are important approaches to pain and disability improvement (Messier et al., 2013; Klippel et al., 2008). A referral for physical therapy or to an exercise program for people with similar problems can 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 plan to use an analgesic agent, if appropriate, before exercising. Adequate pain management is important for the success of an exercise program. Open discussion regarding the use of complementary and alternative therapies is important to maintain safe and effective practices for patients looking for a “cure.”

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 HLAB27 genetic marker is found.

Types of Spondyloarthropathies Ankylosing Spondylitis Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues. Occasionally, the large synovial joints, such as the hips, knees, or shoulders, may be involved. Ankylosing spondylitis is more prevalent in males than in females and is usually diagnosed in the second or third decade of life. The disease is more severe in males, and significant systemic involvement is likely. Back pain is the characteristic feature. As the disease progresses, ankylosis of the entire spine may occur, leading to respiratory compromise and complications.

Reactive Arthritis (Reiter’s Syndrome) The disease process involved in Reiter’s syndrome is called reactive because the arthritis occurs after an infection. It mostly 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 15% to 25%, 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 (Klippel et al., 2008).

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Medical Management

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NSAIDs and corticosteroids often produce marked improvement in back, skin, and joint symptoms. Sulfasalazine (Azulfidine) and methotrexate (Rheumatrex) may help with peripheral joint disease. Methotrexate is also used to control psoriasis. More recently, anti-TNF therapy is under investigation for treatment of the spondyloarthropathies (Klippel et al., 2008).

resulting in decreased excretion of uric acid, or a combination of both, occurs. Gout affects up to 3% of Canadian adults with a female-to-male ratio of 4:1 (Health Canada, 2010). The incidence of gout increases with age and body mass index (Stamp, Zhu, Dalbeth, et al., 2011). 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 caused by 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 (e.g., diuretics such as thiazides and furosemide), low-dose salicylates, or ethanol, can contribute to uric acid underexcretion.

Surgical Management

Pathophysiology

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 Management

Surgical management may include total joint replacement (see Chapter 68).

Nursing Management Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. Affected patients are primarily young men. Their major concerns are often related to prognosis and job modification, especially among those who perform physical work. Patients may also express concerns about leisure and recreational activities.

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 (human immunodeficiency virus [HIV] infection, acquired immunodeficiency syndrome [AIDS]), and some inherited disorders (hypermobility syndromes). However, the most common conditions are the crystal-induced 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 that results in hyperuricemia. Oversecretion of uric acid or a renal defect

Hyperuricemia (serum concentration greater than 7 mg/ dL [0.4 fmol/L]) can, but does not always, cause urate crystal deposition (Karpoff & Labus, 2008). However, as uric acid levels increase, the risk becomes greater. 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 IgG. IgG enhances crystal phagocytosis, thereby demonstrating immunologic activity (Klippel et al., 2008).

Clinical Manifestations 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. For people with hyperuricemia 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 joint (90% of patients)

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TABLE 55-5

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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 leukocyte infiltration, thus reducing inflammation; does not alter serum or urine levels of uric acid; used in acute and chronic management

probenecid (Benemid)

Uricosuric agent; inhibits renal reabsorption of urates and increases the urinary excretion of uric acid; prevents tophi formation Xanthine oxidase inhibitors; interrupt the breakdown of purines before uric acid is formed; inhibits xanthine oxidase because it blocks uric acid formation

Acute management: administer when attack begins; dosage increased until pain is relieved or diarrhea develops Chronic management: causes GI upset in most patients Be alert for nausea and rash

allopurinol (Zyloprim), febuxostat (Uloric)

(Hannon et al., 2010). The tarsal area, ankle, or knee may also be affected. Less commonly, the wrists, fingers, and elbows may be affected. Trauma, alcohol ingestion, dieting, medications, surgical stress, or illness may trigger the acute attack. 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. However, with time, attacks tend to occur more frequently, to involve more joints, and to 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, and 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 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 in the fluid. Colchicine (oral or parenteral), an NSAID such as indomethacin, or a corticosteroid is prescribed 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 (Benemid), correct hyperuricemia and dissolve deposited urate. When reduction of the serum urate level is indicated, uricosuric agents are the medications of choice. If the patient has, or is at risk for, renal insufficiency or renal calculi (kidney stones), allopurinol, a xanthine oxidase inhibitor, is recommended (Stamp, 2014). A new medication, febuxostat (Uloric), was approved by Health Canada in 2010 for the treatment of gout that does not respond to usual treatment. Corticosteroids may also be used in patients who have no response to other therapy. If the patient experiences several acute

Monitor for side effects, including bone marrow depression, vomiting, and abdominal pain

episodes or there is evidence of tophi formation, prophylactic treatment is considered. Specific treatment is based on the serum uric acid level, 24-hour urinary uric acid excretion, and renal function (Table 55-5).

Nursing Management Historically, gouty arthritis was thought to be a condition of royalty and the very rich, with the disease attributed to “high living.” This has not been shown to be entirely true. Although severe dietary restriction is not necessary, the nurse should encourage the patient 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 with prescribed medications is essential, along with avoidance of factors that increase pain and inflammation, such as trauma, stress, and alcohol. Between acute episodes, the patient feels well and may abandon preventive behaviours, which may result in an acute attack. Acute attacks are most effectively treated if therapy is begun early in the course.

FIBROMYALGIA Fibromyalgia is a chronic pain syndrome that involves chronic fatigue, generalized muscle aching, and stiffness. Approximately 3% of the Canadian population is affected by this syndrome. It is four to nine times more common in women than in men (Murphy et al., 2006). See Chapter 13.

Medical Management 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. In addition, selective serotonin reuptake inhibitors and anticonvulsants have been effective in preliminary reports (Klippel et al., 2008). Individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in affected patients.

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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 patients 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 help them make the changes that are necessary to improve their quality of life (Schaefer, 2005).

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: that caused by Neisseria gonorrhoeae and that caused by a nongonococcal bacterium. The most prevalent of the nongonococcal organisms include Staphylococcus aureus and the various 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 absent in older patients, in those with diabetes, and in those with suppressed immune systems. Diagnosis and treatment may be delayed by patients with preexisting 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 IV 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 IV antibiotic therapy, the nurse

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arranges for home care and instructs the patient and care providers in safe administration of the drug and changes that should be reported 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 tumours include lipoma, hemangioma, fibroma, and tumourlike lesions such as ganglion, bursitis, and synovial cyst. Malignant tumours include primary tumours, such as synovial and bone sarcomas, and secondary involvement as manifestations of joint invasion by leukemia, lymphoma, myeloma, or metastasis. Neoplasms may manifest as back or neck pain. Neurovascular disorders include the compression syndromes, such as those with peripheral entrapment (e.g., carpal tunnel syndrome), radiculopathy, and spinal stenosis. Raynaud’s phenomenon 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 that affect 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 labelled miscellaneous disorders because it contains a mix of disorders that are frequently associated with arthritis and other conditions. These include the direct consequences 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.

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Critical Thinking Exercises 1 Your patient with a rheumatic disorder has NSAIDs, corticosteroids, and a biologic response modifier prescribed. How do the actions, uses, and indications of these medications differ? What instructions and recommendations would you give to the patient to ensure their safe administration? 2

A 30-year-old woman with a recent diagnosis of RA states she is having joint pain, stiffness, and swelling, especially in her hands and wrists. What resources would you use to identify the current guidelines for treatment of patients with RA? What is the evidence base for these treatment practices? Identify the criteria used to evaluate the strength of the evidence for these practices.

3 A 79-year-old woman with a 10-year history of OA of the right knee complains of pain every day and difficulty walking. She is taking multiple medications and currently she uses a walker to ambulate but needs to stop and rest every so often because of the pain. Describe the pharmacologic treatment and nursing measures that are indicated for this patient. What teaching is important for the patient? How would you modify your teaching if the patient understands little English?

REFERENCES *Asterisks indicate nursing research articles. **Double asterisk indicates classic reference.

BOOKS Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby. Firestein, G. S., Panayi, G. S., & Willheim, F. A. (2006). Rheumatoid arthritis. Oxford, UK: Oxford University Press. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Karch, A. (2013). 2014 Lippincott’s nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins. Karpoff, S., & Labus, D. M. (2008). Portable diagnostic tests. Philadelphia, PA: Lippincott Williams & Wilkins. Klippel, J. H., Stone, J. H., Crofford, L. J., et al. (2008). Primer on the rheumatic diseases (13th ed.). New York, NY: Springer. Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). St. Louis, MO: WB Saunders. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Health Canada. (2010a). Summary Basis of Decision (SBD) for ULORIC. Ottawa, ON: Author. Retrieved from http://www.hc-sc.gc.ca/dhp-mps/ prodpharma/sbd-smd/drug-med/sbd_smd_2010_uloric_129969-eng. php. Stamp, L. K. (2014). Safety profile of anti-gout agents: An update. Curr Opin Rheumatol, 26(2), 162–168. Stamp, L. K., Zhu, X., Dalbeth, N., et al. (2011). Serum urate as a soluble biomarker in chronic gout—evidence that serum urate fulfills the OMERACT validation criteria for soluble biomarkers. Seminars in Arthritis and Rheumatism, 40(6), 483–500.

Rheumatoid Arthritis *Allen, M., Oberle, K., Grace, M., et al. (2008). A randomized clinical trial of elk velvet antler in rheumatoid arthritis. Biological Research for Nursing, 9 (3), 254–261. Beasley, J. (2012). Osteoarthritis and rheumatoid arthritis: Conservative therapeutic management. Journal of Hand Therapy, 25(2), 163–172. De Keyser, F. (2011). Choice of biologic therapy for patients with rheumatoid arthritis: The infection perspective. Current Rheumatology Reviews, 7(1), 77. Eustice, C., & Eustice, R. (2008). Which rheumatoid arthritis patients are good candidates for the Prosorba column? Available at: http://arthritis. about.com/od/arthqa/f/prosorba.htm Health Canada. (2010b). Life with Arthritis in Canada : A personal and public health challenge. Ottawa, ON: Author. Retrieved from http://www. phac-aspc.gc.ca/cd-mc/arthritis-arthrite/lwaic-vaaac-10/3-eng.php. Khanna, D., Arnold, E. L., Pencharz, J. N., et al. (2006). Measuring process of arthritis care: The arthritis foundation’s quality indicator set for rheumatoid arthritis. Seminars in Arthritis and Rheumatism, 35(4), 211–237. Macfarlane, G. J., Paudyal, P., Doherty, M., et al. (2012). A systematic review of evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases: Osteoarthritis. Rheumatology, 51(12), 2224–2233. Soubrier, M., Mathieu, S., Payet, S., et al. (2010). Older-onset rheumatoid arthritis. Joint Bone Spine, 77(4), 290–296. *Sousa, K. H., Ryu, E., Kwok, O., et al. (2007). Development of a model to measure symptom status in persons living with rheumatoid arthritis. Nursing Research, 56(6), 434–440. Taylor-Gjevre, R. M., Gjevre, J. A., Nair, B., et al. (2011). Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis. Musculoskeletal Care, 9 (3), 152–159. Vlieland, T. P. V., & Van den Ende, C. H. (2011). Nonpharmacological treatment of rheumatoid arthritis. Current Opinion in Rheumatology, 23(3), 259–264. Osteoarthritis Eustice, C., & Eustice, G. (2006). What is viscosupplementation? Available at: http://arthritis.about.com/od/kneetreatments/g/viscosupplement. htm Ganz, D. A., Chang, J., Roth, C. P., et al. (2006). Quality of osteoarthritis care for community-dwelling older adults. Arthritis and Rheumatism, 55(2), 241–247. Henrotin, Y., & Lambert, C. (2013). Chondroitin and Glucosamine in the Management of Osteoarthritis: An Update. Current Rheumatology Reports, 15(10), 1–9. Messier, S. P., Mihalko, S. L., Legault, C., et al. (2013). Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. Journal of the American Medical Association, 310(12), 1263–1273. Systemic Lupus Erythematosus Barnabe, C., Joseph, L., Belisle, P., et al. (2012). Prevalence of systemic lupus erythematosus and systemic sclerosis in the First Nations population of Alberta, Canada. Arthritis Care and Research, 64(1), 138–143. Ding, H. J., & Gordon, C. (2013). New biologic therapy for systemic lupus erythematosus. Current Opinion in Pharmacology, 13(3), 405– 412. Pons-Estel, G. J., Alarcón, G. S., Scofield, L., et al. (2010). Understanding the epidemiology and progression of systemic lupus erythematosus. Seminars in Arthritis and Rheumatism, 39(4), 257–268. Sang, A., Zheng, Y. Y., & Morel, L. (2013). Contributions of B cells to lupus pathogenesis. Molecular immunology. Suen, J., & Chiang, B. (2012). CD4 (+) FoxP3 (+) regulatory T-cells in human systemic lupus erythematosus. Journal of the Formosan Medical Association, 11(9), 465–470. Wandstrat, A. E., Carr-Johnson, F., Branch, V., et al. (2006). Autoantibody profiling to identify individuals at risk for systemic lupus erythematosus. Journal of Autoimmunity, 27(1), 153–160. Other Rheumatic Diseases Gabrielli, A., Avvedimento, E. V., & Krie, G. T., (2009). Scleroderma. New England Journal of Medicine, 360(19), 1989–2003. *Schaefer, K. M. (2005). The lived experience of fibromyalgia in African American women. Holistic Nursing Practice, 19 (1), 17–25.

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**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 and Rheumatism, 33(2), 160–172.

RESOURCES American College of Rheumatology and Association of Rheumatology Health Professionals: www.rheumatology.org

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American Fibromyalgia Syndrome Association, Inc.: www.afsafund.org Arthritis Society (National Office): http://www.arthritis.ca. Canadian Arthritis Network/Le réseau Canadien de l’arthrite: http:// www.arthritisnetwork.ca. Canadian Spondylitis Association: http://www.spondylitis.ca/en/. Lupus Canada: http://www.lupuscanada.org. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health: www.niams.nih.gov Scleroderma Society of Canada: http://www.scleroderma.ca. Sjögren’s Society of Canada:http://www.sjogrenscanada.org. Spondylitis Association of America: www.spondylitis.org

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12

Integumentary Function

Case Study Applying Concepts From NANDA, NIC, and NOC A Patient With a Thermal Injury Mr. Arneson is an 82-yearold man who lives with his wife at an assisted living residence. He filled a basin with hot water to soak his feet and immersed his left foot in the basin before checking the water temperature. He sustained a deep partial thickness burn on his foot and ankle and has been admitted to the residence’s skilled nursing unit. The nurse documents that the skin of his left foot is bright red with three 2- to 4-cm bullae on the dorsum, and that Mr Arneson cannot bear weight on his foot. He reports the burn to be “quite painful.” His wife admits to being concerned because he is not eating his meals.

A patient with a thermal injury receives the nursing diagnoses Impaired Skin Integrity

requires

requires nursing interventions Skin Care: Topical Treatments and

requires

outcomes should show improvement in enhances

enhances

Wound Care

and

Acute Pain

and

requires

increase

Risk for Infection

and Risk for Imbalanced Nutrition: Less Than Body Requirements

Wound Healing Second Intention

and may require

may improve

Pain Management

improves

and

may be decreased by may benefit from

requires

Infection Protection

and Nutrition Management

Pain Control

and leads to reduced risk or improved leads to reduced risk or improved improves

Infection Severity

and Nutritional Status

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

Impaired Skin Integrity—Altered epidermis and/or dermis

NIC Nursing Interventions

Skin Care: Topical Treatments— Application of topical substances or manipulation of devices to promote skin integrity and minimize skin breakdown

NOC Nursing Outcomes

Return to functional baseline status, stabilization of, or improvement in: Wound Healing Secondary Intention—Extent of regeneration of cells and tissues in an open wound

Wound Care—Prevention of wound complications and promotion of wound healing Acute Pain—Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of 70 years, Health Canada (2012) recommends 800 IU of vitamin D per day, and 600 IU daily for women who are pregnant or lactating. The Canadian Cancer Society recommends that adult Canadians take 1,000 IU of vitamin D3 daily (2014). An upper limit of vitamin D3 allows room for obtaining vitamin D from food sources such as milk, multivitamins, and the sun but varies between 2,000 and 4,000 IU, depending on the authoritative source (Canadian Cancer Society, 2012; Health Canada, 2014; Institute of Medicine, 2011).

Immune Response Function Recent research has confirmed a definite action of Langerhans cells (specialized cells in the skin) in facilitating the uptake of immunoglobulin E (IgE)-associated allergens. This action plays a pivotal role in the pathogenesis of atopic dermatitis and other allergic diseases such as asthma and allergic rhinitis. These findings support the

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concept of a systemic regulatory mechanism as a trigger for allergic diseases and suggest that this trigger can be aggravated by local inflammation of atopic eczema (Simandl, 2010). Langerhans cells in atopic dermatitis are different from those in healthy individuals (Polasik, Placek, & Romanska-Gocka, 2010).

Gerontologic Considerations The skin undergoes many physiologic changes associated with aging. A lifetime of excessive sun exposure, systemic diseases, and inadequate nutrition can increase the range of skin conditions and the rapidity with which they appear. In addition, certain medications (e.g., antihistamines, antibiotics, diuretics, antidepressants, antipsychotics, and antidiabetic preparations) are photosensitizing and increase the damage that results from sun exposure (Canadian Dermatology Association, 2014a). An increasing vulnerability to injury and certain diseases is the outcome. Skin conditions are common among older adults (Stephen, 2012), but signs of older adult abuse need to be differentiated (e.g., welts on palms or soles, knuckle-shaped bruises, multiple scars) (Yaffe & Tazkarji, 2012). Significant changes occur with aging. Major changes in the skin of older adults 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 which results in fewer anchoring sites between the two skin layers; even minor injury or stress to the epidermis can cause it to shear away from the dermis, a phenomenon that may account for the increased vulnerability of aged skin to trauma. With increasing age, the epidermis and dermis thin and flatten, causing wrinkles, sagging, and overlapping skin folds (Fig. 56-2) (Martini et al., 2012). 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 dermal layers thin, skin becomes fragile and transparent. The blood supply to the skin also changes with age. Vessels,

CHART 56-1

Benign Changes in Skin of Older Adults • Cherry angiomas (bright red “moles”) • Diminished hair, especially on scalp and pubic area • Dyschromias (colour variations)

• • • • • • •

Solar lentigo (liver spots) Melasma (dark discoloration of the skin) Lentigines (freckles) Neurodermatitis (itchy spots) Seborrheic keratoses (crusty brown “stuck-on” greasy patches) Spider angiomas Telangiectasias (spidery or linear red marks on skin caused by stretching of the superficial blood vessels) Wrinkles Xerosis (dryness) Xanthelasma (yellowish waxy deposits on upper and lower eyelids)

especially the capillary loops, decrease in number and size. These vascular changes contribute to delayed wound healing, commonly seen in older adults. 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 (Anderson, Hunter, & Bickley, 2010). 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 by aging include the barrier function of skin, sensory perception, and thermoregulation (Anderson et al., 2010). Photoaging (damage from excessive sun exposure), has detrimental effects on the aging of skin. A lifetime of outdoor work or outdoor activities (e.g., construction work, lifeguarding, sunbathing, sports) without prudent use of sunscreens can lead to profound wrinkling; increased loss of elasticity; mottled, pigmented areas; cutaneous atrophy; and benign or malignant lesions (Canadian Dermatology Association, 2014b; Skillen, 2012). Many skin lesions are part of aging. Recognizing these lesions enables the patient to feel less anxious about skin changes. Chart 56-1 summarizes some skin lesions that are expected to appear as the skin ages and which require no special attention unless the skin becomes infected or irritated.

ASSESSMENT OF THE INTEGUMENT Health History

FIGURE 56-2. Hands with wrinkling and overlapping folds common to

aging skin.

Initiate the health history interview by collecting identifying data and acquiring a general impression of the overall health of the patient. Inquire about any family and personal history of medications, or chemicals; previous skin disorders, skin cancer, skin allergies, and allergic reactions to food. Ongoing research is considering the success of developing tolerance from infancy based on the timing of

CHAPTER 56

introducing solid food (Abrams & Becker, 2013). Obtain the names of cosmetics, soaps, shampoos, and other personal hygiene products if there have been any recent skin conditions noticed with the use of these products. Perform a symptom/sign analysis of the patient’s presenting integumentary concern. Determine the location and spread of the condition, the nature of any discomfort (e.g., pain, itching), the intensity or severity of discomfort, and the onset, frequency, and timing. Ask about aggravating and alleviating factors as well as associated symptoms. Determine if environmental factors are involved and explore the significance of the condition for the patient. Finally, ask what the patient thinks is the cause. Chart 56-2 lists selected questions useful in obtaining appropriate information.

Physical Examination Assessment of the integument involves the entire skin area, mucous membranes, scalp, hair, and nails. The skin reflects an individual’s overall health, and alterations commonly correspond to disease in other organ systems. Use inspection and palpation to examine the integument. Find CHART 56-2

Assessing for Skin Disorders Patient history relevant to skin disorders may be obtained by asking the following questions: What site was first affected? Where and how fast did it spread? What did the rash or lesion look like when it first appeared? Do you have any itching? Burning? Tingling? Crawling sensations? Have you lost any sensation? How severe are the sensations that you feel? When did you first notice the rash or lesion? Was it a particular time or season? How long did it last when it first appeared? How often do you notice it? What makes it worse? What makes it better? What topical medication/cream/salve have you put on the lesion? What other symptoms have you noticed when you have the rash or lesion? Was it related to recently consuming alcohol? Eating certain foods? What medications are you taking? Do you have a history of hay fever? Asthma? Hives? Eczema? Allergies? Who in your family has skin conditions or rashes? Does anything touching the skin cause a rash? What skin products do you use? What is your occupation? What in your immediate environment (plants, animals, chemicals, infections) might have an association with your disorder? Has anything changed in your environment? Are you experiencing increased stress at this time? How has this rash or skin lesion affected your daily life? What do you think is the cause of your skin lesion or rash? Is there anything else you would like to tell me?

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Assessment of Integumentary Function

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a well-lit and warm environment. Take advantage of a penlight to study lesions. Instruct the patient to disrobe and ensure adequate draping. If you anticipate palpating a rash or skin lesions, wear disposable gloves when initiating the examination. Explain that this is routine practice; 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.

Inspection and Palpation Inspect and palpate the skin, hair, and nails. Pay attention to colour and vascularity; palpate for temperature, mobility, turgor, moisture, texture, and edema. Inspect and palpate the condition of the hair and nails. Use gloves for inspecting the hair, not only to be protected if lice or mites are discovered, but also to avoid contact with skin lesions. Lice are the most common parasitic infestation in children and lice resistance to topical treatment is increasingly common (Smith & Goldman, 2012). Focus on the colour, distribution, and configuration (pattern) of any skin lesions. Skin colour varies from person to person, ranging 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 absent or diminished skin colour and vascularity, and is best observed in the conjunctivae, around the mouth, on the hard palate, or the ear lobes. 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. 56-3).

Erythema Erythema is redness of the skin caused by the congestion of capillaries. In light-skinned people, it is easily observed wherever it appears. Always inspect for colour changes before palpating, otherwise changes may be missed. To determine possible inflammation, palpate the skin for increased warmth, edema, or hardness (intracellular infiltration). Because dark skin tends to assume a purple-grey cast when an inflammatory process is present, it may be difficult to detect erythema; inspect the palms and soles in a dark-skinned individual.

FIGURE 56-3. Examples of skin colour changes: the bluish tint of cya-

nosis (left) and the yellow hue of jaundice (right).

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GENETICS IN NURSING PRACTICE

Chart 56-3. 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 integumentary impairment or alterations. • Inquire about the nature and type of skin lesions and age at onset (e.g., 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 (e.g., 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 Examination

• Assess for related clinical features, such as sparse eye-

brows and eyelashes, unusually shaped teeth, alopecia, nail changes (e.g., hypohidrotic ectodermal dysplasia). • Assess for related alterations in vision, such as nystagmus, strabismus; albinism; retinal changes (e.g., pseudoxanthoma elasticum); Lisch nodules and/or optic glioma (neurofibromatosis type 1). 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 counselling and evaluation so that family members can discuss heredity, risk to other family members, availability of genetic testing, and gene-based interventions.

Rash When the patient reports itching (pruritus), ask the patient to indicate which areas of the body are involved. Stretch the skin gently to decrease the reddish tone and make the rash more visible. Pointing a penlight laterally across the skin may highlight the rash, making it easier to observe. Palpate for differences in skin texture by running the tips of the fingers lightly over the skin. The borders of a rash may be palpable. Include the patient’s mouth and ears in the examination. (Sometimes, rubeola [measles] causes a red cast to appear on the tip of the ears.) Measure the patient’s temperature and palpate the lymph nodes.

Cyanosis Cyanosis is the bluish discoloration that results from a lack of oxygen in the blood. It appears with shock, or with

• Offer appropriate genetic information and resources. • Assess patient’s understanding of genetic 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.

GENETIC RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEB Canadian Association of Genetic Counsellors (CAGC), http://www.cagc-accg.ca—A Listing of genetic centres across Canada Canadian Cancer Society, http://www.cancer.ca—Information on the genetic factors/risks and genetic testing Canadian Directory of Genetic Support Groups, http:// www.lhsc.on.ca/programs/medgenet—Resource guide for families and professionals Canadian Genetic Diseases Network, http://www.cgdn.ca— Its stated mission is to be the primary catalyst in advancing Canada’s scientific and commercial competitiveness in genetic research and the application of genetic discoveries to the prevention, diagnosis, and treatment of human disease Canadian Organization for Rare Disorders (CORD), http:// www.cord.ca—Information on over 6,000 rare disorders and links individuals/families together with the same rare disorder GeneTests, http://www.genetests.org—Publicly funded medical genetic information resource developed for physicians, other health care providers, and researchers Genetic Alliance, http://www.geneticalliance.org—Increases the capacity of genetic advocacy groups to achieve their missions and leverages the voices of millions of individuals and families living with genetic conditions Genetics Society of Canada (GSC), http://life.biology. mcmaster.ca/GSC/—Promotes research and communicates the results and implications of genetics to the public OMIM Online Mendelian Inheritance in Man, http://www. ncbi.nlm.nih.gov/entrez/query.fcgi?db= OMIM— Catalogue of human genes and genetic disorders

respiratory or circulatory compromise. In people with light skin, cyanosis manifests as a bluish hue to the lips, fingertips, and nail beds (Fig. 56-3). Other indications of decreased tissue perfusion include cold, clammy skin; a rapid, thready pulse; and rapid, shallow respirations. Examine the conjunctivae of the eyelids for pallor and petechiae (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 greyish cast. To detect cyanosis, observe the areas around the mouth, lips, hard palate, over the cheekbones, palms, soles, and earlobes.

Colour Changes Almost every process that occurs in the skin causes some colour change. For example, hypopigmentation (decrease in the melanin of the skin, resulting in a loss

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of pigmentation) may be caused by a fungal infection, eczema, or vitiligo (a condition characterized by nonfunctional melanocytes in circumscribed areas of the skin, resulting in white patches) (Martini et al., 2012). Hyperpigmentation (increase in the melanin of the skin, resulting in increased pigmentation) may occur as a result of aging, disease or injury to the skin (postinflammatory), or sun injury. Changes in skin colour in individuals 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 expected. 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 colour are genetically determined.

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Assessment of Integumentary Function

A

B

C

D

E

F

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Assessing Patients With Dark Skin Colour gradations that occur in dark skin are largely determined by genetics; they may be described as light, medium, or dark. In individuals 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. Inspect for it. The buccal mucosa, tongue, lips, and nails are pink. The degree of pigmentation of the patient’s skin may affect the appearance of a lesion. Lesions may be black, purple, or grey 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 or a year. 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 56-2 provides an overview of colour changes in light-skinned 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. Not as apparent is the psychological and emotional impact of such conditions (e.g., psoriasis) (Aldeen & Basra, 2011). Skin lesions vary in size, shape, and cause and are classified according to their appearance and origin. These lesions are 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 56-4). A preliminary assessment of the eruption or lesion helps to identify the type of dermatosis and detect whether the lesion is primary or secondary. Observe the anatomic distribution of the eruption because certain diseases affect known sites of the body and are distributed in characteristic patterns and shapes (Figs. 56-4 and 56-5). To deter-

FIGURE 56-4. 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).

mine the extent of the regional distribution, compare the left and right sides of the body while assessing the colour and shape (configuration) of the lesions. After inspection, palpate the lesions to determine their texture, shape, and border, and to detect if they are soft, filled with fluid, or hard and fixed to the surrounding tissue. Use a metric ruler to measure the size of the lesions for future comparisons. Document the dermatosis on the patient’s health record; describe the distribution, configuration, and type clearly, using precise terminology. Determine the characteristic distribution of the lesions (e.g., bilateral, symmetric, truncal, extremities), and obtain the remaining details: • Type of lesion (primary or secondary) (e.g., macule, papule, pustule, vesicle, bulla) • Colour of lesion • Any associated redness, heat, pain, or swelling • Size and location of involved area • Configuration (pattern) of eruption (e.g., discrete, confluent, linear, dermatomal, annular) Perform a comprehensive assessment if acute open wounds or lesions are found on inspection of the skin.

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TABLE 56-2

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Colour Changes in Light and Dark Skin

Etiology Pallor Anemia—decreased hematocrit Shock—decreased perfusion, vasoconstriction 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

Light Skin

Dark Skin

Generalized pallor

Brown skin appears yellow-brown, dull; black skin appears ashen grey, dull. (Observe areas with least pigmentation: conjunctivae, mucous membranes, palms, soles.) Ashen grey, dull; cool to palpation

Marked localized pallor (lower extremities, especially when elevated) Whitish pink

Tan, cream, white

Patchy, milky white spots, often symmetric bilaterally

Patchy, milky white spots

Dusky blue

Dark but dull, lifeless; only severe cyanosis is apparent in skin. (Observe conjunctivae, oral mucosa, nail beds, hard palate.)

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 grey 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

Document the description in the patient’s record. Documentation includes the following characteristics: • Wound bed: Inspect for necrotic and granulation tissue, epithelium, exudate, colour, and odour. • Wound edges and margins: Observe for undermining (extension of the wound under the surface skin), and evaluate for condition. • Wound size: Measure in millimetres or centimetres, as appropriate, to determine diameter and depth of the wound and surrounding erythema. • Surrounding skin: Assess for colour, suppleness and moisture, irritation, and scaling.

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 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.)

Both patients and health care professionals use the ABCDE method for screening moles for possible melanoma (Canadian Dermatology Association, 2014b; Stephen, 2012). The ABCDE method is widely used in Canadian family practice, but Herschorn (2012) suggests that using dermoscopy with a handheld light magnifier increases the accuracy of diagnosis, reduces unnecessary referrals, and limits the biopsy rates for benign lesions. The letters ABCDE stand for the following: • A for asymmetry; one half is not like the other half • B for borders; look for irregular edges, ragged, notched, and not well-defined borders

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CHART 56-4

Primary and Secondary Skin Lesions Primary Skin Lesions Primary skin lesions are original lesions arising from previously healthy skin. MACULE, PATCH

VESICLE, BULLA

Vesicle

Macule

Bulla

Patch

Circumscribed, elevated, palpable mass containing serous fluid

Flat, nonpalpable skin colour change (colour may be brown, white, tan, purple, red) • Macule:

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CHART 56-4 Primary

and Secondary Skin Lesions, continued

Secondary Skin Lesions Secondary skin lesions result from changes in primary lesions and are the progression of the primary disease to a different appearance. EROSION

SCAR (CICATRIX)

Scar

Erosion

• Skin mark left after healing of a wound or lesion • Represents replacement by connective tissue of the injured

• Loss of superficial epidermis • Does not extend to dermis • Depressed, moist area

tissue

• Young scars: red or purple • Mature scars: white or glistening

Examples: Ruptured vesicles, scratch marks

Examples: Healed wound or surgical incision

ULCER

KELOID

Ulcer

• Skin loss extending past epidermis • Necrotic tissue loss • Bleeding and scarring possible

Keloid

• • • •

Hypertrophied scar tissue Secondary to excessive collagen formation during healing Elevated, irregular, red Greater incidence among black Canadians Example: Keloid of ear piercing or surgical incision

Examples: Stasis ulcer of venous insufficiency, pressure ulcer FISSURE • Linear crack in the skin • May extend to dermis Examples: Chapped lips or hands, athlete’s foot

ATROPHY Fissure

SCALES

Atrophy

Scales

• • • •

Flakes secondary to desquamated, dead epithelium Flakes may adhere to skin surface Colour varies (silvery, white) Texture varies (thick, fine) Examples: Dandruff, psoriasis, dry skin, pityriasis rosea

• • • •

Thin, dry, transparent appearance of epidermis Loss of surface markings Secondary to loss of collagen and elastin Underlying vessels may be visible Examples: Aged skin, arterial insufficiency LICHENIFICATION

CRUST

Lichenification 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

• Thickening and roughening of the skin • Accentuated skin markings • May be secondary to repeated rubbing, irritation,

scratching Example: Contact dermatitis

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Primary and Secondary Skin Lesions, continued Vascular Skin Lesions SPIDER ANGIOMA

PETECHIA (PL. PETECHIAE)

Petechiae

• • • •

Spider angioma

Round red or purple macule Small: 1–2 mm Secondary to blood extravasation Associated with bleeding tendencies or emboli to skin

ECCHYMOSIS (PL. ECCHYMOSES)

• • • • • •

Red, arteriole lesion Central body with radiating branches 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)

Ecchymoses

• • • • •

Round or irregular macular lesion Larger than petechia Colour 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 • Common age-related skin alteration • Usually not clinically significant

Telangiectasia

• • • • •

Shape varies: spiderlike or linear Colour bluish or red 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

• C for colour; look for variation or change in colour with tan, brown, black, red, blue, grey, or white areas. • D for diameter; look for growth in size of the lesion larger than a pencil eraser (6 mm) • E for evolution; look for change in size, shape, symptoms (itchiness, tenderness), surface elevation, bleeding, or colour.

Assessing Vascularity and Hydration After evaluating the colour of the skin and inspecting skin lesions, assess any vascular alterations in the skin. Include in your description the location, distribution, colour, size, and presence of pulsations. Common vascular changes include petechiae, ecchymoses, telangiectases (spidery or linear red marks on the skin caused by stretching of the superficial blood vessels), angiomas, and venous stars. Assess skin moisture, temperature, and texture primarily by palpation. Skin turgor indicates the hydration status of a patient, but may also be reduced in older adults and not to be confused with dehydration. Create a fold of skin and release it quickly. Observe for mobile skin that returns to the original position quickly.

Assessing the Nails and Hair Many alterations in the nail or nail bed reflect local or systemic alterations in progress or resulting from past events (Fig. 56-6). 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 local trauma. Paronychia, an inflammation of the skin around the nail, is usually accompanied by tenderness and erythema. The angle between the healthy nail and its base is 160 degrees. When palpated, the nail base is usually firm. Clubbing of the nails is manifested by a straightening of the angle (180 degrees or greater) and softening of the nail base. The softened area feels spongelike when palpated. Pitting of the nail may be the first indication that the individual will present with psoriasis in due course. Inspect and palpate the hair. Wear disposable gloves as lesions on the scalp may not be initially visible. Ensure that the examination room is well-lit. Separate the hair so that you can inspect the condition of the scalp easily seen. Assess the colour, texture, moisture, and distribution of the hair. Inspect for any lesions, evidence of itching,

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B

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the third decade of life when the loss of melanin begins to become apparent. It is not unusual for the hair of younger people to turn grey as a result of hereditary traits. Individuals with albinism (partial or complete absence of pigmentation) have 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. Establish what types of products are used during the assessment. The texture of scalp hair ranges from fine to coarse, silky to brittle, oily to dry, and shiny to dull; hair can be straight, curly, wavy, or kinky. Dry, brittle hair may result from overuse of hair dyes, hair dryers, and curling irons, or from endocrine disorders, 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, explore the underlying reason; the alteration may arise simply from the overuse of commercial hair products or from changing to a new shampoo.

C

Distribution

D

E

F

FIGURE 56-5. Skin lesion configurations. (A) Linear (in a line). (B) Annu-

lar 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. (2007). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

inflammation, scaling, or signs of infestation (e.g., lice or mites) and document findings.

Colour and Texture Natural hair colour ranges from white to black. Hair colour begins to grey with age, initially appearing during

Beau's lines 180°

Spoon nails >180°

Body hair distribution varies with location. Hair over most of the body is fine (vellus hair), 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 a pattern found is more characteristic of the opposite gender, it may indicate an endocrine disorder that requires further investigation. Expect genetic differences in hair, 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 (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 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 (e.g., braiding too tightly); excessive use of dyes, straighteners, and oils; chemotherapeutic agents (e.g., 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

Early clubbing

Late clubbing

Pitting

Paronychia

FIGURE 56-6. Common nail disorders. From Weber, J. W., & Kelley, J.

(2007). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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 56-7 illustrates the progression of typical male pattern baldness. Though androgenic alopecia is considered a male disorder, millions of women also experience it. Women tend to retain some of the hair on the crown of the scalp and never go completely bald.

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FIGURE 56-7. The progression of male pattern baldness.

Other Changes

Diabetic Dermopathy

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. For some, it is a taboo subject (e.g., having to shave). Sensitive questioning about how it affects daily life and relationships may provide nursing opportunities to support and advise (Onselen, 2011). When menopause is ruled out as the underlying cause, hormonal disorders related to pituitary or adrenal dysfunction are 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, selfconsciousness, 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. Provide understanding, explanations of the condition, and appropriate instructions related to treatment to patients suffering such physical and psychological discomforts. They benefit from nursing support, patience, and encouragement. It takes time to help patients gain insight into their challenges and resolve their difficulties. It is imperative to overcome any aversion that you may feel when caring for patients with unattractive skin disorders. Avoid demonstrating any hesitancy when approaching such patients as hesitancy only reinforces the psychological trauma of the disorder.

Diabetic dermopathy (shin spots) occurs in about 50% of patients with diabetes. These lesions are found on the lower anterior legs, forearms, thighs, and other bony prominences. Caused by breakdown of the small vessels that supply the skin, each shin spot starts as a dull red bump, smaller than a pencil eraser. It slowly spreads to about the size of a quarter, becomes more scaly, and eventually leaves a brownish scar on the skin. The lesions are usually bilateral and occur in linear clusters. No treatment is required (American Diabetes Association, 2014).

SKIN CONSEQUENCES OF SELECTED SYSTEMIC DISEASES Skin Disorders in Diabetes Mellitus Diabetes causes changes in circulation and cell nutrition that can have a great impact on skin status. Some of the more common skin conditions encountered in diabetes are discussed in this section.

Stasis Dermatitis Stasis dermatitis is not unique to diabetes, but because of the blood vessel damage that results from diabetes, it is very common in patients with this disease. Large vessels are damaged, compromising circulation to the lower arms and legs. A lack of nutrients results in the skin becoming very dry and fragile. Minor injuries heal more slowly, and ulcers form easily. The skin takes on a thick leathery texture and a yellowish, waxy hue.

Skin Infections The skin of patients with diabetes is prone to bacterial and fungal infections. Bacterial infections appear as small pimples around hair follicles and the most frequently affected sites include the lower legs, lower abdomen, and buttocks. Sometimes, the lesions enlarge to become furuncles or carbuncles. If the blood glucose level is not well controlled, these infections may be very slow to heal. Fungal infections are quite common in areas that remain moist all the time (under breasts, upper thighs, in axilla). Candida (yeast) infections appear beefy red and have small pustules around the border of the area, with the skin appearing moist and raw. Dermatophyte infections are dry and only minimally red, with more scale. Common sites are the toenails and feet. Be alert to the signs of these common infections. Report them to the attention of the physician and help the patient or family learn basic skin maintenance techniques.

Leg and Foot Ulcers Because of peripheral neuropathy, patients with diabetes do not always sense minor injuries to the lower legs and feet. Infections begin; if left untreated they may lead to

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ulcerations. Ulcerations often go unnoticed and become quite large before being treated. Ulcerations unresponsive to treatment are a leading cause of diabetic foot and leg amputations.

Cutaneous Signs of Human Immunodeficiency Virus Disease Cutaneous signs may be the first manifestation of human immunodeficiency virus (HIV), appearing in more than 90% of people infected with HIV as their immune function deteriorates. These skin signs correlate with helper T-cells that have low counts of CD4 molecules on the surface (Carter & Hughson, 2014). Some disorders such as Kaposi’s sarcoma, oral hairy leukoplakia, facial molluscum contagiosum, and oral candidiasis suggest that CD4 counts are less than 200 to 300 cell/mL (instead of between 500 and 1,500 cells). Be sensitive to these changes so that early intervention can be initiated.

DIAGNOSTIC EVALUATION In addition to the health history, physical examination, identification of primary and secondary skins lesions, certain diagnostic procedures are used to help diagnose 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 performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis.

Immunofluorescence Designed to identify the site of an immunologic 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 and may be used to detect bullous pemphigoid, systemic lupus erythematosus, and dermatitis herpetiformis for example (Pagana & Pagana, 2010).

Patch Testing Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens to healthy skin under occlusive

patches. Wheals < 3 mm in diameter or flares

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Plan of Nursing Care

Chart 57-3. Patients With Dermatoses (Abnormal Skin Conditions), Continued

NURSING INTERVENTIONS

RATIONALE

4. Assess patient’s concerns and fears. Assist anxious patient to develop insight and identify and cope with problems.

4. This gives health care personnel an 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 selfacceptance and socialization.

5. Support patient’s efforts to improve body image (participation in skin treatments; grooming), develop selfacceptance, 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 patient knows (understands and misunderstands) about condition. 2. Keep patient informed; correct misconceptions/misinformation. 3. Demonstrate application of prescribed therapy (wet compresses; topical medication). 4. Advise patient to keep skin moist and flexible with hydration and application of skin cream and lotion. 5. Encourage patient to attain a healthy nutritional status.

1. Provides baseline data for developing the teaching plan. 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. 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.

• Acquires understanding of skin care • Follows treatment as prescribed and

can verbalize rationale for measures taken • Carries out prescribed baths, soaks, wet dressings • Uses topical medication appropriately • Understands importance of nutrition to skin health

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 patient clearly and in detail about 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. 5. Kills or prevents the growth of the infectious organism.

• 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 (e.g., dressing changes, soaks)

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Chart 57-3. 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 patient about possible adverse effects of long-term use of fluorinated topical corticosteroids.

6. Corticosteroids have an antiinflammatory 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.

7. Advise patient to stop using any skin agent that makes condition worse.

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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 should be 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. Alternatively, it may result from 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.

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. Use a powder such as Zeabsorb (Stiefel) to absorb perspiration and prevent yeast infection. Never use cornstarch as it increases yeast. 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

EXPECTED OUTCOMES

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, as these may have allergic effects. The patient should also avoid vasodilating agents or stimulants (e.g., alcohol, caffeine) and mechanical irritants such as rough or woolen clothing. A diet that includes adequate fibre may help maintain soft stools and prevent minor trauma to the anal mucosa.

Secretory Disorders 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. Usual perspiration has no odour. Body odour 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. Usually, underarm 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. Fragrancefree deodorants are available for those with sensitive skin. Open weave products such as J-cloths can be placed under the breasts or abdomen to absorb perspiration.

Hidradenitis Suppurativa Hidradenitis suppurativa is a chronic suppurative folliculitis of the perianal, axillary, and genital areas or under the

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breasts. It develops after puberty and can produce abscesses or sinuses with scarring. The cause is unknown, but it appears to have a genetic basis.

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 Hidradenitis suppurativa 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.

Management 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.

Seborrheic Dermatoses Seborrhea is excessive production of sebum (i.e., secretion of sebaceous glands) in areas where sebaceous glands are usually found in large numbers, such as the face, scalp, eyebrows, eyelids, sides of the nose and upper lip, malar regions (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 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 (redness), predominantly on the forehead, nasolabial fold, beard area, and 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 are 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 are considered.

Medical Management 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, as 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 are advised to ensure maximum aeration of the skin and to carefully clean and dry areas where there are creases or folds in the skin. Patients with persistent candidiasis should be evaluated for diabetes. See previous comments about Zeabsorb powder and J-cloths. 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 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 is 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 need to 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 (primary acne lesions), both closed and open, and by papules, pustules, nodules, and cysts.

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Acne vulgaris is the most commonly encountered skin condition in adolescents and young adults, affecting over 80% of those between the ages of 11 and 30 years (Simandl, 2010b). 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 (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. Closed comedones may evolve into open comedones, in which the contents of the ducts are in open communication with the external environment. The colour of open comedones (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 (e.g., 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 (e.g., comedones, papules, pustules, cysts).

Assessment and Diagnostic Findings The diagnosis of acne is based on the history and physical examination, evidence of lesions that are characteristic of acne, and age. Acne does not occur until puberty. The presence of the typical comedones (i.e., whiteheads and blackheads) along with excessively oily skin is character-

Management of Patients With Dermatologic Conditions

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istic. 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 odour. 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 (e.g., comedonal, papular, pustular, cystic). There is no predictable cure for the disease, but combinations of therapies are available that can effectively control its activity. Table 57-5 summarizes the treatment modalities for acne vulgaris. Topical treatment may be all that is needed to treat mild to moderate lesions and superficial inflammatory lesions (i.e., 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,

TABLE 57-5

Commonly Prescribed Treatments of Acne Vulgaris

Type of Therapy

Prescribed Treatment Agent

Topical

benzoyl peroxide wash, gel benzoyl peroxide/erythromycin (Benzamycin gel) 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 [Differin], azelaic acid [Azelex], tazarotene [Tazorac]) topical antibiotics oral antibiotics (erythromycin, tetracycline, doxycycline, minocin, penicillins)

Systemic

isotretinoin (Accutane) hormones: corticosteroids high dose for antiinflammatory 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

Surgical

excision of sinus tracts and cysts intralesional corticosteroids for antiinflammatory action cryotherapy dermabrasion for scars laser resurfacing of scars

Treatments listed are common but do not include all available forms of therapy.

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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 comedones in most cases. 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 is instructed to discontinue their use if severe irritation occurs. Oil-free cosmetics and creams should be chosen. These products are usually designated as useful 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 is informed that symptoms may worsen during early weeks of therapy because inflammation may occur during the process. Erythema and peeling also frequently occur. 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, as 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.

permanent discolouration 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 usual vaginal bacteria and predispose the patient to candidiasis, which is a fungal infection. ORAL RETINOIDS. Synthetic vitamin A compounds (i.e., 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 (epidermal desquamation), thereby unseating and expelling existing comedones. The most common side effect, experienced by almost all patients, is cheilitis (inflammation or cracks of the lips/ corners of the mouth). Dry and chafed skin and mucous membranes are frequent side effects. These 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. To avoid additive toxic effects, patients are cautioned not to take vitamin A supplements while taking isotretinoin.

!

NURSING ALERT

Two negative pregnancy tests are required before taking Accutane and are continued monthly until the medication is stopped. All women of childbearing age are required to abstain from sexual activity or use at least two forms of birth control from 1 month before, during treatment, and up to 8 weeks after treatment (Stephen, 2012). 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.

Systemic Pharmacologic Therapy

Surgical Management

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 12 years 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

Surgical treatment of acne consists of comedo extraction; injections of corticosteroids into the inflamed lesions; and incision and drainage of large, fluctuant (moving in palpable waves), nodular cystic lesions. Cryosurgery (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 (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

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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.

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 concerns related to the skin disorder or therapy. 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.

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 are warned that discontinuing these medications can exacerbate acne, lead to more flare-ups, and increase the chance of deep scarring. Furthermore, 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 tissue involved. The patient is 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, which is 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, as 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

Management of Patients With Dermatologic Conditions

1797

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.

INFECTIOUS DERMATOSES: BACTERIAL SKIN INFECTIONS Also called pyodermas, pus-forming bacterial infections of the skin may be primary or secondary. Primary skin infections originate in previously usual-appearing skin and are often caused by a single organism. Secondary skin infections arise from a pre-existing skin disorder or from disruption of the skin integrity from injury or surgery. In either case, several microorganisms may be implicated (e.g., 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 (i.e., 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 issues, 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 (filled with serum, pus, or blood) (Stephen, 2010) that soon rupture and become covered with a loosely adherent honey-yellow crust (Fig. 57-1). 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.

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FIGURE 57-1. Impetigo of the nostril.

Medical Management Systemic antibiotic therapy is the usual treatment. It reduces contagious spread, treats deep infection, and prevents acute glomerulonephritis (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 (e.g., cloxacillin, dicloxacillin). In penicillin-allergic patients, erythromycin is an effective alternative. Topical antibacterial therapy (e.g., 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 (e.g., bacitracin/polymyxin [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 to 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 (shaving bumps) are an inflammatory reaction that occurs predominately on the faces of black Canadian 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 remove facial hair, a depilatory cream or electric razor may be used. A furuncle (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 centre 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

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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 acutely ill from infection. 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 Routine Practices and Additional Precautions (PHAC, 2012). Nursing personnel carefully follow isolation precautions to avoid becoming carriers 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 are covered with plastic material and wiped off with disinfectant daily; the bed sheets, towels, and clothing are 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 (longer than about 3 months). The patient must take the full dose for the time prescribed. The purulent exudate (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.

Management of Patients With Dermatologic Conditions

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 varicella-zoster 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.

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 (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 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. 57-2). 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

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

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FIGURE 57-2. Herpes zoster (shingles).

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Integumentary Function

disease may be severe and the clinical course acutely disabling.

Medical Management There is evidence that infection is arrested if oral antiviral agents such as acyclovir (Avirax), 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. 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 to prevent persistent pain patterns. Systemic corticosteroids may be prescribed for patients older than 50 years to reduce the incidence and duration of postherpetic neuralgia (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 anti-inflammatory agent. 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. People who have been exposed to varicella (chickenpox) by primary infection or by vaccination are not at risk for infection after exposure to patients with herpes zoster.

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.

Types of Herpes Simplex 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 (i.e., concentric red rings with white bands between the red rings).

Nursing Management

Genital Herpes

The patient and family members are instructed about the importance of taking antiviral agents as prescribed and in keeping follow-up appointments with the health care professional. 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 older and unable to apply them. Significant others or a home care nurse may need to help with dressing changes. Food preparation for patients who cannot care for themselves or prepare nourishing meals must be arranged.

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 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, refer to Chapter 47.

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

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

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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 are 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.

Management of Patients With Dermatologic Conditions

1801

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.

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. Eczema herpeticum is managed with oral or intravenous acyclovir. 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 triggers, 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 (acute eruption of macules, papules, and vesicles with a multiform appearance). 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

FUNGAL (MYCOTIC) SKIN INFECTIONS Fungi, or 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 (i.e., 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 57-6 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 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 (i.e., athlete’s foot) is the most common fungal infection. It is especially prevalent in those who use communal showers or swimming pools.

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 (e.g., miconazole [Monistat], clotrimazole [Canesten]) are applied to the infected areas. Topical therapy is continued for several weeks because of the high rate of recurrence.

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Integumentary Function

Tinea (Ringworm) Infections

Type and Location

Clinical Manifestations

Treatment

Tinea capitis (head)

•

Common in children

• •

Contagious fungal infection of the hair shaft Tinea corporis (body)

• • • •

Griseofulvin for 6 weeks Shampoo hair 2 or 3 times with ketoconazole (Nizoral) or selenium sulfide shampoo.

• •

Mild conditions: topical antifungal creams Severe conditions: griseofulvin or terbinafine

Tinea cruris (groin area; “jock itch”)

• • • • •

• •

Mild conditions: topical antifungal creams Severe conditions: griseofulvin or terbinafine

Tinea pedis (foot; “athlete’s foot”)

• • •

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.

• •

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

• Tinea unguium (toenails; affects about 50% of adults)

• •

Nursing Management Footwear provides a favourable 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. 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 moisture. For people whose feet perspire excessively, perforated shoes allow 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 (i.e., ringworm of the body), the typical ringed lesion appears on the face, neck, trunk, and extremities (Fig. 57-3). Animal (nonhuman) varieties are known to cause an intense inflammatory reaction in humans. Humans make contact with animal varieties through contact with pets or objects that have been in contact with an animal.

• •

griseofulvin (Grifulvin V) 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 be seen at the edges of such patches. As the hairs in the affected areas are

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 (Sporanox), fluconazole (Diflucan), and terbinafine (Lamisil), have been more effective with fewer systemic side effects than

FIGURE 57-3. Tinea corporis (ringworm) of the face.

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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 (e.g., ketoconazole [Nizoral]) 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 (i.e., 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, people who are obese, 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 (Lamisil) for at least 3 to 4 weeks to ensure eradication of the infection. Oral antifungal agents (e.g., ketoconazole [Nizoral]) 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.

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gernails. It is usually caused by Trichophyton sp (Trichophyton rubrum, Trichophyton mentagrophytes) or Candida albicans. It is usually associated with long-standing fungal infection of the feet. The nails become thickened, friable (easily crumbled), and lustreless. 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.

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.

PARASITIC SKIN INFESTATION Pediculosis: Lice Infestation Lice infestation affects people of all ages. Three varieties of lice infest humans: Pediculus humanus capitis (i.e., head louse), Pediculus humanus corporis (i.e., body louse), and Phthirus pubis (i.e., 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 (i.e., 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 in people with long hair. Head lice may be transmitted directly by physical contact or indirectly by infested combs, brushes, wigs, hats, and bedding.

Tinea Unguium: Onychomycosis

Medical Management

Tinea unguium (i.e., ringworm of the nails) is a chronic fungal infection of the toenails or, less commonly, the fin-

Treatment involves washing the hair with a shampoo containing lindane (Kwell) or pyrethrin compounds with

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Integumentary Function

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—or dry-cleaned to prevent reinfestation. 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.

Nursing Management 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 are 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 is instructed that lindane may be toxic to the central nervous system when used more frequently or for longer periods of time than specified in the package insert.

Pediculosis Corporis and Pubis 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 (e.g., survivors of natural disasters who must live with others in temporary housing without access to running water and clean clothes). Pediculosis pubis is extremely common. The infestation is generally localized in the genital region and is transmitted chiefly by sexual contact.

Clinical Manifestations Chiefly involved are those areas of the skin that come in closest contact with the underclothing (i.e., 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. Pruritus is the most common symptom of pediculosis pubis, particularly at night. Reddish-brown dust (i.e., 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 trans-

mitted infections such as gonorrhea, herpes, or syphilis. There may also be infestation of the hairs of the chest, armpit, beard, and eyelashes. Grey-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-the-counter 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.

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 infection. 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 can occur in anyone. Infestations may or may not be associated with 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.

Clinical Manifestations It takes approximately 4 weeks from the time of contact for a 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

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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.

Gerontologic Considerations Older 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 staff members. Although pruritus may be severe in the older patient, the vivid inflammatory reaction seen in younger people seldom occurs. Scabies may not be recognized in the older adult; 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 completed. 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.

Assessment and Diagnostic Findings The diagnosis is confirmed by recovering S. scabiei or the mites’ by-products 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 evidence of the mite at any stage (e.g., egg, egg casing, larva, nymph, adult).

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.

Management of Patients With Dermatologic Conditions

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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 sheets. All bedding and clothing must be washed in hot water and dried on the hot dryer cycle because the mites can survive up to 36 hours in sheets. If bed sheets 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. Pruritus 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, as it will cause more irritation and increased itching. As well, the patient is advised not to take frequent hot showers, as they can dry the skin and produce pruritus. Oral antihistamines such as diphenhydramine (Benadryl) or hydroxyzine (Atarax) can help to 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 transmitted, the patient may require treatment for coexisting sexually transmitted infection. 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 (i.e., allergic contact dermatitis), resulting from exposure of sensitized people to contact allergens. 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 pre-existing skin disease (Chart 57-4).

Allergic Contact Dermatitis Over 2,000 allergens are known to cause allergic contact dermatitis (ACD). In order of frequency the top ten allergens are nickel jewellery, gold jewellery, Balsam of Peru (found in perfumes and fragrances), thimerosal (a preservative in cosmetics), neomycin sulphate (an antibacterial),

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Integumentary Function

Clinical Manifestations

CHART 57-4

Patient Education Strategies for Avoiding Contact Dermatitis The following precautions may help to 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 (e.g., 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.

fragrance mixture (used to test for allergies to fragrances), formaldehyde (a preservative), cobalt chloride (used as an antiperspirant, in hair dye, metal used in medical products), bacitracin (an antibacterial), and quaternium-15 (similar to formaldehyde, used as a preservative in skin care products) (Simandl, 2010b).

Antibiotics and Allergic Contact Dermatitis In North America, neomycin is the most frequently used antibiotic to treat skin, ear, and eye infections. It is also widely available in over-the-counter (OTC) preparations such as creams, lotions, ointments, and powders (Rietschel & Fowler, 2008). Since patients older than 60 years of age are much more likely to be allergic to neomycin, nurses need to ask about reactions to prescriptions and OTC medications (Gehring & Warshaw, 2008). The American Contact Dermatology Society proclaimed neomycin as the Allergen of the Year for 2010. Bacitracin is the most likely topical antibiotic to cause anaphylaxis (Gehring & Warshaw, 2008). Patients allergic to bacitracin must also avoid neomycin, gentamycin, and streptomycin. Safe antibiotic preparations are Bactroban, Ilotycin, and Silvadene products (Scherman, Jacobs, Zarwas, et al., 2008). White petrolatum has been proven effective on postoperative wounds and avoids the risk of ACD and anaphylaxis (Douglas, 2010).

Risk to Nurses Nurses are the professionals at most risk of allergic contact dermatitis. “Nursing is the occupation with the highest frequency of ACD.” (Douglas, 2010, p. 31), due to frequent exposure to topical antibiotics.

The eruptions of contact dermatitis 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. Many preparations are advocated for relieving dermatitis. In general, a bland, unmedicated lotion is used for small patches of erythema (i.e., 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 to clear the oozing eczematous lesions. A thin layer of cream or ointment containing a corticosteroid may then 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 usual. 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 (i.e., skin surface) and be cast off in 3 to 4 days, which is in sharp contrast to the usual 26 to 28 days. As a result of the increased number of basal cells and rapid cell passage, the usual 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 1% to 2% of Canadians, appearing more often in people who have a European ancestry (Simandl, 2010a). It is thought that the condition stems from a hereditary defect that causes overproduction of keratin. Current evidence supports an immunologic basis for the disease. Although the primary cause is unknown, a combination of specific genetic makeup and

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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. Onset during childhood is strongly related to a family history, whereas onset after 30 years of age is not (Simandl, 2010a). Psoriasis has a tendency to improve and then recur periodically throughout life (Simandl, 2010a).

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. 57-4). 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, discolouration, 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.

Complications Asymmetric rheumatoid factor–negative arthritis of multiple joints occurs in about 5% of people with psoriasis. The arthritic development can occur before or after the skin lesions appear. The relation between arthritis and psoriasis is not understood, although recent studies suggest an interplay between genetics, environmental factors, and the immune system (Simandl, 2010a). Psoriatic arthritis is discussed in more detail later in this chapter.

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Erythrodermic psoriasis, an exfoliative psoriatic state, involves disease progression that involves the total body surface. The patient is 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.

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 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 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 timeconsuming, 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 (e.g., olive oil, mineral oil, Aveeno Oilated Oatmeal Bath) or coal tar preparations (e.g., 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 alpha-hydroxy acids (e.g., 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

FIGURE 57-4. Psoriasis. Courtesy of Roche Laboratories.

Three types of therapy are standard: topical, intralesional, and systemic (Table 57-7). TOPICAL AGENTS. Topically applied agents are used to slow the overactive epidermis without affecting other tissues. These topical formulations include lotions, ointments, pastes, creams, and shampoos. Two topical treatments introduced within the last few years are a vitamin D preparation, calcipotriene (Dovonex), and a retinoid compound, tazarotene (Tazorac). Treatment with these agents tends to suppress epidermopoiesis (i.e., development of epidermal cells) and cause sloughing of the rapidly growing epidermal cells. Older treatments, including tar baths and application of tar preparations on involved skin, are rarely used. Tar

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TABLE 57-7

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Integumentary Function

Current Treatments for Psoriasis

Topical Agents

Use

Selected Agents

Biologicals

Moderate to severe lesions

Cyclosporine (Neoral), alefacept (Amevive), etanercept (Enbrel), infliximab (Remicade)

Topical corticosteroids

Mild to moderate lesions Moderate to severe lesions Severe lesions Lesions on face and groin

Aristocort, Kenalog, Valisone Lidex, Psorcon, Cutivate Temovate, Diprolene, Ultravate Aclovate, DesOwen, Hytone 2.5%

Topical nonsteroidals

Mild to severe

Retinoids such as tazarotene (Tazorac) Vitamin D2 derivative calcipotriene (Dovonex)

Coal tar products

Mild to moderate lesions

Coal tar and salicylic acid ointment (Aquatar, Estar gel, Fototar, Zetar); anthralin (AnthraDerm, Dritho-Cream); Neutrogena T-Derm, Psori Gel

Medicated shampoos

Scalp lesions

Neutrogena T-Gel, T-Sal, Zetar, Head & Shoulders, Desenex, Selsun Blue, Bakers P&S (emulsifying agent with phenol, saline solution, and mineral oil)

Intralesional therapy

Thick plaques and nails

Kenalog, Cordran-impregnated tape, Fluoroplex

Systemic therapy

Extensive lesions and nails

Methotrexate (Folex, Mexate); hydroxyurea (Hydrea); retinoic acid (Tegison) (not to be used in women of childbearing age) Oral gold (auranofin), etretinate, methotrexate

Psoriatic arthritis Photochemotherapy

Moderate to severe lesions

UVA or UVB light with or without topical medications PUVA (combines UVA light with oral psoralens, or topical trisoralen)

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, high-potency topical corticosteroids are not used on the face and intertriginous areas, and their use on other areas should be limited to a 4-week course of twicedaily applications. A 2-week break is taken before repeating treatment with the high-potency corticosteroids. For longterm therapy, moderate-potency corticosteroids are used. On the face and intertriginous areas, only low-potency corticosteroids are appropriate for long-term use (see Table 57-4). Occlusive dressings may be applied to increase the effectiveness of the corticosteroid. 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. Large rolls of tubular plastic can be used to cover the arms and legs. Another option is a vinyl jogging suit. 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, hypopigmentation, striae, 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. The more 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 (e.g., nonsteroidal topical medications, ultraviolet light) may be used instead or in combination to decrease the need for corticosteroids. Tazarotene (Tazorac), a newer nonsteroidal topical preparation, is available and effective for many patients. Treatment with this agent tends to suppress epidermopoiesis (i.e., development of epidermal cells) and causes sloughing of the scales covering psoriatic plaques. As with other retinoids, it causes increased sensitivity to sunlight, so patients are cautioned to use an effective sunscreen and avoid other photosensitizers (e.g., 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 the medication is not injected into healthy skin. 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).

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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; kidneys; and bone marrow. Laboratory studies must be monitored to ensure that the hepatic, hematopoietic, and renal systems are functioning adequately. The patient should avoid drinking alcohol while taking methotrexate, because alcohol ingestion increases the possibility of liver damage. The medication is teratogenic (producing physical defects in the fetus) and is 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 (i.e., 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.

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the narrow-band UVB, which ranges from 311 to 312 nm, decreasing exposure to harmful ultraviolet energy while providing more intense, specific therapy. 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. Table 57-7 summarizes the treatment plans.

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Nursing Process

Care of the Patient With Psoriasis

Photochemotherapy

Assessment

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 (UVA) light, the psoralen binds with DNA and decreases cellular proliferation. PUVA is not without its hazards; it has been associated with longterm risks of skin cancer, cataracts, and premature aging of the skin (Simandl, 2010b). 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 nursing assessment focuses on how the patient is coping with the psoriatic skin condition, appearance of the skin, and appearance of the skin lesions. 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 is affected as well, 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 usual 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. The nurse can create an environment in which the patient feels comfortable discussing important quality-of-life issues related to his or her psychosocial and physical response to this chronic illness.

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Integumentary Function

Diagnosis

Increasing Skin Integrity

Nursing Diagnoses

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, providing an occlusive film on the skin surface so that usual 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).

Based on nursing assessment data, the patient’s major nursing diagnoses may include the following: • Deficient knowledge about 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 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

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 self-concept 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.

Promoting Understanding

Monitoring and Managing Potential Complications

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 (e.g., cut, abrasion, sunburn), current illness (e.g., pharyngeal streptococcal infection), and emotional stress. It is emphasized that repeated trauma to the skin and an unfavourable environment (e.g., cold) or a specific medication (e.g., lithium, beta-blockers, 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. 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.

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 report mild joint discomfort and some pitting of the fingernails may not be diagnosed with psoriasis until the more obvious cutaneous lesions appear. The report of joint discomfort in the patient with psoriasis is 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.

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Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Printed patient education materials may be provided to reinforce faceto-face discussions about treatment guidelines and other considerations. 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 is 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. Grey- or greentinted, 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 is a side effect 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 Canadian Dermatology Association (http://www.dermatology.ca/patients_public/info_ patients/psoriasis/index.html) and the Psoriasis Society of Canada (http://www.psoriasissociety.org) publish periodic bulletins and reports about new and relevant

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Management of Patients With Dermatologic Conditions

developments in this condition. Chart 57-5 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 prescribed therapy b. Verbalizes that trauma, infection, and emotional stress may be trigger factors 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. Absence 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 a pruritic scaling of the skin. There is a profound loss of stratum corneum (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.

CHART 57-5

HOME CARE CHECKLIST •

The Patient With Psoriasis Patient

Caregiver

• Describe the etiology of psoriasis.

✓

✓

• Describe optimal skin maintenance practices to maintain moisture of skin and prevent

✓

✓

• 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.

✓

At the completion of the home care instruction, the patient or caregiver will be able to:

infection.

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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. Pre-existing 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.

Clinical Manifestations Exfoliative dermatitis starts acutely as a patchy or a generalized erythematous eruption accompanied by fever, malaise, and occasionally gastrointestinal symptoms. The skin colour changes from pink to dark red. After a week, the characteristic exfoliation (i.e., 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 (i.e., hyperuricemia), and temperature disturbances.

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 is 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.

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.

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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 may be in extreme discomfort and irritable because of the severe pruritus. 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 (e.g., herpes simplex and zoster infections, contact dermatitis). Immunologically mediated diseases are autoimmune reactions and represent a defect of immunoglobulin M (IgM), immunoglobulin E (IgE), immunoglobulin G (IgG), and protein complement 3 (C3). Some of these conditions are life threatening; others become chronic. 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 (i.e., 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 Pemphigus is a group of serious diseases of the skin characterized by the appearance of bullae (blisters) of various sizes on apparently “normal” skin (Fig. 57-5) and mucous membranes. Available evidence indicates that pemphigus is an autoimmune disease involving IgG. It is thought that the pemphigus antibody is directed against a specific cellsurface 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

NURSING ALERT

The nurse observes the patient for signs and symptoms of heart failure because hyperemia and increased cutaneous blood flow can produce highoutput 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

FIGURE 57-5. Vesicles on the chin (in pemphigus). (From Sauer, G. C.

(1985). Manual of skin diseases. Philadelphia, PA: JB Lippincott.)

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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.

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 odour emanates from the bullae and the exuding serum. There is blistering or sloughing of uninvolved skin when minimal pressure is applied (i.e., 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.

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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 older adults, with a peak incidence at about 60 years of age. There is no gender or genetic predilection, and the disease can be found throughout the world.

Management Medical treatment includes topical corticosteroids for localized eruptions and systemic corticosteroids for widespread involvement. Systemic corticosteroids (e.g., prednisone) may be continued for months, in alternate-day 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 (see Chapter 43).

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 age 20 and 40 years but can appear at any age. Most patients with dermatitis herpetiformis have a subclinical defect in gluten metabolism.

Management

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 reepithelization (i.e., 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 Chapter 42). Immunosuppressive agents (e.g., azathioprine, cyclophosphamide, gold) may be prescribed to help control the disease and reduce the corticosteroid dose. Plasmapheresis (i.e., plasma exchange) temporarily decreases the serum antibody level and has been used with variable success, although it is generally reserved for life-threatening cases.

Most patients respond to dapsone (a 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 consultation 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.

Bullous Pemphigoid Bullous pemphigoid is an acquired disease of flaccid blisters appearing on normal or erythematous skin. It appears more

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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.

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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 denuded areas of skin • Anxiety and ineffective coping related to appearance of skin and no hope of a cure • Deficient knowledge about medications and side effects

Collaborative Problems/ Potential Complications Based on 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 Oral Health Restoration The patient’s entire oral cavity may be affected with erosions and denuded surfaces (Dietzen, 2010; Scardina, Pisano, & Messina, 2010). Necrotic tissue 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 areas of blistering have a characteristic odour 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, as 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 Chapter 58).

Anxiety Reduction 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 freely express 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 counselling may assist the patient in dealing with fears, anxiety, and depression.

Monitoring and Managing Potential Complications INFECTION PROTECTION. 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 odour from skin or oral lesions. C. albicans of the mouth (i.e., 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 concerns 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 hospitalized patients, environmental contamination is reduced as much as possible. Protective isolation measures and standard precautions are warranted.

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FLUID AND ELECTROLYTE MANAGEMENT.

Extensive denudation of the skin leads to fluid and electrolyte imbalance because of significant loss of fluids and sodium chloride from the skin (Tang & Lee, 2010). 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 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, high-calorie foods (e.g., Ensure, Sustacal, eggnog, milkshakes) help to 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. Reports that anxiety and ability to cope with condition have improved 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. Body temperature within expected range e. Keeps intake record to ensure adequate fluid intake and normal fluid and electrolyte balance f. Verbalizes rationale for intravenous infusion therapy g. Has urine output within expected limits h. Has serum chemistry and hemoglobin and hematocrit values within expected limits

Toxic Epidermal Necrolysis and Stevens–Johnson Syndrome Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are potentially fatal skin disorders and the

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most severe form of erythema multiforme. These diseases are mucocutaneous reactions that constitute a spectrum of reactions, with TEN being the most severe. 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, nonsteroidal anti-inflammatory drugs (NSAIDs), and sulfonamides are the most frequent medications implicated in TEN and SJS (Simandl, 2010b).

Clinical Manifestations TEN and SJS are characterized initially by conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise, and myalgias (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 who are immunosuppressed, including those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), have a high risk of TEN and SJS. Although the incidence of TEN and SJS in the general population is about 2 to 3 cases per 1 million person-years, the risk associated with sulfonamides in HIV-positive individuals may approach 1 case per 1,000. 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.

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.

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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 centre, 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 (i.e., 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 with TEN thought to result from a medication reaction, corticosteroids may be administered; however, the patients is closely monitored for the previously stated adverse effects. One report stated that administration of intravenous immunoglobulin (IVIG) to ten 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. 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 (e.g., pigskin, amniotic membrane) or plastic semipermeable dressings (e.g., 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.

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Nursing Process

Care of the Patient With Toxic Epidermal Necrolysis Assessment For patients with toxic epidermal necrolysis, a careful inspection of the skin is made, including its appear-

ance 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, colour, and odour. 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 colour are monitored. The insertion sites of intravenous lines are inspected for signs of local infection. Daily body weight is 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 assessment data, the patient’s major nursing diagnoses may include the following: • Impaired tissue integrity (i.e., 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 (i.e., hypothermia) related to heat loss secondary to skin loss • Acute pain related to denuded skin, oral lesions, and possible infection • Anxiety related to physical appearance of the skin and prognosis

Collaborative Problems/ Potential Complications Based on 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.

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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, are 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 odour. 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 unexpected results are reported. The patient is weighed daily (with a bed scale if necessary). 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. The nurse regulates intravenous fluids at prescribed infusion rates and assesses for systemic (i.e., overinfusion or underinfusion) and local (e.g., infection) complications.

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 works rapidly and efficiently 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

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patient’s behavioural 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 expected. 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.

Monitoring and Managing Potential Complications 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 must 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. 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, which is 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.

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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.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients with TEN or SJS with involvement of large areas of the skin require care that is similar to that of patients with thermal burns. As the patient completes the acute inpatient stage of illness, the focus is directed toward rehabilitation and outpatient care or care in a rehabilitation centre. Throughout this care, the patient and family members are involved in the care and are instructed in the procedures, such as wound care and dressing changes, that will need to be continued at home. The patient and family members are assisted in acquiring dressing supplies that will be needed at home. The patient and family members are also provided with instructions about pain management, nutrition, measures to increase mobility, and prevention of complications, including prevention of infection. They are taught the signs and symptoms of complications and are instructed when to notify the health care professional. Instructions are provided in writing to the patient and family so that they can refer to these instructions when necessary at later times. CONTINUING CARE. Interdisciplinary follow-up care is imperative to ensure that the patient’s progress continues. Some patients will require care in a rehabilitation centre before returning home. Others will require outpatient physical and occupational therapy for an extended period. When the patient returns home, the home care nurse coordinates the care provided by the various members of the health care team (e.g., physician, physical therapist, occupational therapist, dietician). The nurse also monitors the patient’s progress, provides ongoing assessment to identify complications, and monitors the patient’s adherence to the plan of care. The patient’s adaptation to the home care environment and the patient and family’s needs for support and assistance are also assessed. Referrals to community agencies are made as appropriate.

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 expected 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 expected 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 expected range b. Laboratory values within expected ranges c. Has no unexpected discharges or signs of infection d. Continues to see objects at baseline acuity level e. Shows no signs of keratoconjunctivitis

ULCERATIONS Superficial loss of surface tissue as a result of death of the cells is called ulceration. A simple ulcer, such as the kind found in a small, superficial, partial-thickness burn, tends to heal by granulation (i.e., 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 Chapter 32). 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, friction and shear forces, and insufficient blood supply, usually at bony prominences. Information about these ulcers is presented in Chapter 12.

BENIGN TUMOURS OF THE SKIN Cysts Cysts of the skin are epithelium-lined cavities that contain fluid or solid material. Epidermal cysts (i.e., epidermoid cysts) occur frequently and may be described as slowgrowing, firm, elevated tumours found most frequently on the face, neck, upper chest, and back. Removal of the cysts provides a cure. Pilar cysts (i.e., trichilemmal cysts), formerly called sebaceous cysts, are most frequently found on the scalp. They originate from the middle portion of the hair follicle

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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 colours, ranging from light tan to black. They are usually located on the face, shoulders, chest, and back and are the most common skin tumours seen in middle-aged and older 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 tumour 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, as 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 (SCC); they are usually removed by cryotherapy or shave excision.

Verrucae: Warts Warts are common, benign skin tumours 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 age 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 (i.e., 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 trichloroacetic acid, and curettage. Condylomata (see Chapter 47) that affect the uterine cervix predispose the patient to cervical cancer.

Angiomas Angiomas are benign vascular tumours that involve the skin and the subcutaneous tissues. They are present at birth and may occur as flat, violet-red patches (i.e., portwine angiomas) or as raised, bright-red, nodular lesions (i.e., strawberry angiomas). The latter tend to involute spontaneously within the first few years of life, but portwine angiomas usually persist indefinitely. Most patients use masking cosmetics (e.g., Covermark or Dermablend) to camouflage the lesion. The argon laser is being used on various angiomas with success. Treatment of strawberry angiomas is more successful if undertaken as soon after birth as possible.

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Pigmented Nevi: Moles Moles are common skin tumours of various sizes and shades, ranging from yellowish brown to black. They may be flat, macular lesions or elevated papules or nodules that occasionally contain 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 colour or size or become symptomatic (e.g., 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 colour. 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 colour, 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 dark-skinned 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 tumour of connective tissue that occurs predominantly on the extremities. It is a firm, dome-shaped papule or nodule that may be skin coloured 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 (i.e., 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.

MALIGNANT TUMOURS OF THE SKIN: SKIN CANCER Skin cancer, especially basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are the most common cancers

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in Canada, accounting for approximately 44% of all newly diagnosed cancers (Canadian Cancer Society’s Advisory Committee on Cancer Statistics [CCSACCS], 2013). Predictions for nonmelanoma skin cancer for 2013 were 81,900 new cases (males—45,100; females—36,800) and 270 deaths (CCSACCS). Because the skin is easily inspected, skin cancer is readily seen and detected and is the most successfully treated type of cancer. Exposure to the sun is the leading cause of skin cancer; incidence is related to the total amount of exposure to the sun. Almost all skin cancers are preventable (Canadian Dermatology Association, 2008a). 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, tanning beds, 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 (Chart 57-6).

Basal Cell and Squamous Cell Carcinomas 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.

CHART 57-6

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 to 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 (older people) History of x-ray therapy for acne or benign lesions Scars from severe burns Chronic skin irritations Immunosuppression Genetic factors

FIGURE 57-6. Basal cell carcinoma (left) and squamous cell carci-

noma (right). (Reprinted by permission from New England Journal of Medicine, 326, 169–170, 1992.)

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. 57-6). The tumours 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, grey 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 pre-existing 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 they may develop from a precancerous condition, such as actinic keratosis (i.e., lesions occurring in sun-exposed areas), leukoplakia (i.e., premalignant lesion of the mucous membrane), or scarred or ulcerated lesions. SCC appears as a rough, thickened, scaly tumour that may be asymptomatic or may involve bleeding (see Fig. 57-6). 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 (Canadian Dermatology Association, 2008b).

Prognosis The prognosis for BCC is usually good. Tumours remain localized, and although some require wide excision with

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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, tumours 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 (Canadian Dermatology Association, 2008a, 2008b).

Medical Management The goal of treatment is to eradicate the tumour. The treatment method depends on the tumour location; the cell type, location, and depth; the cosmetic desires of the patient; the history of previous treatment; whether the tumour 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 tumour entirely. The best way to maintain cosmetic appearance is to place the incision properly along natural skin tension lines and natural anatomic body lines (Langer’s lines). In this way, scars are less noticeable. The size of the incision depends on the tumour size and location but usually involves a length to width ratio of 3:1. The adequacy of the surgical excision is verified by microscopic evaluation of sections of the specimen. When the tumour 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.

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MOHS’ MICROGRAPHIC SURGERY. Mohs’ micrographic surgery is the technique that is most accurate and that best conserves healthy tissue. The procedure removes the tumour layer by layer (Tschoeke, Fisk, Pellino, et al., 2010). The first layer excised includes all evident tumour and a small margin of normal-appearing tissue. The specimen is frozen and analyzed by section to determine if all of the tumour has been removed. If not, additional layers of tissue are shaved and examined until all tissue margins are tumour-free. In this manner, only the tumour and a safe, normal-tissue margin are removed. Mohs’ surgery is the recommended tissue-sparing procedure, with extremely high cure rates for BCC and SCC. It is the treatment of choice and the most effective for tumours around the eyes, nose, upper lip, auricular and periauricular areas, and the forehead. The Mohs’ procedure occurs in ambulatory care settings and is performed under local anesthetic. The length of the procedure depends on how many layers of tissue need to be removed and if a skin graft is required. It may take 5 to 6 hours. 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 (i.e., excising the skin tumour 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 in diameter. This method takes advantage of the fact that the tumour in each instance is softer than surrounding skin and therefore can be outlined by a curette, which “feels” the extent of the tumour. The tumour is removed, and the base is cauterized. The process is repeated twice. Usually, healing occurs within a month. CRYOSURGERY. Cryosurgery destroys the tumour by deep freezing the tissue. A thermocouple needle apparatus

NURSING RESEARCH PROFILE

Chart 57-7. Pain and Mohs’ Procedure Tschoeke, N., Fisk, S., Pellino, S. T., et al. (2010). Patient’s pain experience during and following the Mohs’ procedure. Dermatology Nursing, 22(6), 11–17. Purpose The purpose of this study was to determine the pain experienced by patients during the Mohs’ procedure for the removal of basal cell, squamous cell, or melanoma types of skin cancer and the first hours post-surgery. Design The researchers (nurse clinicians in dermatology) developed a pain questionnaire to be used with patients following a Mohs’ procedure. A total of 87 participants (51% males and 49% females) were surveyed about the pain they experienced during the Mohs’ procedure and during the first 24 hours post-surgery. The average age of participants was 64.8 years, and ranged from 18 to 88 years of age. All were given a prescription for an opioid analgesic to fill for postoperatic pain.

Findings Most patients reported low pain scores during the Mohs’ procedure and in the first 24 hours post-surgery. Only 25% took the prescribed opioid pain medication, while 43% took a nonprescription medication such as acetaminophen. Thirty-two percent of the patients utilized nondrug approaches to relieve their pain: cold packs (28%), relaxation (9%), deep breathing (2%), napping (1%), and walking (1%). Increased pain resulted from swelling (32%), dressings (17%), bruising (8%), and bleeding (3%). Nursing Implications Suggestions for patients following a Mohs’ procedure are to use cold (wet washcloth in a bag in the freezer, which can be shaped to fit over the surgical site); use of music and other distractions; and eating a soft diet to decrease chewing which stresses the suture line and causes pain. Remind the patient not to bend over!

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is inserted into the skin, and liquid nitrogen is directed to the centre of the tumour until the tumour 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 tumour 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. 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 (e.g., 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 is 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 is also be cautioned to avoid exposure to the sun.

Nursing Management 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 57-8).

Promoting Home and Community-Based Care 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. Follow-up examinations are at regular intervals, usually every 3 months for a year, and should include palpation of the adjacent lymph nodes. The patient is 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. TEACHING ABOUT PREVENTION. Studies show that regular daily use of a sunscreen with a sun protection factor (SPF) of at least 15 can reduce the recurrence of skin cancer by as much as 40%. The sunscreen is 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. Intermittent application of sunscreen only when exposure is anticipated has been shown to be less effective than daily use. Research has shown that daily use of sunscreen on the hands and face reduces the total incidence of solar keratoses, which are precursors of SCC, but has no effect on the overall incidence of BCC. These data are inconsistent, but one theory is that people have a false sense of security when wearing sunscreen and tend to stay out in the sun for longer periods. This longer exposure is believed to contribute to the increasing incidence of melanoma. Although the evidence is insufficient, nurses discuss the issues with patients who are at high risk of skin cancer.

CHART 57-8

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. Avoid unnecessary exposure to the sun, especially during the time of day when ultraviolet radiation (sunlight) is most intense (1,000 to 1,500 hr). • Avoid sunburn. • Apply sunscreen before being in the sun; sunscreens block harmful sun rays. • Use a sunscreen with a sun protection factor (SPF) of 15 or higher. Sunscreens are rated in strength from 4 (weakest) to 50 (strongest). The SPF indicates 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 hr 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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Siegel (2010) studied the use of ultraviolet-filtered photography with nursing students to show them their actual skin damage that had already occurred. This approach “personalizes the sun damage and thus alters the students’ behaviour and perception of tanning and skin cancer.” (Siegel, 2010, p. 18). All nurses have an ongoing role to play in performing skin assessments with patients of all ages in many settings.

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CHART 57-9

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

Malignant Melanoma A malignant melanoma is a cancerous neoplasm in which atypical melanocytes (i.e., 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. 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 behaviours. Most melanomas arise from cutaneous epidermal melanocytes (Metelitsa, Dover, Smilie, et al., 2010; Pruthi, Guilfoyle, Nugent, et al., 2009), but some appear in pre-existing nevi (i.e., 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, changes in the ozone layer, and better methods of early detection. Peak incidence occurs between age 20 and 45 years. 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 2013 was 6,000 (3,300 men and 2,700 women) and the number of deaths is 1,060 (630 men and 430 women) (CCSACCS, 2013).

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 years who have used a tanning bed more than ten times per year. In general, 1 in 100 whites will get melanoma every year. Up to 10% of melanoma patients are members of melanoma-prone families who have multiple changing moles (i.e., 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 57-9 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. The absence of this gene can be identified in melanoma-prone families (Price, Herlyn, Dent, et al., 2005).

• Environmental exposure to intense sunlight • History of melanoma (personal or family) • Skin with giant congenital nevi

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. 57-7). This type of melanoma may appear in a combination of colours, with hues of tan, brown, and black mixed with grey, blueblack, or white. Sometimes, a dull pink rose colour 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 older 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 colour.

Nodular Melanoma Nodular melanoma is a spherical, blueberrylike nodule with a relatively smooth surface and a relatively uniform, blue-black colour (see Fig. 57-7). It may be dome shaped with a smooth surface. It may have other shadings of red, grey, or purple. Sometimes, nodular melanomas appear as irregularly shaped plaques. The patient may describe this as a blood blister that fails to resolve. A nodular melanoma invades directly into adjacent dermis (i.e., vertical growth) and therefore has a poorer prognosis.

FIGURE 57-7. Two forms of malignant melanoma: superficial spreading (left) and nodular (right). (From Stephen, T. C., Skillen, D. L., Day, R. A., et al. (Eds.). (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins.)

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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 of the feet, 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 older 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 tumour 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 (e.g., bacillus Calmette–Guérin [BCG] vaccine, Corynebacterium parvum, levamisole) offer encouraging results. Some investigational therapies include biologic response modifiers (e.g., interferon-alpha, interleukin-2), adaptive immunotherapy (i.e., lymphokine-activated killer cells), and monoclonal antibodies directed at melanoma antigens. One of these, aldesleukin (Proleukin), shows promise in preventing recurrence of melanoma. Laboratory assay of tyrosinase, an enzyme believed to be produced only by melanoma cells, is under investigation. Several other studies are attempting to develop autologous immunization against specific tumour 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 rarely produce a satisfactory outcome. Further surgical intervention may be performed to debulk the tumour or to remove part of the organ involved (e.g., 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 (e.g., 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 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 pre-existing moles or the development of new, pigmented lesions. People at risk are assessed very 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 ABCDEs of moles (Chart 57-10).

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CHART 57-10

Assessment The ABCDEs 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 COLOUR • Normal moles are usually a uniform light to medium brown. Darker colouration indicates that the melanocytes have penetrated to a deeper layer of the dermis. • Colours 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 coloured (bluish-black, bluish-grey, 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. E FOR EVOLUTION • The lesion is elevated (some melanomas are flat or slightly elevated). • Mole is suddenly increasing in size. • Additional colours may appear. • Mole that was flat or slightly elevated shows rapid increase in height. • Skin surrounding a mole is reddened. • Surface of mole changes from smooth to scaly, crusting, oozing. • Itching is the most common early symptom.

From Canadian Dermatology Association, 2014a.

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 (i.e., those situated near the mole) are inspected.

Diagnosis Nursing Diagnoses Based on nursing assessment data, the patient’s major nursing diagnoses may include the following: • Acute pain related to surgical excision and grafting • Anxiety and depression related to possible lifethreatening consequences of melanoma and disfigurement • Deficient knowledge about early signs of melanoma

Collaborative Problems/ Potential Complications Based on 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 (e.g., 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 centres 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 a melanoma. Anticipating the need for and administering appropriate analgesic medications are important.

Reducing Anxiety and Depression Psychological support is essential when disfiguring surgery is performed. Support includes allowing patients to express feelings about the seriousness of

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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 tumour, the nurse answers questions, clarifies information, and helps to 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 cope with the challenges associated with diagnosis, treatment, and continuing follow-up. The patient’s family is included in all discussions to clarify the information presented, ask questions that the patient might be reluctant to ask, and provide emotional support to the patient.

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 (i.e., horizontally) and is characterized by peripheral growth with minimal or no dermal invasion, the prognosis is favourable. When the melanoma progresses to the vertical growth phase (i.e., 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 to provide holistic care. The nurse must be knowledgeable about the most effective current therapies and delivers supportive care, provides and clarifies information about the therapy and the rationale for its use, identifies 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 (e.g., difficulty breathing, shortness of breath, increasing cough), bone (e.g., pain, decreased mobility and function, pathologic fractures), and liver (e.g., change in liver enzyme levels, pain, jaundice). Nursing care is based on the patient’s symptoms and emotional needs. 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 Chapter 18).

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. According to the

Canadian Dermatology Association (2011), “Up to 70% of all melanomas are first identified by the patient themselves (53%) or close family members (17%).” Patients at risk are taught to examine their skin and scalp monthly in a systematic manner (Chart 57-11). 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 must be taught sun-avoiding measures and the importance of annual assessment by a health care professional.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Experiences relief of pain and discomfort a. States pain is diminishing b. Exhibits healing of surgical scar without heat, redness, or swelling 2. Reports feeling 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 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, colour, 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 Tumours 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 coloured or different shades of red.

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Now stand in front of the full length mirror. Raise your arms toward your chest. Your palms should be toward you. Look in the mirror to check the backs of your forearms and elbows.

Remove all your clothing. To begin, raise your arms to waist height with your palms facing upwards. Examine your palms, fingers and forearms. Open your fingers and check the skin in between them. Turn your hands over and look at the backs of your hands, fingers, fingernails and forearms. Again, open your fingers and look at the skin in between them.

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For this step, you will need the hand-held mirror. Holding up the mirror in front of you and standing again with your back to the full length mirror, look at the back of your neck, your back and buttocks. Check the backs of your arms also.

Next, stand with your back toward the full length mirror. Check your buttocks and the backs of your thighs and calves.

Now turn your body sideways to the left. Raise your arms over your head. Your palms should be facing each other. Check the whole side of your body, starting at the top with your hands, moving to your arms, underarms, torso area, thighs and calves. Finally, turn to the right and check the other side of your body in the same way.

Now lower your arms to your sides, with palms facing away from the mirror. You should be able to see the whole front of your body. Check your face, neck and arms. Turn your palms toward the mirror and check your upper arms and shoulders. Examine your chest, stomach, pubic area, thighs and lower legs.

Remaining seated, bring your right leg over the left leg, resting your foot on your left knee. Using the hand-held mirror, if necessary, look at the top of your foot, your toes, toenails, and the skin in between your toes. Check the bottom of your foot also. Now do the same so you can examine your left foot.

Sitting down on the chair and with your right leg resting on the other chair or stool, look at the inside of your leg from the top of your thigh right down to your ankle, using the hand-held mirror if necessary. Now do the same with your left leg.

Staying in the same position, examine your scalp. It is recommended that you use a hair dryer (on a cold air setting) to part your hair to reveal the skin. You may find this step difficult and are encouraged to have your partner or a friend conduct your scalp examination with the aid of the hair dryer.

Reprinted by permission, from Canadian Dermatology Assoc., Dec 28, 2008.

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Patient Education: A Guide to Skin Cancer Self-Examination

Ensure the area where you will be checking your skin is well lit. You will need a full length mirror, a hand-held mirror, a hair dryer, and either two chairs or two stools.

For more information or to view photos of what to look for, go to www.dermatology.ca

CHART 57-11

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OTHER MALIGNANCIES OF THE SKIN Kaposi’s Sarcoma First described by Moritz Kaposi in 1872, Kaposi’s sarcoma (KS) has received renewed attention since its association with HIV 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. KS is a malignancy of endothelial cells that line the small blood vessels. KS is manifested clinically by lesions of the skin, oral cavity, gastrointestinal tract, and lungs. The skin lesions consist of reddishpurple to dark-blue macules, plaques, or nodules. KS is subdivided into three categories: • Classic KS occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Most patients have nodules or plaques on the lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal. • Endemic (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. • Immunosuppression-associated KS occurs in transplant recipients and people with AIDS. This form of KS is characterized by local skin lesions and disseminated visceral and mucocutaneous diseases. The greater the degree of immunosuppression, the higher the incidence of KS. Immunosuppression-related KS that results from AIDS is an aggressive tumour that involves multiple body organs. Its presentation resembles that of KS associated with immunosuppressive therapy. Most patients are between age 20 and 40 years. More information on AIDS-related KS can be found in Chapter 52.

Basal and Squamous Cell Carcinomas in the Immunocompromised Population The incidence of BCC and SCC is increased in all immunocompromised individuals, including those infected with HIV. Clinically, the tumours have the same appearance as in non–HIV-infected people; however, in HIV patients, the tumours may grow more rapidly and recur more frequently. These tumours are managed the same as for the general population. Frequent follow-up (every 4 to 6 months) is recommended to monitor for recurrence.

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 tumours, 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. Skin grafts are commonly used to repair defects that result from excision of skin tumours, 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 (i.e., thin, intermediate, or thick) or full-thickness 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. 57-8). 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 colour match • Matching the texture and hair-bearing qualities • Obtaining the thickest possible skin graft without jeopardizing the healing of the donor site (Fig. 57-9)

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Epidermis

Dermis

Thin .010" Medium .020"

Splitthickness skin graft

Thick .035"

Subcutaneous

Full-thickness skin graft .040"

Muscle

Sweat gland Hair follicle FIGURE 57-8. Layers of skin appropriate for split-thickness and full-thickness graft.

• Considering the cosmetic effects of the donor site after healing so that it is in an inconspicuous location

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 reepithelization of the raw, exposed dermis. Usually, a single layer of nonadherent, fine-mesh 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 (e.g., 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 (e.g., 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. Split-thickness grafts

Graft Application

Full-thickness grafts

A graft is obtained by a variety of instruments: razor blades, skin-grafting 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.

Fat-dermal grafts FIGURE 57-9. Common donor skin graft sites. Blue skin areas are

appropriate for full-thickness grafts; green areas are used for splitthickness grafts; rose sites are used for fat-dermal grafts.

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For a graft to survive and be effective, certain conditions must be met: • The recipient site must have an adequate blood supply so that usual 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 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 (i.e., 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 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 immediately 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 (i.e., 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 tumour ablation (i.e., removal, usually by excision) in an adjacent part of the body.

Flaps offer an aesthetic solution because a flap retains the colour 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 (i.e., attachment) with vessels at the recipient site. The procedure usually is completed in one step, eliminating 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 issues. 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 (i.e., 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 moulded 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 (i.e., small inclusion cysts that disappear after several months), scarring, atrophy, sensitivity changes, and long-term (4 to 5 months) erythema or pruritus.

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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 is usual. 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 iodide 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 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 (i.e., motor-driven wire brush, diamondimpregnated 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 the procedure. 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

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after planing, 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 large defect or reconstruct a lost part of the face (e.g., 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.

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Nursing Process

Care of the Patient With Facial Reconstruction 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. Anxiety and depression are common when the appearance and function of the face are affected by injury or disease. 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

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themselves. Health care professionals 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 reinforces facts and clarifies 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 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 procedure • Imbalanced nutrition (less than body requirements) related to altered physiology of oral cavity, drooling, impaired chewing and swallowing, or excision affecting 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

Collaborative Problems/ Potential Complications Based on assessment data, potential complication that may develop includes the following: • Infection

Planning and Goals 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 self-concept, effective family coping, and absence of infection.

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 behaviour is a sign of hypoxia (i.e., reduced oxygen supply to tissues). Sedatives or opioids are not prescribed in this situation, as 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 26 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 Chapters 14 and 36).

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 (i.e., 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 37 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

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measuring body weight daily and assessing serum protein and electrolyte levels periodically.

Monitoring and Managing Potential Complications

Enhancing Communication

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 increased tension and infection (i.e., 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 odour. 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 colour and temperature indicative of poor circulation. Signs of necrosis, increased drainage, or an odour 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.

Communication problems may range from minimal difficulty to the loss of oral speech. Some tumours 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. Other more advanced technologic means of communicating have been developed and may be used if the communication barrier is longer term. 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.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Maintains patent airway a. Demonstrates respiratory rate within expected limits b. Exhibits usual breath sounds c. Demonstrates no signs of choking or aspiration

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2. Achieves increasing comfort a. Reports decreasing pain b. Follows instructions on proper positioning c. Avoids movements that stress operative site 3. Attains adequate nutrition a. Consumes adequate amounts of food and fluids b. Maintains weight within expected range or progressively regains weight lost in early postoperative period c. Maintains serum protein and electrolyte levels within expected 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 selfcare activities c. Uses prosthetic devices independently (when appropriate) d. Verbalizes plans for resuming usual activities (e.g., 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 expected limits b. Undergoes appropriate wound healing without signs of infection or sepsis c. Lists signs of infection that should be reported d. Understands need for asepsis (i.e., sterile procedures) and good personal hygiene

Face-Lift Rhytidectomy (i.e., 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 two 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 pulse-dye laser are used in dermatologic surgery. Each type of laser emits its own wavelength within the colour 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 tumours, 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 colour. 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

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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 by-product smoke, referred to as a plume.

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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 is 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 (e.g., Telfa) usually eases discomfort.

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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 port-wine stain, is rare. The patient should be informed that several treatments may be necessary.

Management Immediately after undergoing CO 2 laser surgery, the treated area turns a charcoal colour. 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 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 UVB and UVA light.

Critical Thinking Exercises 1

You are caring for an elderly woman in her home. She has a long history of peripheral vascular disease and now has developed a venous stasis ulcer on her lower leg just above the ankle. Her physician has prescribed a moisture-retentive dressing that is impregnated with hydrogel. The dressing is to be changed every 3 days, and the patient asks you why the dressing is not changed every day. How would you explain to the patient the purpose of the dressing? Identify the evidence that supports the use of moisture-retentive dressings for venous ulcers. Discuss the strength of the evidence regarding their effectiveness in the promotion of wound healing.

2 You are caring for a middle-aged woman who has recently been diagnosed with diabetes mellitus. On preparing for discharge, she tells you that she has had itchy, dry, flaky

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skin during the winter months for several years and that she bathes every morning and night to try to get rid of the itching and dryness. She also states that it is difficult for her to avoid scratching her itchy skin. What teaching would you provide to this patient? What are this patient’s risks of developing more serious skin conditions if the dryness and itching of her skin continue? 3 You are assigned to the emergency department and are caring for a young adult who is being treated for heatstroke following a golf game on a very hot day. As he is awaiting discharge, he tells you that he is concerned about developing skin cancer because he spends so much time in the sun. After providing the patient with information about risk factors for, and prevention of, heatstroke, what other patient education would you provide? What are the risk factors for skin cancer? What health promotion strategies would be encouraged for this patient?

health care settings. Retrieved from http://www.ipac-canada.org/ pdf/2013_PHAC_RPAP-EN.pdf Rietschel, R., & Fowler, J. (2008). Fischer’s contact dermatitis. Lewiston, NY: BC Decker. Simandl, G. (2010a). Structure and function of the skin. In R. A. Hannon, C. Pooler, & C. M. Porth, (Eds.). Pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1476–1487). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Simandl, G. (2010b). Disorders of skin integrity. In R. A. Hannon, C. Pooler, & C. M. Porth, (Eds.). Pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1488–1531). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012). Skin, hair, and nails assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al., (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 267–325). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2010). The skin, hair, and nails. In T. C. Stephen, D. L. Skillen, R. A. Day, et al., (Eds.), Canadian Bates guide to health assessment for nurses (1st ed., pp. 245–278). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS AND DOCUMENTS Burns, D. A., Breathnach, S. M., Cox, N., et al. (2010). Rook’s textbook of dermatology (8th ed.). Hoboken, NJ: Wiley-Blackwell. Canadian Cancer Society’s Advisory Committee on Cancer Statistics (2013). Canadian Cancer Statistics 2013. Toronto, ON: Canadian Cancer Society. Canadian Dermatology Association (2008a). Basal cell skin cancer. Ottawa, ON: Author. Retrieved from http://www.dermatology.ca/skinhair-nails/skin/skin-cancer/#!/skin-hair-nails/skin/skin-cancer/basalcell-skin-cancer/ Canadian Dermatology Association (2008b). Squamous cell. Ottawa, ON: Author. Retrieved from http://www.dermatology.ca/wp-content/ uploads/2012/01/SCC-Handout-EN.pdf Canadian Dermatology Association. (2011). 2011 Melanoma Fact Sheet. Retrieved from http://www.dermatology.ca/wp-content/uploads/ 2012/01/2011-Melanoma-Factsheet-EN.pdf Canadian Dermatology Association. (2014a). Skin cancer self-examination poster. Ottawa, ON: Author. Retrieved from http://www.dermatology. ca/wp-content/uploads/2012/01/MMPoster-2009EN.gif Canadian Dermatology Association. (2014b). Basal cell skin cancer. Retrieved from http://www.dermatology.ca/skin-hair-nails/skin/ skin-cancer/#!/skin-hair-nails/skin/skin-cancer/basal-cell-skincancer/ Canadian Dermatology Association. (2014c). Melanoma. Ottawa, ON: Author. Retrieved from http://www.dermatology.ca/wp-content/ uploads/2012/01/Melanoma-handout-EN.pdf Demis, D. J. (Ed.). (1998). Clinical dermatology. Philadelphia, PA: LippincottRaven Publisher. Dietzen, K. K. (2010). Care of patients with oral cavity problems. In D. D. Ignatavicius, & M. L. Workman (Eds.). Medical-surgical nursing: patient-centered collaborative care (6th ed., pp. 1231–1242). St. Louis, MO: Saunders. Fitzpatrick, T. B., & Wolff, K. (2008). Fitzpatrick’s dermatology in general medicine (7th ed.). New York, NY: McGraw-Hill Medical. Gawkrodger, D. J. (2008). Dermatology: An illustrated colour text (4th ed.). New York, NY: Churchill Livingstone Elsevier. Hall, J. (Ed.). (2010). Sauer’s manual of skin diseases (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Krasner, Rodeheaver, & Sibbald. (2002). Chronic wound care: A clinical source book for health care professionals (3rd ed.). Wayne, PA: HMP Communications. Murphy, J. L. (Ed.). (2004). Nurse practitioners’ prescribing reference (2nd ed.). New York, NY: Prescribing Reference. Public Health Agency of Canada. (2012). Routine practices and additional precautions for preventing the transmission of infection in

Aly, R., Forney, R., & Bayles, C. (2001). Treatments for common superficial fungal infections. Dermatology Nursing, 2, 91–101. *Beitz, J. M., & Goldberg, E. (2005). The lived experience of having a chronic wound: A phenomenological study. MedSurg Nursing, 14(1), 51–62. Boggild, A. K., & From, L. (2003). Barriers to sun safety in a Canadian outpatient population. Journal of Cutaneous Medicine and Surgery, 7(4), 229–298. Bolton, L., McNees, P., van Rijswijk, L., et al. (2004). Wound healing outcomes using standardized assessment and care in clinical practice. Journal of Wound, Ostomy, and Continence Nursing, 31(2), 65–71. Bowen, G. M., White, G. L., & Gerwels, J. W. (2005). Mohs micrographic surgery. American Family Physician, 72(5), 845–848. Bryant, R. A., & Rolstad, B. S. (2001). Examining threats to skin integrity. Ostomy Wound Management, 47(6), 18–27. Campton-Johnston, S., & Wilson, J. (2001). Infected wound management: Advanced technologies, moisture-retentive dressings, and diehard methods. Critical Care Nursing Quarterly, 24(2), 64–77. Choucair, M. M., & Fivenson, D. P. (2001). Leg ulcer diagnosis and management. Dermatologic Clinics, 19(4), 52–56. Darlington, S., Williams, G., Neale, R., et al. (2003). A randomized controlled trial to assess sunscreen application and beta carotene in the prevention of solar keratoses. Archives of Dermatology, 139(4), 451–455. Douglas, J. D. (2010). Allergic contact dermatitis and topical antibiotics. Dermatology Nursing, 22(5), 29–32. Ersser, S. J. (2010). Therapeutic effectiveness and the human encounter. Dermatology Nursing, 22(5), 23–24. 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. Gehring, K., & Warshaw, E. (2008). Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management. Journal of the American Academy of Dermatology, 58(1), 1–21. Gottleib, A. (2003). Psoriatic arthritis: A guide for dermatology nurses. Dermatology Nursing, 15(2), 107. Halder, R. M. (2000). New and emerging therapies for vitiligo. Dermatologic Clinics, 18(1), ix, 79–89. Hilton, D. C., Williams, L. C., & Nesbitt, L. T. (2000). Systemic glucocorticosteroid therapy in dermatology. Dermatology Nursing, 12(4), 258–263. Koo, J. Y., Lowe, N. J., Lew-Kaya, D. A., et al. (2000). Tazarotene plus UV-B phototherapy in the treatment of psoriasis. Journal of the American Academy of Dermatology, 43(5 pt 1), 821–828. Kravitz, S., McGuire, J., & Zinszer, K. (2008). Management of skin ulcers: Understanding the mechanism and selection of enzymatic debriding agents. Advances in Skin and Wound Care, 21(2), 72–74. 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.

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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. Leung, D. Y. (2000). Atopic dermatitis: New insights and opportunities for therapeutic intervention. Journal of Allergy and Clinical Immunology, 105, 860–876. Levin, N., & Greer, K. E. (2000). Cutaneous manifestations of endocrine disorders. Dermatology Nursing, 13(3), 185–195. Lim, H. W., Naylor, M., Honigsmann, H., 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. *Loescher, L. J., Harris, R. B., Lim, K. H., et al. (2006). Thorough skin self-examination in patients with melanoma. Oncology Nursing Forum, 33(3), 633–637. MacDonald, S. P., Hull, M. L., Wood, P. E., et al. (2003). Guidelines for the management of alopecia areata. British Journal of Dermatology, 149(4), 692–699. Metelitsa, A. I., Dover, D. C., Smylie, M., et al. (2010). A populationbased study of cutaneous melanoma in Alberta, Canada (1993–2002). Journal of the American Academy of Dermatology, 62(2), 227–232. Mutasim, D. F. (2002). Bullous diseases in the elderly. Clinics in Geriatric Medicine, 18(1), 43–58. 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. Price, K. L., Herlyn, M., Dent, C. L., et al. (2005). The prevalence of interferon-alpha transcription deficits in malignant melanoma. Melanoma Research, 15(2), 91–98. Pruthi, D. K., Guilfoyle, R., Nugent, Z., et al. (2009). Incidence and anatomic presentation of cutaneous malignant melanoma in central Canada during a 50-year period: 1956 to 2005. Journal of the American Academy of Dermatology, 61(1), 44–50. 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., et al. (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.

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Scardina, G. A., Pisano, T., Messina, P. (2010). Oral mucositis: Review of literature. New York State Dentals Journal, 76(1), 34–78. Scherman, A. Jacobs, S., Zarwas, M. (2008). Contact allergy: Alternatives for the 2007 North American Contact Dermatitis Group (NACDG) standard screening tray. Disease-a-Month, 54(1–2), 134–143. Shaw, J. C. (2001). Hormonal therapy in dermatology. Dermatologic Clinics, 19(1), 169–178. Siegel, V. (2010). Exploring the role of the nurse in skin cancer prevention. Dermatology Nursing, 22(16), 18–21. Talarico, L. D. (1998). Aging skin: Best approaches to common problems. Patient Care Nurse Practitioner, 1(5), 28–40. Tang, V. C. U., & Lee, E. W. Y. (2010). Fluid balance chart: Do we understand it? Clinical Risk, 16(1), 10–13. Tschoeke, N., Fisk, S., Pellino, T., et al. (2010). Patient’s pain experience during and following the Mohs’ procedure. Dermatology Nursing, 22(6), 11–17. 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.

RESOURCES AND WEB SITES Canadian Alopecia Areata Foundation (CANAAF); http://canaaf.org/ Canadian Association of Wound Care; http://www.cawc.net Canadian Cancer Society/Société canadienne du cancer; http://www. cancer.ca Canadian Dermatology Association; http://www.dermatology.ca Canadian Directory of Genetic Support Groups, Support Group Directory; http://www.lhsc.on.ca/programs/medgenet/ Center for Genetic Health Tips; http://www.cgdn.ca Canadian Organization for Rare Disorders (CORD); http://www.cord.ca Canadian Society for Molecular Biosciences (CSMB); http://www.csmbscbm.ca/index.aspx Dermatology Information System, a cooperation between the Department of Clinical Social Medicine (University of Heidelberg) and the Department of Dermatology (University of Erlangen); http://www. dermis.net Eczema Canada; http://www.eczemacanada.ca GeneTests; http://www.genetests.org Health Canada; http://www.hc-sc.gc.ca/ Lupus Canada; http://www.lupuscanada.org Melanoma Education Foundation; http://www.skincheck. org Psoriasis Society of Canada; http://www.psoriasissociety.org Rosacea Awareness Program; http://www.about-rosacea.com

CHAPTER

58 Management of Patients With Burn Injury Adapted by Michelle Zwicker

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 each phase. 4. Compare and contrast the potential fluid and electrolyte alterations of the emergent/resuscitative and acute phases of burn management. 5. 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. 6. 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. 7. Use the nursing process as a framework for care of the patient during the three phases of burn care.

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The 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 For children 0–19 years of age in Canada, the incidence of severe burn injuries has decreased between 1994 and 2003. During this time period, 494 children died and 10,229 were admitted to hospitals for burns (Spinks, Wasiak, Cleland, et al., 2008). Half of all pediatric burns were caused by scalding with hot liquids and steam. Males in all age groups were twice as likely as females to experience burns. Heat, electricity, radiation as in sunburn, friction, and chemicals were the cause of admission of approximately 3,200 people to Canadian hospitals in 2005–2006 because of burn injuries. Of those admitted to the emergency departments, the majority were adults aged 40 to 49 years, followed by children (Shehata, Youssef, & Pater, 2013). The risk of death increases significantly if the patient has sustained both a cutaneous burn injury and a smoke inhalation injury. Young children and older people are at particularly high risk for burn injury. Their skin is thin and fragile; there-

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fore, even a limited period of contact with a source of heat can create a full-thickness burn. Chart 58-1 presents the ranking of “fire/burn” as cause of death by age group in the United States. 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 also one of the leading causes of household fires in North America. The U.S. Fire Administration/National Fire Data Center (2005b, 2005c) reports the major factors contributing to cooking fires include unattended cooking, grease, and combustible materials on the stovetop. The U.S. Fire Administration/National Fire Data Center (2010) now reports that smoking is the leading cause of fatal residential building fires, with the origins of the fires being the bedroom and common areas such as the living room and family rooms. Burns can also occur from work-related injuries. Education to prevent burn injuries in the workplace should include safe handling of chemicals and chemical products and increasing awareness of the potential for injuries caused by hot objects and substances. Patients with burns secondary to the illegal manufacturing of the drug methamphetamine are appearing with increasing frequency in burn centres. These patients are often admitted with both severe burns and inhalation injury (Santos, Wilson, Hornung, et al., 2005). The National Institute for Burn Medicine, which collects statistical data from burn centres 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 or lighters, 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

Glossary alloderm: processed dermis from human cadaver skin; can be used as dermal layer for skin grafts autograft: 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: compound of carbon monoxide and hemoglobin, formed in the blood with exposure to carbon monoxide collagen: 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 grafted 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: linear excision made through eschar to release constriction of underlying tissue excision: surgical removal of tissue fasciotomy: incision made through the fascia to release constriction of underlying muscle heterograft: graft obtained from an animal of a species (i.e., pigskin) other than that of the recipient; also called a xenograft homograft: 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

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There are four major goals relating to burns:

CHART 58-1

Ranking of “Fire/Burn” as Cause of Death by Age Group Age (years) 1–4 5–9 10–14 15–24 25–34 35–44 45–54 55–64 65–85+ All ages, all races, both sexes

Rank 3 3 3 7 5 5 4 5 5 7

Unintentional Injuries and Adverse Effects, from the National Center for Injury Prevention and Control, 2002.

of gasoline. The U.S. Home Product Report, 1993–1997 (2000) indicated that there were over 140,000 gasolinerelated 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 58-2). Promoting the use of smoke alarms and carbon monoxide detectors has had the greatest impact on decreasing fire deaths in Canada.

CHART 58-2

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 and carbon mon• • • • • • • • • • • •

oxide detectors in the home; check batteries once a month. Develop and practice a home exit fire drill with all members of the household. Set the water heater temperature no higher than 48.9°C. Do not smoke in bed. Do not fall asleep while smoking. Do not smoke while using oxygen. 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 pot handles turned into centre of stove. Keep hot curling irons and hot irons out of reach of children. Keep a working fire extinguisher in your home and in your car.

1. Prevention 2. Institution of lifesaving measures for the severely burned person 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, Calvert, Peck, 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 preexisting medical conditions, respectively. Chances of survival are greater in children older than 5 years and in adults younger than 40 years. Outcome depends on the depth and extent of the burn as well as on the preinjury 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 (Sheridan & Tompkins, 2004).

Gerontologic Considerations Scalds and flames are the leading causes of burn injury in older people. Reduced mobility, changes in vision and cognitive function, and decreased sensation in the feet and hands place older people at higher risk for burn injury. 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 older patients than in younger patients. Thinning and loss of elasticity of the skin in the older predisposes 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 older population. Nurses need to assess an older patient’s ability to perform activities of daily living safely, assist older patients and families to modify the environment to ensure safety, and make referrals as needed.

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PATHOPHYSIOLOGY OF BURNS

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Burn Depth

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, electrical (which can include thermal), chemical, and radiation. 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 severity of the burn injury depends on the temperature of the burning agent and the duration of contact with the agent. Hot beverages (i.e., coffee, tea, hot chocolate) are usually served at 71° to 82°C, resulting in almost instantaneous burns that will require surgery. One second of contact with hot tap water at 68°C may result in a burn that destroys both the epidermis and the dermis, causing a full-thickness (third-degree) injury. Fifteen seconds of exposure to hot water at 56.1°C results in a similar fullthickness injury. Splash and spill burns may not be as deep as burns suffered in a bathtub if the source of the hot liquid is removed immediately from the skin, therefore lessening the severity of the burn. Temperatures less than 43°C are tolerated for long periods without injury. A temperature of 38°C is considered safest for bathing (American Burn Association, 2000).

Classification of Burns Burn injuries are described according to the depth of the injury and the extent of body surface area injured.

TABLE 58-1

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Burns are classified according to the depth of tissue destruction as superficial injuries, superficial partialthickness injuries, deep partial-thickness injuries, or fullthickness injuries. Burn depth determines whether reepithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider. See Chapter 57 for discussion and a diagram of the skin layers; see also Table 58-1. (The categories of superficial, 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 burn injury the epidermal layer of the skin is injured. The damaged skin may be painful and appear dark pink, dry, and tender, as in a sunburn. It usually heals quickly within 7 days. In a superficial partial-thickness burn, the epidermis is destroyed and the upper layers of the dermis are injured. It is characteristically dark pink or red in colour, with blisters present. There is some mild edema and it is very painful. Capillary blanching is still present. It takes longer to heal, usually 10 to 14 days. A deep partial-thickness burn involves destruction of the epidermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. It has decreased sensation and has delayed capillary blanching. Hair follicles and other dermal appendages remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars; skin grafting may be necessary. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, may involve the subcutaneous and fascia layers as well. Wound colour ranges widely from white to red, brown, or black. The burned area is painless because nerve fibres are destroyed, and it does not blanch. The wound appears leathery; hair follicles and sweat glands are destroyed (Fig. 58-1). Excision of the burn wound and skin grafting is necessary.

Characteristics of Burns According to Depth Superficial (First Degree)

Superficial Partial Thickness (Second Degree)

Deep Partial Thickness (Second Degree)

Full Thickness (Third Degree)

Skin Depth

Minimal epithelial damage

Epidermis Minimal dermis

Entire epidermis, part of dermis Leaving hair and sweat glands intact

Mechanism of Injury Pain

Sunburn (ultraviolet light)

Hot liquids; flash flame

Painful Pain usually resolves within 3–5 d Pinkish red, dry. Blisters after 24 h Blanches with pressure

Supersensitive to pain

Hot liquid or solids; flame; chemicals; electrical injury Sensitive to pressure

Complete epidermis, Complete dermis Portion of subcutaneous fat, may involve connective tissue, bone, muscle Sustained flame, electrical, chemical, and steam Limited/no pain

Dry, pale, waxy No blanching

Leathery, cracked, avascular, white, cherry red, or black

30 d to mo Late hypertrophic scarring, marked contracture formation

Cannot self-regenerate; needs grafting

Colour

Healing Time

5–10 d with no scarring

(Morton, Fontaine, Hudak, et al., 2005)

Moist Blisters Pink or mottled red Blanches to light pressure 21–28 d Minimal scarring

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Zone of hyperemia 9%

Zone of stasis Zone of coagulation

Skin Anterior 18% Subcutaneous tissue 9%

Posterior 18%

9%

1% 18% 18%

FIGURE 58-1. 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.

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

FIGURE 58-2. 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 numeric 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.

Extent of Body Surface Area Injured

Palm Method

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.

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.

Rule of Nines

Electrical Burns

An estimation of the TBSA involved in a burn is simplified by using the rule of nines (Fig. 58-2). 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.

Electrical injury accounts for a small percentage of burn unit admissions each year, yet it is one of the worst types of burn injuries that can be sustained. The devastating effects of an electrical injury can cause lifelong neurovascular problems. High-voltage (more than 1,000 volts) injury can cause tissue and bone destruction resulting in amputations and may lead to cardiac and respiratory abnormalities resulting in the possible loss of life. A true electrical injury results when a current of electricity travels through the body and exits to the ground itself. With a true electrical injury, there is contact with the electrical source (an entrance wound), and contact with the grounding site (an exit wound). An arc injury is the result of the electricity’s traveling on the outside of the body or arcing around it. Often, the clothes catch fire because of the high energy. The patient ends up with a thermal burn and often small, spiderlike markings that make a path on the skin. The cutaneous injury from electrical sources is usually small compared with the damage under the surface of the skin. Electricity travels through areas of least resistance and destroys everything in its path—nerves and blood

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, changes with growth. Because of changes in body proportion with growth, the calculated TBSA changes with age as well. 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 postburn days because the demarcation usually is not clear until then.

CHAPTER 58

vessels first; bones are destroyed last, as they are most resistant. The stronger the current and the longer the duration of contact are, the more severe the injury is. For a patient with an electrical burn, once the patient is out of the path of the electricity, emergency care can safely be provided. The ABCs of emergency care are always followed. An electrical current immediately contracts muscles as it travels through the body, and cardiac arrhythmias and spinal injuries often result from the muscular contraction. A cardiac monitor should be used for 3 days after the injury or until the patient is stable due to the arrhythmias that may develop. Until it is known that the patient has no fractures, it is imperative that a neck collar remains in place and that the patient be logrolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. For a patient with an electrical burn, prompt administration of intravenous (IV) fluids using fluid resuscitation formulas and monitoring of urine output are critical components of care. Patients with electrical burns are prone to acute renal failure because of the release of myoglobin from the destruction of muscle and tissue. Myoglobin can constrict renal arteries and renal tubules blocking the flow of urine through the kidneys. Patients can have gross hematuria on admission to the hospital. Administration of high amounts of IV fluids helps to maintain the flow of urine. It is difficult to assess the amount of fluid a patient will require because the electrical injury creates so much damage inside the body. The nurse should expect 75 to 100 mL/h of urine output for an adult patient who is receiving fluid resuscitation. In patients with electrical injuries, neurovascular checks of affected extremities are very important. A person can have neurovascular complications for as long as 2 years after the incident occurred. Baseline neurologic and functional status must be assessed as soon as possible to rule out any abnormalities that might appear at a later date (DeBoer & O’Connor, 2004; O’Keefe Gatewood & Zane, 2004).

Local and Systemic Responses to Burns 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 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 pro-

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tein from the intravascular space into the interstitial spaces. Figure 58-3 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 (Ahrns, 2004). 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 pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock will occur (see Chapter 16). 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 and electrolytes begin to remobilize back into the intravascular compartment and blood volume increases. If renal and cardiac function is adequate, urinary output increases. Diuresis continues for several days to 2 weeks.

Burn Edema Local swelling due to thermal injury is often extensive. Edema is defined as the presence of excessive fluid in the tissue spaces (Supple, 2004). As noted previously, 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 the greatest 18 to 24 hours after injury. 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 postburn period. Unnecessary overresuscitation will increase edema formation in both burn tissue and nonburn 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, which is a surgical incision into the eschar and superficial fascia (devitalized tissue resulting from a burn), permitting the cut edges to separate and restore blood flow to the tissues distal to the eschar and relieve the constricting effect of the burned tissue. This procedure can be performed in the emergency department or at the bedside.

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Physiology/Pathophysiology Major Burns >30% TBSA Cell lysis

Hemolysis

Capillary permeability

Hyperkalemia

Loss of skin barrier

Possible inhalation injury

Thermoregulation problems Sodium, H2 O, and protein shift from intravascular to interstitial spaces

Hemoglobin/ myoglobin in urine

Impaired immune response

Hyponatremia

Concentration of red blood cells

Inflammatory 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 58-3. Overview of physiologic changes that occur after major burn. TBSA, total body surface area; H2O, water; GI, gastrointestinal.

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 due to sodium and water shifting into the cells. Hyponatremia is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space.

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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. Anaerobic metabolism begins due to increased lactic acid levels, and metabolic acidosis occurs. 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 the use of smoke detectors and carbon monoxide detectors. Often, burn victims make it out of 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. When they reenter the burning home and are overcome with toxic smoke and fumes, they become disoriented or unconscious (McCall & Cahill, 2005; Sheridan & Tompkins, 2004). Inhalation injury has a significant impact on survivability of a burn patient. Inhalation injuries in combination with cutaneous burns are an important comorbid factor in burn injury that increases morbidity and mortality significantly (Tredget, Shankowsky, Taerum, et al., 1990). Deterioration in severely burned patients can occur even 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 (inflammation) of the upper airway, including the pharynx and larynx. It can also be exacerbated by the accumulation of excess interstitial fluid. 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.

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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 by-product 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 hemoglobin-binding 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 (it will reduce the half-life of carbon monoxide from 4 hours to 40 minutes). Restrictive defects arise when edema develops under full-thickness burns encircling the neck and thorax. Chest excursion may be greatly restricted, resulting in decreased tidal volume. In such situations, escharotomy is necessary to help improve ventilation and oxygenation. Pulmonary abnormalities are not always immediately apparent. More than half of all burn patients with pulmonary involvement do not initially demonstrate pulmonary signs and symptoms. Any patient with possible inhalation injury must be observed for at least 48 hours for respiratory complications. Airway obstruction may 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 • Laboured 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

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diagnosis in the early postburn period. Pulmonary function studies may also be useful in diagnosing decreased lung compliance or obstructed airflow (Fitzpatrick & Cioffi, 2002; McCall & Cahill, 2005; Sheridan & Tompkins, 2004). 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 2 to 5 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 24.

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 (e.g., 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 Chapter 45). The immunologic defenses of the body are greatly altered by burn injury. Serious burn injury diminishes resistance to infection as alternations in the immune cells affect their ability to function. As a result, sepsis continues to be the leading cause of morbidity and mortality in patients with thermal injuries (Bowler, Jones, Walker, et al., 2004; Neely, Fowler, Kagan, et al., 2004). 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 (Saffle, 2003; Gosain & Gamelli, 2005b). 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. 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. Narcotics for pain management may also slow peristalsis. 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 vomi-

tus. These signs suggest gastric or duodenal erosion (Curling’s ulcer). Patients with large burn wounds are at risk for abdominal compartment syndrome, especially if fluid resuscitation is delayed (Sheridan & Tompkins, 2004). Fluid shifts into the abdominal cavity cause increased abdominal distention, decreasing urine output and resulting in hypotension and difficulty with ventilation. Bladder pressures greater than 25 to 30 mm Hg over time are an indicator of increasing abdominal pressure. Drainage of fluid via an abdominal tap or laparotomy aids in reducing abdominal pressure. Three components of the gastrointestinal tract are altered after burn injury: first, the mucosal barrier becomes permeable; second, the permeability allows for overgrowth of gastrointestinal bacteria; and third, the bacteria translocate to other organs, causing infection. Patients are unable to defend against their own bacteria due to immunosuppression in burn injury. In addition, alcohol ingestion is common in the burn population. Alcohol is known to affect intestinal integrity and immune response, leading to translocation of bacteria and possible bleeding complications (Gosain & Gamelli, 2005a).

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 58-2.

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 58-3.

Airway, Breathing, Circulation Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life. Therefore,

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TABLE 58-2

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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

• • • • • • • • • • • •

it is important to remember the ABCs of all trauma care during the early postburn period: • 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” (Disability, Exposure, and Fluid Resuscitation) in the trauma assessment: disability, exposure, and fluid resuscitation (Weibelhaus & Hansen, 2001).

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 counselling

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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.

CHART 58-3

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 until the flames go out (“stop, 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 (i.e., pillowcase) 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. Flushing/rinsing should be done for at least 20 minutes. 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.

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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 (DeBoer & O’Connor, 2004).

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NURSING ALERT

No food or fluid is given by mouth, and the patient is placed in a position (HOB elevated) that will prevent aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury. The burn wound, once it has been cooled, should be wrapped in a clean, dry sheet/cloth. A pillow case is suitable for upper and lower limb injuries. Polyvinyl chloride film (cling film) is a good alternative to cover the burned areas as it forms an impermeable, nonadherent barrier that minimizes contamination by shielding the burn wound from secondary infection, reduces pain produced by the exposure of the damaged nerve endings (in partial-thickness burns) to the air currents, and provides protection during transport (Shrivastava & Goel, 2010). Being transparent, it also allows the wound to be viewed for assessment without having to be removed, it does not shed fibres into the wound, and it is easily removed without causing further trauma. It is important to lay the film on the patient, not wrap the area, as swelling may lead to constriction. It is advisable to avoid using wet dressings as heat loss during transfer can be considerable. Topical creams should not be applied as this may interfere with subsequent assessments, unless the Burn Centre has specifically requested it (Edwards, 2011). Once the rescue workers have covered the burn wounds, they should keep the patient warm, have an established airway, supply oxygen, and insert at least one large-bore IV line.

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 lifesaving 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. 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, TBSA involved, depth of the burn, the place where the burn occurred, how the burn was treated at the scene, and any history of falling with the injury. A history of pre-existing 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) IV catheter should be inserted in a nonburned area (if not inserted earlier). Most patients have a central venous catheter inserted so that large amounts of IV fluids can be given quickly and central venous pressures can be monitored. If the burn exceeds 25% TBSA, a nasogastric tube should be inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus (absence of peristalsis), and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the abdomen and prevent vomiting. For burns greater than 25% TBSA, an indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function during fluid resuscitation. 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, masks, 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. 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. Baseline height, weight, arterial blood gases, hemoglobin, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained. If the patient is older or has an electrical burn, a baseline electrocardiogram is obtained. Because burns are contaminated

CHAPTER 58

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 burn patient is usually anxious and in pain, those in attendance should provide reassurance and support, explanations of procedures, and adequate pain relief. As poor tissue perfusion often accompanies burn injuries, only IV pain medication (usually morphine or fentanyl) is given, titrated for the patient. If the patient wishes to see a spiritual advisor, one is notified.

Transfer to a Burn Centre The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn centre. 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 centre. Chart 58-4 lists the American Burn Associa-

CHART 58-4

Burn Unit Referral Criteria A burn unit may treat adults or children or both. Burn injuries that should be referred to a burn unit include the following: 1. Partial-thickness burns greater than 10% total body surface area (TBSA) 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Full-thickness burns in any age group >5% TBSA 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality 8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma centre before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. 9. Burned children in hospitals without qualified personnel or equipment for the care of children 10. Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention Excerpted from Guidelines for the Operation of Burn Centers (pp. 79–86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons.

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tion’s criteria for burn centre referral after initial assessment and management. If the patient is to be transported to a burn centre, the following measures are instituted before transfer: • A secure IV catheter is inserted with lactated Ringer’s solution infusing at the rate required to maintain a urine output of at least 30 to 60 mL/h. • 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. • An indwelling urinary catheter is inserted for burns greater than 25% TBSA. All assessments and treatments are documented, and this information is provided to the burn centre personnel. The transferring facility must relay accurate intake and output totals to burn centre personnel so that adequate fluid resuscitation measures continue.

Management of Fluid Loss and Shock Next to handling respiratory difficulties, the most urgent need is preventing hypovolemic shock by replacing lost fluids and electrolytes. As mentioned previously, survival of burn victims depends on adequate fluid resuscitation. Table 58-3 summarizes the fluid and electrolyte changes in the emergent phase of burn care. IV lines and an indwelling urinary 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 postburn (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 (Atiyeh, Gunn, & Hayek, 2005). FLUID REPLACEMENT THERAPY. The total volume and rate of IV 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 60 mL/h 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/min.

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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, hemoglobin, and serum sodium levels. If the hematocrit and the hemoglobin levels decrease or if the urinary output exceeds 60 mL/h, the rate of IV 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

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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)

Potassium (K+) excess

Massive cellular trauma causes release of K+ into extracellular fluid (ordinarily, most K+ is intracellular).

Sodium (Na+) deficit

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.

Metabolic acidosis (base-bicarbonate deficit) Hemoconcentration (elevated hematocrit)

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, Melcer, Horbrand, 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 postburn 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 (lactated Ringer’s solution or physiologic sodium chloride). Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 postburn 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. The length of time since the 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 58-5.

As early as 1978, the National Institutes of Health 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 postburn hours. Recently, the Parkland formula has been renamed the Consensus formula because it is the most widely used resuscitation guideline. The Advanced Burn Life Support curriculum supports the use of the Consensus formula for resuscitation in burn injury (Latenser, 2009). The Consensus formula provides for the volume of IV solution required in the first 24 hours after burn injury. In general, 4 mL/kg per percent burn of lactated Ringer’s solution may be used initially for adults as it most closely resembles extracellular (normal body) fluids. Starting from the time of injury, half of the calculated fluid total is to be given over the first 8 postburn hours, and the other half is 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 hourly infusion rates. Fluid boluses are recommended only in the presence of marked hypotension, not low urine output. Although the Consensus formula is commonly used today, there is still not complete agreement about which fluid resuscitation formula is best for burn injury. Again, practitioners should take note that the resuscitation formulas serve only as guidelines, and the patient’s response to fluid therapy is the best parameter to use (Atiyeh et al., 2005). 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 millilitres 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 Consensus formula in a 70-kg patient with a 50% TBSA burn: 1. Consensus formula: 4 mL/kg/% TBSA 2. 4 × 70 × 50 = 14,000 mL/24 h 3. Plan to administer: First 8 hours = 7,000 mL, or 875 mL/h; next 16 hours = 7,000 mL, or 437.5 mL/h

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CHART 58-5

Guidelines and Formulas for Fluid Replacement in Burn Patients Consensus Formula

Lactated Ringer’s solution: 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 × 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 previous day’s colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and thirddegree (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

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. There is a need for close monitoring for risk of hypernatremia and renal failure.

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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 older patients with even relatively minor burns during the emergent and acute phases. Acute renal failure is much more common in older patients than in those younger than 40 years. The margin of difference between

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 litre, 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. The risk of hypernatremia and the risk of renal failure must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications.

hypovolemia and fluid overload is very small. Suppressed immunologic response, a high incidence of malnutrition, and an inability to withstand metabolic stressors (e.g., a cold environment) further compromise the older person’s ability to heal. As a result of these issues in older 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 consideration. 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 monitored

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hourly; the Doppler device is useful for this. Elevation of burned extremities is crucial to decrease edema. Elevation of the upper and lower extremities on pillows may be helpful. Suspension of limbs using IV poles may be used, but close monitoring of pressure areas is required. Large-bore IV catheters and an indwelling urinary catheter are inserted, if not already in place, 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-coloured 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 IV fluids. Administering and monitoring IV 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 head-to-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 behaviour. 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 (Chart 58-6).

Acute or Intermediate Phase of Burn Care The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is

directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, wound débridement, topical antibacterial therapy, wound dressing, dressing changes, and skin grafting), pain management, and nutritional support are priorities at this stage and will be discussed in detail. Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke components with lung tissues become apparent. Pulmonary complications are not unusual in burn injury. Those with ventilator-associated pneumonia (VAP) have a 40% mortality rate, increasing to 60% to 77% for VAP with an inhalation injury. Tracheobronchial toilet or bronchioalveolar lavage can assist in the diagnosis and treatment of pneumonia (Wahl, Ahrns, Brandt, et al., 2005). Ideally, the best practice is to remove the endotracheal tube as soon as possible so that a route for pathogens is not accessible to the lungs. The arterial blood gas values and other parameters determine the need for intubation or mechanical ventilation. As capillaries regain integrity, at 48 or more postburn hours, fluid moves from the interstitial to the intravascular compartment and diuresis begins (Table 58-4). If cardiac or renal function is inadequate, for instance in the older patient or in the patient with pre-existing cardiac disease, fluid overload occurs and symptoms of congestive heart failure may result (see Chapter 31). Early detection allows for early intervention and carefully calculated fluid intake. Vasoactive medications, diuretics, and fluid restriction may be used to support circulatory function and prevent congestive heart failure and pulmonary edema. Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to intravascular compartments, losses of fluid from large burn wounds, and the patient’s physiologic responses to the burn injury. Blood components are administered as needed to treat blood loss and anemia. Fever is common in burn patients after burn shock resolves. A resetting of the core body temperature in severely burned patients results in a body temperature a few degrees higher than normal for several weeks after the burn. Bacteremia and septicemia also cause fever in many patients. Acetaminophen and hypothermia blankets may be required to maintain body temperature in a range of 37.2° to 38.3°C to reduce metabolic stress and tissue oxygen demand. Central venous, peripheral arterial, or pulmonary artery thermodilution catheters may be required for monitoring venous and arterial pressures, pulmonary artery pressures, pulmonary capillary wedge pressures, or cardiac output. Early placement of pulmonary artery catheters can be useful in patients with known myocardial dysfunction, age greater than 65 years, severe inhalation injury, or fluid requirements greater than 150% of that predicted by formula (Yowler et al., 2000). Generally, however, invasive vascular lines are avoided unless essential because they provide an additional port for infection in an already greatly compromised patient. (text continued on page 1857)

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Plan of Nursing Care NURSING INTERVENTIONS

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Chart 58-6. Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury

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 laboured 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. 8. Assist with bronchoscopy

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

• Breaths sounds clear on auscultation • Arterial oxygen saturation >94% 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 airway patency and mechanical ventilation. Escharotomy enables chest excursion in circumferential chest burns. 7. Monitoring allows early detection of decreasing respiratory status or complications of mechanical ventilation. 8. Gold standard for assessment of inhalation injury. Allows for direct visualization of upper and lower airways, direct evidence of charring, soot deposition, and/or mucosal ulceration.

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 mobilize, turn, cough, and deep breathe. Encourage patient to use incentive spirometry. Suction as needed.

1. A patent airway is crucial to respiration. 2. Humidity liquefies secretions and facilitates expectoration. 3. These activities promote mobilization and removal of secretions.

• Patent airway • Respiratory secretions are minimal, colourless, and thin

• Respiratory rate, pattern, and breath sounds normal

continued >

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 58-6. Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury, Continued

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from 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. 3. Maintain intravenous (IV) lines and regulate fluids at appropriate rates, as prescribed. 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.

1. Hypovolemia is a major risk immediately after the burn injury. Over resuscitation might cause fluid overload.

• Serum electrolytes within normal

2. Output and weight provide information about renal perfusion, adequacy of fluid replacement, and fluid requirement and fluid status. 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.

• Heart rate less than 120 beats/min • Exhibits clear sensorium • Voids clear yellow urine with specific

limits

• Urine output between 30–60 mL/h • Blood pressure higher than 90/60 mm Hg

gravity within normal limits

5. Elevation promotes venous return, decreases the cardiac workload of the heart, assists in the prevention of aspiration and facilitates ventilation, and reduces edema in the head, neck, and hands. 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 warm blankets, heat lamps, and forced-air warming blankets (i.e., Bair huggers). 2. Work quickly when wounds must be exposed. 3. Assess core body temperature frequently.

1. A stable environment minimizes evaporative heat loss.

• Body temperature remains 36.1°–38.3°C

• Absence of chills or shivering

2. Minimal exposure minimizes heat loss from wound. 3. Frequent temperature assessments help to detect developing hypothermia.

Nursing Diagnosis: Pain related to tissue and nerve injury and emotional impact of injury Goal: Control of pain 1. Use a pain intensity scale to assess pain level (i.e., 0 to 10). Differentiate from hypoxia.

2. Administer IV opioid analgesics as prescribed. Observe for respiratory depression in the patient who is not mechanically ventilated. Assess response to analgesic.

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. IV administration is necessary because of altered tissue perfusion from burn injury.

• States pain level is decreased • Absence of nonverbal cues of pain

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Plan of Nursing Care

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Chart 58-6. Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury, Continued

NURSING INTERVENTIONS

RATIONALE

3. Provide emotional support and reassurance.

3. Emotional support is essential to reduce fear and anxiety resulting from burn injury. Fear and anxiety increase the perception of pain.

EXPECTED OUTCOMES

Nursing Diagnosis: Anxiety related to fear and emotional impact of burn injury Goal: Minimization of patient and family’s anxiety 1. Assess patient and family’s understanding of burn injury, coping skills, and family dynamics. 2. Individualize responses to the patient and family’s coping level. 3. Explain all procedures to the patient and the family in clear, simple terms. 4. Maintain adequate pain relief. 5. Consider administering prescribed antianxiety medications if the patient remains extremely anxious despite nonpharmacologic interventions. 6. Consider consulting psychology.

1. Previous successful coping strategies can be encouraged 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 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. 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. 6. Depression, regression, and manipulative behaviour are common responses of patients who have burn injuries.

• Patient and family verbalize understanding of emergent burn care

• Able to answer simple questions • The patient will develop effective coping strategies

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.

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. May also indicate sepsis. 5. Acute respiratory failure is life threatening, and immediate intervention is required. 6. Intubation allows mechanical ventilation. Escharotomies allow improved chest excursion with respirations.

• Arterial blood gas values within

acceptable limits: PO2 >80 mm Hg, PCO2

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Plan of Nursing Care NURSING INTERVENTIONS Distributive Shock 1. Assess for decreasing urine output, central venous pressures, 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. 3. Remove blood pressure cuff after each reading. 4. Elevate burned extremities. 5. Report loss of pulse or sensation or presence of pain to physician immediately. 6. Prepare to assist with escharotomies.

Paralytic Ileus 1. For burns greater than 25% - maintain nasogastric tube on low intermittent suction until bowel sounds resume. 2. Auscultate for bowel sounds, abdominal distention.

Chart 58-6. Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury, Continued

RATIONALE

EXPECTED OUTCOMES

1. Such signs and symptoms may indicate distributive shock and inadequate intravascular volume.

• Urine output between 30–60 mL/h • Blood pressure within patient’s

2. As fluid shifts into the interstitial spaces in burn shock, edema occurs and may compromise tissue perfusion. A pulse rate 120 beats/min usually indicative of hypovolemia. Narrowed pulse pressure provides an earlier indication of shock than systolic blood pressure alone. 3. Optimal fluid resuscitation prevents distributive shock and improves patient outcomes. 1. These values reflect renal function. 2. These laboratory values indicate possible renal failure.

expected range (usually >90/60 mm Hg) • Heart rate within patient’s expected range (usually 0.16). There were significant differences between burn patients’ acceptable level, resting level, and procedural pain levels (p = 0.01). Patients reported their baseline pain as less than their acceptable level of pain. Other findings noted that family presence during procedure was related to decreased procedural pain and decreased use of medications prescribed for relief of anxiety. Nursing Implications Because burn patients describe burn wound care procedures to be the most painful experience, efforts should be made to identify strategies that are effective in reducing pain intensity. Also, since pain and anxiety were linked, strategies need to be developed to decrease both. The researchers suggested that use of both pharmacologic and nonpharmacologic interventions during wound care procedures may be warranted to help patients cope with anxiety, resting pain, and pain associated with wound care procedures. Future studies of the effect of different pharmacologic interventions with larger and more diverse samples are needed.

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Research has shown that sleep deprivation leads to increased reports of pain, and vice versa, in patients with burns. The problem arises with administration of opioids, which affect various sleep stages by decreasing rapid eye movement (REM) sleep, leading to hyper arousal. Many other agents used to treat burn injury, such as bronchodilators and antipruritics, interfere with sleep, which in turn can interfere with pain management (Jaffe & Patterson, 2004). The use of nonpharmacologic measures aids in the management of burn pain. These measures include relaxation techniques, deep-breathing exercises, distraction, guided imagery, hypnosis, therapeutic touch, humour, and information giving as well as music therapy (Ferguson & Voll, 2004). Researchers have found that music affects both physiologic and psychological aspects of the pain experience. It diverts the patient’s attention from the painful stimulus; provides reality orientation, distraction, and sensory stimulation; and allows for patient self-expression (Calne, 2004).

Nutritional Support Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. Metabolic responses are mediated by the stimulation of the sympathetic nervous system to release catecholamines, cortisol, glucagon, and insulin. The body’s response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. Hypermetabolism can affect morbidity and mortality by increasing the risk of infection and slowing the healing rate. Patients’ metabolic demands vary with the extent of the burn injury and age (Demling, 2005b). Hypermetabolism is evident immediately after a burn injury. The degree of the response depends on the size of the burn and the patient’s age, body composition, size, and genetic response to insult (Dudek, 2010). Persistent hypermetabolism may last up to 1 year after burn injury (Hart, Wolf, Chinkes, et al., 2000). Major metabolic abnormalities seen after a burn injury include increased catabolic hormones (cortisol and catechols); decreased anabolic hormones (human growth factor and testosterone); a marked increase in the metabolic rate; a sustained increase in body temperature; a marked increase in glucose demands; rapid skeletal muscle breakdown with amino acids serving as the energy source; lack of ketosis, indicating that fat is not a major source of calories; and catabolism that does not respond to nutrient intake (Demling & Seigne, 2000). Metabolic measures using indirect calorimetry provide more accurate assessments of energy expenditure and caloric demand. Therefore, it is essential to control the stress response by increasing the anabolic process through adequate nutrition and increased muscle activity, decreasing heat loss from wounds, and maintaining a warm environment. Controlling secondary stress, such as pain and anxiety, also helps to control the stress response. The most important of these interventions is to provide adequate nutrition and calories to decrease catabolism (Supple, 2004). Healing of the burn wound consumes large quantities of energy. Patients with burns greater than 40% TBSA have resting metabolic rates twice that of normal (Pereira, Murphy, & Herndon, 2005). Effective nutrition management depends on how well the energy

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Management of Patients With Burn Injury

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expenditure due to the burn injury can be estimated and matched with appropriate amounts of micronutrients, carbohydrates, lipids, and protein. The goal of nutritional support is to promote a state of positive nitrogen balance by optimizing nutrition to match nutrient utilization (Flynn, 2004). The nutritional support required is based on the patient’s preburn status and the TBSA burned. Several formulas exist for estimating the daily metabolic expenditure and caloric requirements of patients with burn injuries. The most commonly used formulas include the Curreiri formula, which uses body weight and percent burn, and a variation of the Harris–Bennedict equation, which determines basal energy requirements based on stress and burn size (Demling & Seigne, 2000). Nutritional targets have remained static in recent years, with most programs striving for protein goals of 2 to 3 g/kg/d and caloric targets of 1.5 times a calculated basal metabolic rate or 1.2 times the resting energy expenditure measured using indirect calorimetry. Glucose is ideally not the only fuel because high levels are not oxidized in this hormonal milieu. Additionally, adequate amounts of micronutrients and vitamins are essential (Sheridan & Thompkins, 2004). Lipids are included in the nutritional support of every burn patient because of their importance for wound healing, cellular integrity, and absorption of fat-soluble vitamins. Carbohydrates are included to meet caloric requirements and to spare protein (provide adequate energy so that protein is not broken down to fuel the hypermetabolic response), which is essential for wound healing. The patient also needs adequate vitamins and minerals. Existing formulas may underestimate the daily metabolic expenditures associated with burns. The formulas fail to account for added stressors such as pain, anxiety, daily dressing changes, and decreased activity levels. These must be considered when estimating appropriate nutritional support. Research findings have brought about changes in specific guidelines for estimating energy expenditure during the various phases of postburn recovery. The proportions of fat, protein, and carbohydrate must be carefully planned for maximal use (Demling & Seigne, 2000). The enteral route of feeding is far superior to the parenteral route, and most patients tolerate gastric feedings without difficulty. Enteral feedings preserve the intestinal barrier function and absorption of peptides and amino acids, which leads to higher nitrogen retention. Feedings are started as soon as possible. The placement of feeding tubes into the stomach is preferred as it maintains gastric peristalsis, the secretion of digestive enzymes from the stomach, and it is easier to obtain access for gastric feeds. Placement of feeding tubes into the duodenum helps prevent aspiration and allows for continuous, uninterrupted feedings during surgical procedures. If the oral route is used, high-protein, high-calorie meals and supplements are given. Inhalation injury and prolonged intubation lead to dysphagia in patients with burn injuries. Speech therapists work closely with the burn team to help the patient preserve swallowing function. Their work enables the patient to eat with less risk of aspiration and less energy consumption (Dubose, Groher, Mann, et al., 2005; Snyder & Ubben, 2003). Dietary consultations are useful in helping patients meet their nutritional needs. Daily calorie counts aid in assessing the adequacy of nutritional intake. Overfeeding must be

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avoided, because it increases metabolism, oxygen consumption, and carbon dioxide production (Saffle, 2003). Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited. Because a burn injury lowers the patient’s resistance to infection and disease, the nutritional status must be improved and maintained although the patient has a poor appetite and is weak. One goal of nutrition management is to decrease or stop the catabolic process and promote protein anabolism. Beta-blockers that alter the catabolic state in children with burn injuries are also being investigated (Supple, 2004). Supplemental vitamins and minerals, including the nonessential amino acid glutamine, are given to provide support when the patient is in the hypermetabolic, infection-prone state of acute burn injury (Sheridan & Tompkins, 2004). In addition, research is focused on aggressive alteration of the hyperglycemic response and administration of insulin therapy to promote wound healing. Other treatment modalities include early excision and skin grafting of the burn wound, aggressive prevention or treatment of infections, and adequate exercise with physical therapy to lessen muscle wasting and increase strength. Additional pharmacologic modalities used to alter the hypermetabolic state of burn injury include the use of oxandrolone (Oxandrin), an anabolic steroid; an adrenergic antagonist (propranolol [Indural]); and an anabolic protein, recombinant human growth hormone (Pereira et al., 2005). Indications for parenteral nutrition include inadequate intake of enteral nutrition due to clinical status, prolonged wound exposure, periods of ileus, often induced by sepsis, and malnutrition or debilitated condition before injury. This route is more difficult to monitor and is not without serious potential complications. The risk of infection at the site of the central venous catheter required for parenteral nutrition must be considered. Moreover, the risk of Curling’s ulcer continues in the acute phase. When properly used for moderate periods, properly administered parenteral nutrition has not been associated with morbidity and can have an important protective effect on lean body mass (Sheridan & Thompkins, 2004).

results in the replacement of normal integument with highly metabolically active tissues that lack the normal architecture of the skin. In the collagen layer beneath the epithelium, many fibroblasts proliferate gradually. Myofibroblasts, cells that have the ability to contract, are also present in immature wounds. As the myofibroblasts contract, the collagen fibres, which normally lie in flat bundles, tend to form a wavy pattern. Eventually, the collagen bundles take on a super-coiled appearance, and collagen nodules develop. The scar becomes red (because of its hypervascular nature), raised, and hard. Burn personnel must be proactive in the prevention and management of scar formation. Compression measures are instituted early in burn wound treatment. Elastic bandages (ACE, Tensor) are used initially to help promote adequate circulation, but they can also be used as the first form of compression. Scar management occurs mainly in the rehabilitative phase, after the wounds are closed. Hypertrophic scarring may cause severe contracture across involved joints. Therefore, prevention and management of this type of scarring is essential (see Prevention of Hypertrophic Scarring section in the rehabilitation phase discussion). However, these scars are limited to the area of injury and gradually regress over time.

Disorders of Wound Healing

Contractures

Disorders of wound healing in the burn patient result from excessive abnormal healing or inadequate new tissue formation. Hypertrophic scarring and keloid formation result from excessive abnormal healing.

Keloids Keloids are the result of an overgrowth of granulation tissue that may develop and extend beyond the wound surface (unlike scar tissue which stays within the wound edges. Keloids tend to be found in people with darkly pigmented skin, tend to grow outside of wound margins, and are likely to recur after surgical excision.

Failure to Heal Failure of the wound to heal may result from many factors, including infection, an underlying disease process, shearing, pressure, or inadequate nutrition. A serum albumin level of less than 2 g/dL is usually a factor in impaired healing in the burn patient.

Contractures are another concern as wounds heal. The burn wound tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing. An opposing force provided by splints, traction, and purposeful movement and positioning must be used to counteract deformity in burns affecting joints.

Scars One of the most devastating sequelae of a burn injury is the formation of hypertrophic scars. Clinicians cannot reliably predict or prevent the formation of hypertrophic scars. Hypertrophic scars are more common in children, in people with dark skin, and in areas of stretch or motion. The pathophysiology behind these scars is not completely understood, but they are characterized by an overabundant matrix formation, especially collagen. Hypertrophic scars and wound contractures are more likely to occur if the initial burn injury extends below the level of the deep dermis. Healing of such deep wounds

!!"##

Nursing Process

Care of the Patient During the Acute Phase Assessment Continued assessment of the burn patient during the early weeks after the burn injury focuses on

CHAPTER 58

hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Assessment of respiratory and fluid status remains the highest priority for detection of potential complications. The nurse assesses vital signs frequently. Continued assessment of peripheral pulses is essential for the first few postburn days while edema continues to increase, potentially damaging peripheral nerves and restricting blood flow. Observation of the electrocardiogram may give clues to cardiac dysrhythmias resulting from potassium imbalance, pre-existing cardiac disease, or the effects of electrical injury or burn shock. Assessment of residual gastric volumes and pH in the patient with a nasogastric tube is also important. Blood in the gastric fluid or the stools must also be noted and reported. Assessment of the burn wound requires an experienced eye, hand, and sense of smell. Important wound assessment features include size, colour, odour, eschar, exudate, abscess formation under the eschar, epithelial buds (small pearl-like clusters of cells on the wound surface), bleeding, granulation tissue appearance, status of grafts and donor sites, and quality of surrounding skin. Any significant changes in the wound are reported to the physician, because they usually indicate burn wound or systemic sepsis and require immediate intervention. Other significant and ongoing assessments focus on pain and psychosocial responses; daily body weights; caloric intake; general hydration; and serum electrolyte, hemoglobin, and hematocrit levels. Assessment for excessive bleeding from blood vessels adjacent to areas of surgical exploration and débridement is necessary as well. The Plan of Nursing Care provides an outline of nursing activities in the acute phase of burn care.

Diagnosis Nursing Diagnoses Based on assessment data, priority nursing diagnoses in the acute phase of burn care may include the following: • Excessive fluid volume related to resumption of capillary integrity and fluid shift from the interstitial to intravascular compartment • Risk for infection related to loss of skin barrier and impaired immune response • Imbalanced nutrition (less than body requirements) related to hypermetabolism and wound healing needs • Impaired skin integrity related to open burn wounds • Acute pain related to exposed nerves, wound healing, and treatments • Impaired physical mobility related to burn wound edema, pain, and joint contractures • Ineffective coping related to fear and anxiety, grieving, and forced dependence on health care providers

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Management of Patients With Burn Injury

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• Interrupted family processes related to burn injury • Deficient knowledge about course of burn treatment

Collaborative Problems/ Potential Complications Based on assessment data, potential complications that may develop in the acute phase of burn care may include the following: • • • • •

Heart failure and pulmonary edema Sepsis Acute respiratory failure ARDS Visceral damage (electrical burns)

Planning and Goals The major goals for the patient may include restoration of normal fluid balance, absence of infection, attainment of anabolic state and normal weight, improved skin integrity, reduction of pain and discomfort, optimal physical mobility, adequate patient and family coping, adequate patient and family knowledge of burn treatment, and absence of complications. Achieving these goals requires a collaborative, interdisciplinary approach to patient management (Chart 58-8).

Nursing Interventions Restoring Normal Fluid Balance To reduce the risk of fluid overload and consequent congestive heart failure, the nurse closely monitors IV and oral fluid intake, using IV infusion pumps to minimize the risk of rapid fluid infusion. To monitor changes in fluid status, careful intake and output and daily weights are obtained. Changes, including those of blood pressure and pulse rate, are reported to the physician (invasive hemodynamic monitoring is avoided because of the high risk of infection). Lowdose dopamine to increase renal perfusion and diuretics may be prescribed to promote increased urine output. The nurse’s role is to administer these medications as prescribed and to monitor the patient’s response.

Preventing Infection A major part of the nurse’s role during the acute phase of burn care is detecting and preventing infection. The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Culture results and white blood cell counts are monitored. Strict aseptic technique is used for wound care procedures. Aseptic technique is also used for any invasive procedures, such as insertion of IV lines and urinary catheters or tracheal suctioning. Meticulous hand hygiene before and after each patient contact or any object or furniture in the patient’s environment is also an essential component of preventing infection, (text continued on page 1874)

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Plan of Nursing Care NURSING INTERVENTIONS

Chart 58-8. Care of the Patient During the Acute Phase of Burn Injury

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Fluid volume excess related to resumption of capillary integrity and fluid shift from interstitial to intravascular compartment Goal: Maintenance of optimal fluid balance 1. Monitor vital signs, intake and output, weight. Assess for edema, jugular venous distention (JVD), crackles, and increased arterial pressures. 2. Notify physician of urine output

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Plan of Nursing Care

Chart 58-8. Care of the Patient During the Acute Phase of Burn Injury, Continued

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

2. Educate the patient about the usual pain trajectory in burn recovery and options for pain control. Allow patient as much control as possible regarding pain management. 3. Offer analgesics approximately 20 min before painful procedures. 4. Provide analgesia before pain becomes severe. 5. Instruct and assist patient in relaxation, imagery, and distraction techniques. 6. Assess and document the patient’s response to interventions.

2. Knowledge reduces fear of the unknown and provides some measure of control to the patient.

• Gives no physiologic or nonverbal

7. Administer antianxiety and antipruritic agents as indicated. 8. Lubricate healing burn wounds with water- or silica-based lotion (nonperfumed).

3. Premedication allows time for therapeutic response. 4. Pain is more easily controlled before it becomes severe. 5. Nonpharmacologic pain measures provide multiple interventions to decrease pain sensation. 6. Patient’s responses assist in ascertaining best pain control techniques for the patient. 7. These medications help to increase patient’s comfort. 8. These preparations decrease sensation of skin tightness.

cues of moderate or severe pain

• Uses pain control measures such as

nitrous oxide, relaxation, imagery, and distraction techniques to assist with coping with pain • Can sleep without being disturbed by pain • Reports skin is comfortable with no itching or tightness

Nursing Diagnosis: Impaired physical mobility related to burn wound edema, pain, and joint contractures Goal: Achievement of optimal physical mobility 1. Position patient carefully to prevent flexed position in burned areas. 2. Implement range-of-motion (ROM) exercises several times daily. 3. Assist with early sitting and ambulation. 4. Use splints and exercise devices recommended by occupational and physical therapists. 5. Encourage self-care to the extent of the patient’s ability.

1. Proper positioning reduces risk of flexion contractures. 2. ROM exercises minimize muscle atrophy. 3. Early mobility encourages increased use of muscles. 4. Such devices encourage activity while maintaining proper position of joints. 5. Self-care promotes both independence and increased activity.

• Improves ROM of joints daily • Demonstrates preinjury ROM of all joints

• Absence of signs of periarticular calcification or HO (heterotopic ossification: abnormal formation of bone in response to soft tissue trauma) • Participates in activities of daily living

Nursing Diagnosis: Ineffective individual coping related to fear and anxiety, grieving, and forced dependence on health care providers Goal: Use of appropriate coping strategies to deal with postburn problems 1. Assess patient for coping abilities and previous successful coping strategies. 2. Demonstrate acceptance of patient. Provide positive feedback and support. 3. Assist patient to set achievable shortterm goals for increased independence in activities of daily living. 4. Use multidisciplinary approach to promote mobility and independence. 5. Consult with health care team members for assistance with regressive or maladaptive behaviours.

1. Psychosocial data provide baseline for planning care. 2. Acceptance encourages self-esteem and continued progress toward independence. 3. Short-term goal setting leads to pattern of success for patient. Longterm goals may seem unrealistic or unattainable to patient. 4. Communication among disciplines provides consistent approach. 5. Collaboration uses the expertise of others.

• Verbalizes reactions to burns, therapeutic procedures, and losses

• Identifies effective coping strategies

used previously in stressful situations

• Accepts dependency on health care providers during acute illness

• Resolves grief over losses resulting from burn injury

• Participates in decision making regarding care

• Has hopeful attitude toward future

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Chart 58-8. Care of the Patient During the Acute Phase of Burn Injury, Continued

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Altered family processes related to burn injury Goal: Achievement of appropriate patient/family processes 1. Assess patient and family’s perception of impact of burn injury on family functioning. 2. Demonstrate willingness to listen. Provide realistic support. 3. Refer family to social services and other resources as needed. 4. Explain the burn patient’s coping patterns to family. Discuss ways that they can support the patient.

1. Assessment data provide baseline from which to plan care. 2. Empathetic attitude promotes verbalizing of concerns. 3. Collaboration assists to address concerns comprehensively. 4. Explanations help to decrease anxiety about the unknown and promote appropriate support of patient by family.

• Patient verbalizes feelings regarding alteration in family interactions

• Family can emotionally support the patient during hospitalization

• Family states that needs are met

Nursing Diagnosis: Knowledge deficit about course of burn treatment Goal: Verbalization of understanding of course of burn treatment by patient and family 1. Assess readiness of patient and family to learn. 2. Explore patient and family’s previous experience with hospitalization and illness. 3. Review general course of burn treatment with patient and family. 4. Explain importance of patient participation in care for optimal results. 5. Realistically explain length of time involved in burn recovery.

1. Limit education to patient and family’s ability to process information. 2. This information provides a baseline for explanations and indication of patient and family’s expectations. 3. Knowing what to expect prepares patient and family for upcoming events. 4. This information provides specific direction to patient. 5. Honesty promotes realistic expectations.

• States rationale for different aspects of treatment

• States realistic time period for recovery

• Patient and family participate in management plans as appropriate

Collaborative Problems: Congestive heart failure, pulmonary edema, sepsis, acute

respiratory failure, acute respiratory distress syndrome, visceral damage (electrical burns)

Goal: Absence of complications

Congestive Heart Failure (CHF) and Pulmonary Edema 1. These signs may indicate decreased 1. Assess for decreased urine output, cardiac output and the onset of JVD, or an S3 or S4 heart sound. CHF. 2. Increased pressures indicate 2. Monitor for increases in arterial presincreased preload and intravascular sures or decrease in cardiac output. volumes. Decreasing cardiac output reflects less oxygen and nutrients available to the tissues and may indicate the onset of CHF. 3. Such signs may indicate progression 3. Assess for crackles on lung auscultaof CHF to pulmonary edema. tion, dyspnea, orthopnea, or decreased oxygenation detected by pulse oximetry or arterial blood gas values. 4. Prompt medical intervention is 4. Report the above mentioned signs needed. and symptoms to the physician. 5. Elevation facilitates gas exchange. 5. Position patient with the head of bed up 45 degrees to 90 degrees as tolerated. 6. Diuretics increase urine output and 6. Administer diuretics as prescribed. decrease cardiac preload and intraAssess patient’s response. vascular volumes.

• Breath sounds clear upon auscultation • Absence of dyspnea, orthopnea, JVD, and S3 or S4 heart sounds

• Urine output, arterial pressures, and cardiac output within normal limits

continued >

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Plan of Nursing Care NURSING INTERVENTIONS Sepsis 1. Assess for fever, increased pulse, widened pulse pressure, and flushed, dry skin in unburned areas. Watch trends and notify physician if noted. 2. Monitor wound, blood, sputum, and urine cultures, and notify physician of positive cultures. 3. Administer fluids, vasoactive medications, and antibiotics as prescribed. Monitor for therapeutic response. Check that infecting organisms are sensitive to prescribed antibiotics. 4. Monitor for therapeutic serum antibiotic levels.

Chart 58-8. Care of the Patient During the Acute Phase of Burn Injury, Continued

RATIONALE

EXPECTED OUTCOMES

1. Such signs may indicate impending sepsis.

• Negative blood, sputum, and urine

2. Positive cultures indicate infection and possible sepsis.

pulse pressure, and flushed, dry skin in unburned areas

3. Antibiotics kill susceptible bacteria. Intravenous fluids and vasoactive medications maintain intravascular volume and blood pressure. 4. Antibiotics are most effective at therapeutic levels. Excessive levels can cause organ damage.

Acute Respiratory Failure/Acute Respiratory Distress Syndrome (ARDS) 1. Such problems indicate possible 1. Assess for respiratory distress, acute respiratory failure. Pulmonary changes in respiratory patterns, or complications may not appear for onset of adventitious breath sounds. 24 to 48 h after the burn injury. Report to physician. 2. Decreasing oxygenation indicates 2. Monitor pulse oximetry and arterial deteriorating respiratory status. blood gas levels for decreasing oxyMedical intervention is needed. gen saturation and PO2. Report to physician. 3. Respiratory problems reflect 3. Monitor the mechanically ventilated increased difficulty with ventilation patient for decreased spontaneous and may indicate the onset of ARDS. tidal volumes and lung compliance. 4. These measures optimize diffusion 4. In collaboration with the physician of oxygen across the alveolar– and respiratory therapist, administer capillary membrane. positive end-expiratory pressure and pressure support. Assess patient’s response. Visceral Damage (Electrical Burns) 1. Assess patient for signs of deep pain. Focus on areas between the contact point with the electrical source and contact point with the grounding site. 2. Monitor electrocardiogram (ECG) rhythm. 3. Report to physician any complaints of deep pain or dysrhythmias. 4. Monitor electrolytes, enzymes, clotting factors (CK and troponin).

cultures

• Absence of tachycardia, widening

1. Pain may reflect visceral damage.

• Arterial blood gases within normal limits

• Normal lung compliance • Absence of respiratory distress • Improved PO2 level

• Absence of visceral organ damage • Stable cardiac rhythm

2. The patient with electrical burns is at risk for arrhythmias. 3. Visceral damage requires immediate intervention. 4. CK-MB and troponin levels are often elevated with electrical injuries, especially if the current pathway involves the chest/thorax

even though gloves are worn to provide care. Gloves are not a substitution for hand hygiene. The nurse protects the patient from sources of contamination, including other patients, staff members, visitors, and equipment. Invasive lines and tubing must be routinely changed according to recommendations of the CDC (2011). Tube feeding reservoirs, ventilator circuits, and drainage containers are replaced regularly. Fresh flowers, plants, or fresh

fruit baskets are not permitted in the patient’s room because of the risk of microorganism growth. Visitors are screened to avoid exposing the immunocompromised burn patient to pathogens. Patients can inadvertently promote migration of microorganisms from one burned area to another by touching their wounds or dressings. Bed linens also can spread infection through either colonization with wound microorganisms or fecal contamination.

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Regularly bathing unburned areas and changing linens can help to prevent infection.

Maintaining Adequate Nutrition Oral fluids should be initiated slowly when bowel sounds resume. The patient’s tolerance is noted. If vomiting and distention do not occur, fluids may be increased gradually and the patient may advance to a normal diet or to tube feedings. The nurse collaborates with the dietitian or nutrition support team to plan a protein- and calorie-rich diet that is acceptable to the patient. Family members may be encouraged to bring nutritious and favourite foods to the hospital. Milkshakes and sandwiches made with meat, peanut butter, and cheese may be offered as snacks between meals and late in the evening. Nutritional supplements such as Ensure and Resource may be provided. Caloric intake must be documented. Vitamin and mineral supplements may be prescribed. If caloric goals cannot be met by oral feeding, a feeding tube is inserted and used for continuous or bolus feedings of specific formulas. The volume of residual gastric secretions should be checked to ensure absorption. Parenteral nutrition may also be required but should be used only if gastrointestinal function is compromised (see Chapter 37). Patients should be weighed each day and their weights graphed. Patients can use this information to set goals for their own nutritional intake and to monitor weight loss and gain. Ideally, the patient will lose no more than 5% of preburn weight if aggressive nutritional management is implemented. The patient with anorexia requires encouragement and support from the nurse to increase food intake. The patient’s surroundings should be as pleasant as possible at mealtime. Catering to food preferences and offering high-protein, high-vitamin snacks are ways of encouraging the patient to increase intake.

Promoting Skin Integrity Wound care is usually the most time-consuming element of burn care after the emergent phase. The physician will prescribe the desired topical antibacterial agents and specific biologic, biosynthetic, or synthetic wound coverings and will plan for surgical excision and grafting. The nurse needs to make astute assessments of wound status, to use creative approaches to wound dressing, and to support the patient during the emotionally distressing and very painful experience of wound care. The nurse serves as the coordinator of the complex aspects of wound care and dressing changes for the patient. The nurse must be aware of the rationale and nursing implications for the various wound management approaches. Nursing functions include assessing and recording any changes or progress in wound healing and keeping all members of the health care team informed of changes in the wound or treatment. A diagram, updated daily by the nurse responsible for the patient’s care, helps to inform all of

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those concerned about the latest wound care procedures in use for the patient. The nurse also assists the patient and family by providing instruction, support, and encouragement to take an active part in dressing changes and wound care when appropriate. Discharge planning needs for wound care are anticipated early in the course of burn management, and the strengths of the patient and family are assessed and used in preparing for eventual discharge and home care.

Relieving Pain and Discomfort Pain measures discussed earlier are continued during the acute phase of burn recovery. Analgesic agents and anxiolytic medications are administered as prescribed. Frequent assessment of pain and discomfort is essential. To increase its effectiveness, analgesic medication is provided before the pain becomes severe. Nursing interventions such as teaching the patient relaxation techniques, giving the patient some control over wound care and analgesia, and providing frequent reassurance are helpful. Guided imagery may be effective in altering the patient’s perceptions of and responses to pain. Other pain-relieving approaches include distraction through video programs or video games, hypnosis, biofeedback, and behavioural modification. The nurse assesses the patient’s sleep patterns daily. Lack of sleep and rest interferes with healing, comfort, and restoration of energy. If necessary, sedatives are prescribed on a regular basis in addition to analgesics and anxiolytics. The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. The patient is encouraged to take analgesic medications before painful procedures. The patient’s response to the medication and other interventions is assessed and documented. Healing burn wounds are typically described by patients as itchy and tight. Oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based lotion, exercise and splinting to prevent skin contracture, and diversional activities help to promote comfort in this phase.

Promoting Physical Mobility An early priority is to prevent complications resulting from immobility. Deep breathing, turning, and proper repositioning are essential nursing practices that prevent atelectasis and pneumonia, control edema, and prevent pressure ulcers and contractures. These interventions are modified to meet the patient’s needs. Low–air-loss and rotation beds may be useful, and early sitting and ambulation are encouraged. Whenever the lower extremities are burned, elastic pressure bandages (ACETM, TensorTM) should be applied before the patient is placed in an upright position. These bandages promote venous return and minimize swelling. The burn wound is in a dynamic state for a year or more after wound closure. During this time, aggressive efforts must be made to prevent contracture and hypertrophic scarring. Both passive and active range-of-motion

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exercises are initiated from the day of admission and are continued after grafting, within prescribed limitations. Splints or functional devices may be applied to extremities for contracture control. The nurse monitors the splinted areas for signs of vascular insufficiency, nerve compression, and areas of pressure.

Strengthening Coping Strategies In the acute phase of burn care, the patient is facing the reality of the burn trauma and is grieving over obvious losses. Depression, regression, and manipulative behaviour are common responses of patients who have burn injuries. Withdrawal from participation in required treatments and regression must be viewed with an understanding that such behaviour helps the patient cope with an enormously stressful event. Although most patients recover emotionally from a burn injury, some have more difficult psychological reactions to the injury and its outcomes (Sgroi, Willebrand, Ekselius, et al., 2005). Personality characteristics, rather than the size or severity of the injury, determine the ability of the patient to cope after burn injury (Kildal, Willebrand, Andersson, et al., 2004). Difficulty coping along with other psychological stressors often limits the patient’s physical and psychological recovery (Fauerbach, Lezotte, Hills, et al., 2005). Patients who experience a burn injury may have high rates of involvement in risky behaviours (e.g., alcohol and substance abuse, depression) before the injury (Kildal et al., 2004). They may also have poor coping skills. Coping styles and perceived threat of death at the time of the burn injury are strong predictors of how well the patient recovers psychologically in the postburn period (Willebrand, Andersson, & Ekselius, 2004). The presence of nightmares may be a screening tool for symptoms of posttraumatic stress disorder (PTSD) (Low, Dyster-Aas, Kildal, et al., 2006). Intrusive thoughts of the burn event and reliving it over and over may also occur and can indicate PTSD (DysterAas, Willebrand, Wikehult, et al., 2008). Much of the patient’s energy goes into maintaining vital physical functions and wound healing in the early postburn weeks, leaving little emotional energy for coping in a more effective manner. Nurses can assist patients to develop effective coping strategies by setting specific expectations for behaviour, promoting truthful communication to build trust, helping patients practice appropriate strategies, and giving positive reinforcement when appropriate. Most importantly, the nurse and all members of the health care team must demonstrate acceptance of the patient. The patient frequently vents feelings of anger. At times, the anger may be directed inward because of a sense of guilt, perhaps for causing a fire or even for surviving when loved ones perished. The anger may reach outward toward those who escaped unharmed or to those who are now providing care (Wikehult, Hedlund, Marsenic, et al., 2008). One way to help the patient handle these emotions is to enlist someone to whom the patient can vent feelings without fear of retaliation. A nurse, social worker, psychiatric

liaison nurse, or clergy member who is not involved in direct care activities may fill this role successfully. Burn patients are very dependent on health care team members during the long period of acute illness. However, even when physically unable to contribute much to self-care, they can be included in decisions regarding care and encouraged to assert their individuality in terms of preferences and recognition of their unique identities. As patients improve in mobility and strength, the nurse works with them to set realistic expectations for self-care, including self-feeding, assistance with wound care procedures, exercise, and planning for the future. Many patients respond positively to the use of contractual agreements and other strategies (i.e., a daily schedule) that recognizes their independence and their specific role as part of the health care team moving toward the goal of self-care. Consultation with psychiatric/ mental health care providers may be helpful to assist the patient in developing effective coping strategies.

Supporting Patient and Family Processes Family functioning is disrupted with burn injury. One of the nurse’s responsibilities is to support the patient and family and to address their spoken and unspoken concerns. Family members need to be instructed about ways that they can support the patient as adaptation to burn trauma occurs. The family also needs support by the health care team. The burn injury has tremendous psychological, economic, and practical impact on the patient and family. Referrals for social services or psychological counselling should be made as appropriate. This support continues into the rehabilitation phase. Burn patients are commonly sent to burn centres far from home. Because burn injuries are not anticipated, family roles are disrupted. Therefore, both the patient and the family need thorough information about the patient’s burn care and expected course of treatment. Patient and family education begins at the initiation of burn management. Barriers to learning are assessed and considered in teaching. The preferred learning styles of both the patient and family are assessed. This information is used to tailor teaching activities. The nurse assesses the ability of the patient and family to grasp and cope with the information. Verbal information is supplemented by videos, models, or printed materials, if available. Patient and family education is a priority in the acute and rehabilitation phase. Nurses must remain sensitive to the possibility of changing family dynamics. It is not unusual for the provider in the family to be the one who is injured. Roles begin to change, which adds more stress to the family. In addition, families are often relocated due to loss of property from a fire. Social services play an integral part in providing support at this time.

Monitoring and Managing Potential Complications HEART FAILURE AND PULMONARY EDEMA. The patient is assessed for fluid overload, which may

CHAPTER 58

occur as fluid is mobilized from the interstitial compartment back into the intravascular compartment. If the cardiac and renal systems cannot compensate for the excess vascular volume, congestive heart failure and pulmonary edema may result. The patient is assessed for signs of heart failure, including decreased cardiac output, oliguria, jugular vein distention, edema, and the onset of an S3 or S4 heart sound. If invasive hemodynamic monitoring is used, increasing central venous, pulmonary artery, and wedge pressures indicate increased fluid volume. Crackles in the lungs and increased difficulty with respiration may indicate a fluid buildup in the lungs, which is reported promptly to the physician. In the meantime, the patient is positioned comfortably, with the head of the bed raised (if not contraindicated because of other treatments or injuries) to promote lung expansion and gas exchange. Management of this complication includes providing supplemental oxygen, administering IV diuretic agents, carefully assessing the patient’s response, and providing vasoactive medications, if indicated. SEPSIS. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient’s status. Early signs of sepsis may include confusion, increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas. As with many observations of the burn patient, one needs to look for patterns or trends in the data. (Refer to Chapter 16 for a more detailed discussion of septic shock.) Wound and blood cultures are performed as prescribed, and results are reported to the physician immediately. The nurse also observes for and reports early signs of sepsis and promptly intervenes, administering prescribed IV fluids and antibiotics to prevent septic shock, which is a complication with a high mortality rate. Antibiotics must be given as scheduled to maintain proper blood concentrations. Serum antibiotic levels are monitored for evidence of maximal effectiveness, and the patient is monitored for toxic side effects. ACUTE RESPIRATORY FAILURE AND ACUTE RESPIRATORY DISTRESS SYNDROME. The patient’s

respiratory status is monitored closely for increased difficulty breathing, change in respiratory pattern, and onset of adventitious (abnormal) sounds. Typically, at this stage, signs and symptoms of injury to the respiratory tract become apparent. Respiratory failure may follow. As described previously, signs of hypoxia (decreased oxygen to the tissues), decreased breath sounds, wheezing, tachypnea, stridor, and sputum tinged with soot (or in some cases containing sloughed tracheal tissue) are among the many possible findings. Patients receiving mechanical ventilation must be assessed for a decrease in tidal volume and lung compliance. The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, decreased lung compliance, and significant shunting. The physician should be notified immediately of deteriorating respiratory status. Medical management of the patient with acute respiratory failure requires intubation and mechani-

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cal ventilation (if not already in use). If ARDS has developed, higher oxygen levels, positive end-expiratory pressure, and pressure support are used with mechanical ventilation to promote gas exchange across the alveolar–capillary membrane. VISCERAL DAMAGE. The nurse must be alert to signs of necrosis of visceral organs due to electrical injury. Tissues affected are usually between the contact point with the electrical source and contact point with the grounding site of the electrical burn. All patients with electrical burns should undergo electrocardiographic monitoring, with arrhythmias being reported to the physician. Monitoring of electrolytes, enzymes, and clotting factors (CK and troponin) should also be done. Careful attention must also be paid to signs or reports of pain related to deep muscle ischemia. To minimize the severity of complications, visceral ischemia must be detected as early as possible. The physician can perform a fasciotomy to relieve the swelling and ischemia in the muscles and fascia and to promote oxygenation of the injured tissues. Because of the deep incisions involved with fasciotomy, the patient must be monitored carefully for signs of excessive blood loss and hypovolemia.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Achieves optimal fluid balance a. Maintains intake and output and body weight that correlate with expected pattern b. Exhibits vital signs and central venous, pulmonary artery, and pulmonary artery wedge pressures within designated limits c. Demonstrates increased urine output in response to diuretic and vasoactive medications d. Has heart rate less than 110 beats/min 2. Has no localized or systemic infection a. Has wound culture results showing minimal bacteria b. Has normal urine and sputum culture results 3. Demonstrates anabolic nutritional status a. Gains weight daily after initial loss secondary to fluid diuresis and no oral intake of food or fluid b. Shows no signs of protein, vitamin, or mineral deficiencies c. Meets required nutritional needs entirely by oral intake d. Participates in selecting diet containing prescribed nutrients e. Exhibits normal serum protein levels 4. Demonstrates improved skin integrity a. Sustains generally intact skin that remains free of infection, pressure, and injury b. Demonstrates remaining open wound areas that are pink, reepithelializing, and free of infection c. Demonstrates donor graft sites that are clean and healing

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5.

6.

7.

8.

9.

10.

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Integumentary Function

d. Has healed wounds that are soft and smooth e. Demonstrates skin that is lubricated and elastic; soft and supple Has minimal pain a. Requests analgesic agents for specific wound care procedures or physical therapy activities b. Reports minimal or tolerable pain c. Gives no physiologic, verbal, or nonverbal cues that pain is moderate or severe d. Uses pain control measures such as nitrous oxide, relaxation, imagery, and distraction techniques to cope with and alleviate pain and discomfort e. Can sleep without being disturbed by pain f. Reports skin is comfortable, with no itching or tightness Demonstrates optimal physical mobility a. Improves range of motion of joints daily b. Demonstrates preinjury range of motion of all joints c. Has no signs of calcification around the joints d. Participates in activities of daily living Uses appropriate coping strategies to deal with postburn problems a. Verbalizes reactions to burns, therapeutic procedures, and losses b. Identifies coping strategies used effectively in previous stressful situations c. Accepts dependency on health care providers during acute phase d. Verbalizes realistic view of problems resulting from burn injury and plans for future e. Cooperates with health care providers in required therapy f. Participates in decision making regarding care g. Resolves grief over losses resulting from burn injury and circumstances surrounding injury (e.g., death of others, damage to home or other property, loss of income) h. States realistic objectives for plastic surgery, further medical intervention, and results i. Verbalizes realistic abilities and goals j. Displays hopeful attitude toward future Relates appropriately in patient/family processes a. Patient and family verbalize feelings regarding change in family interactions b. Family emotionally supports patient during hospitalization c. Family states that own needs are met Patient and family verbalize understanding of treatment course a. States rationale for different aspects of treatment b. States realistic time period for recovery Absence of complications a. Breath sounds clear on auscultation b. Exhibits no dyspnea or orthopnea and can breathe easily when standing, sitting, and lying down c. Exhibits no S3 or S4 heart sounds or jugular venous distention d. Exhibits urine output; central venous, pulmonary artery, and pulmonary artery wedge pres-

e. f. g. h. i.

sures; and cardiac output within normal or acceptable limits Exhibits normal blood, sputum, and urine culture results Maintains arterial blood gas values within normal or acceptable limits Has normal lung compliance Has no visceral organ damage Has stable cardiac rhythm

Rehabilitation Phase of Burn Care Although long-term aspects of burn care are discussed last in this chapter, rehabilitation begins immediately after the burn has occurred—as early as the emergent period—and often extends for years after injury. In the aftermath of the acute stages of injury, the burn patient increasingly focuses on the alterations in self-image and lifestyle that may occur. Wound healing, psychosocial support, and restoring maximal functional activity remain priorities. The focus on maintaining fluid and electrolyte balance and improving nutritional status continues. Reconstructive surgery to improve body appearance and function may be needed. Burn injuries can have a major impact on quality of life. Changes in physical activity and social, psychological, and employment status may occur (Dyster-Aas, Kildal, & Willebrand, 2007). Therefore, psychological and vocational counselling and referral to support groups may be helpful to promote recovery and quality of life. Family members also need support and guidance in assisting the patient to return to optimal health.

Prevention of Hypertrophic Scarring The wound is in a dynamic state for 1.5 to 2.0 years after the burn occurs. If appropriate measures are instituted during this active period, the scar tissue loses its redness and softens. Healed areas that are prone to hypertrophic scarring require the patient to wear a pressure garment (Fig. 58-6). These devices are especially useful for partialthickness wounds that require more than 2 weeks to heal and for the edges of grafted skin. Applying elastic pressure garments loosens collagen bundles and encourages parallel orientation of the collagen to the skin surface, with the disappearance of the dermal nodules. As pressure continues over time, there is a restructuring of the collagen and a decrease in vascularity and cellularity. However, pressure needs to be continuous. Many areas of the body are difficult to compress due to the contours or the presence of cartilage. Silastic inserts are used under the pressure garments to enhance scar compression. Gentle superficial massage aids in softening the connective tissue (Civaia, Fedele, Gallina, et al., 2003). The physical therapist, occupational therapist, or a representative of the manufacturer of elastic pressure garments measures the patient for correct fit. While awaiting the arrival of the garment, soft, tubular, knitted elastic

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1879

pressure wraps are documented on a regular basis. In addition to these assessment parameters, specific complications and treatments require additional specific assessments; for example, the patient undergoing primary excision requires postoperative assessment. Recovery from burn injury involves every system of the body. Therefore, assessment of the burn patient must be comprehensive and continuous. Priorities will vary at different points during the rehabilitation phase. Understanding the pathophysiologic responses to burn injury forms the framework for detecting early progress or signs and symptoms of complications. Early detection leads to early intervention and enhances the potential for successful rehabilitation. FIGURE 58-6. Elastic pressure garments. Application of pressure gar-

ments helps to prevent hypertrophic burn scarring. Used with permission of Jobst Institute, Inc., Toledo, Ohio.

Diagnosis

pressure bandages can be used to help desensitize the patient’s skin, protect healing areas, apply pressure, and promote venous return. Patients must be instructed about the need for lubrication and protection of the healing skin and the need for pressure garments for at least a year after the injury. A program including elastic pressure garments, splints, and exercise under the supervision of an experienced physical and occupational therapy team is recommended for optimal functional and cosmetic results.

Based on assessment data, priority nursing diagnoses in the long-term rehabilitation phase of burn care may include the following:

!!"##

Nursing Process

Care of the Patient During the Rehabilitation Phase Assessment Information about the patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions is obtained early. The patient’s self-concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern are also essential components of a comprehensive assessment. Information about the patient’s general self-concept, self-esteem, and coping strategies in the past will be valuable in addressing emotional needs. Ongoing physical assessments related to rehabilitation goals include range of motion of affected joints, functional abilities in activities of daily living, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin. The patient’s participation in care and ability to demonstrate self-care in such areas as ambulation, eating, wound cleaning, and applying

Nursing Diagnoses

• Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting, and limited endurance • Disturbed body image related to altered physical appearance and self-concept • Deficient knowledge about postdischarge home care and follow-up needs

Collaborative Problems/ Potential Complications Based on assessment data, potential complications that may develop in the rehabilitation phase include the following: • Contractures • Inadequate psychological adaptation to burn injury

Planning and Goals The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.

Nursing Interventions Promoting Activity Tolerance Nursing interventions that must be carried out according to a strict regimen and the pain that accompanies movement take their toll on a burn patient. The patient may become confused and disoriented and lack the energy to participate optimally in care. The nurse must schedule care in such a way that the patient has periods of uninterrupted rest and sleep. A good time for planned patient rest is after

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the stress of dressing changes and exercise, while pain interventions and sedatives may still be effective. This plan must be communicated to family members and other care providers. Burn patients may have insomnia related to frequent nightmares about the burn injury or to other fears and anxieties about the outcome of the injury. The nurse listens to and reassures the patient and administers hypnotic agents, as prescribed, to promote sleep. Reducing metabolic stress by relieving pain, preventing chilling or fever, and promoting the physical integrity of all body systems will help the patient conserve energy for therapeutic activities and wound healing. The nurse incorporates physical therapy exercises in the patient’s care to prevent muscle atrophy and to maintain the mobility required for daily activities. The patient’s activity tolerance, strength, and endurance will gradually increase if activity occurs over increasingly longer periods. Fatigue, fever, and pain tolerance are monitored and used to determine the amount of activity to be encouraged on a daily basis. Activities such as family visits and recreational or play therapy (e.g., video games, radio, television) can provide diversion, improve the patient’s outlook, and increase tolerance for physical activity.

Improving Body Image and Self-Concept Burn patients frequently suffer profound losses. These include not only a loss of body image due to disfigurement but also losses of personal property, homes, loved ones, and ability to work. They lack the benefit of anticipatory grief often seen in a patient approaching surgery or a person dealing with the terminal illness of a loved one. As care progresses, the patient who is recovering from burns becomes aware of daily improvement and begins to exhibit basic concerns: Will I be disfigured? How long will I be in the hospital? What about my job and family? Will I ever be independent again? Was my burn the result of my carelessness? As the patient expresses such concerns, the nurse must take time to listen and to provide realistic support. The nurse can refer patients to a support group, such as those usually available at regional burn centres. Through participation in such groups, patients will meet others with similar experiences and learn coping strategies to help them deal with their losses. Interaction with other burn survivors allows the patient to see that adaptation to the burn injury is possible. If a support group is not available, visits from burn survivors can be helpful to the patient coping with such a traumatic injury. A major responsibility of the nurse is to assess constantly the patient’s psychosocial needs. What are the patient’s fears and concerns? Does the patient fear loss of control of care, independence, or sanity itself? Is the patient afraid of rejection by family and loved ones? Does he or she fear being unable to cope with pain or physical appearance?

Does the patient have concerns about sexuality, including sexual function? Being aware of these anxieties and understanding the basis of the patient’s fears enable the nurse to provide support and to cooperate with other members of the health care team in developing a plan to help the patient deal with these feelings. When caring for burn patients, the nurse needs to be aware that there are prejudices and misunderstandings in society about those who are viewed as different. Opportunities and accommodations available to others are often denied to those who are disfigured. Such amenities include social participation, employment, prestige, various roles, and status. The health care team must actively promote a healthy body image and self-concept in burn survivors so that they can accept or challenge others’ perceptions of those who are disfigured. Survivors themselves must show others who they are, how they function, and how they want to be treated. The nurse can help patients practice their responses to people who may stare or inquire about their injury once they are discharged from the hospital. The nurse can help patients build self-esteem by recognizing their uniqueness—for example, with small gestures such as providing a birthday cake, combing the patient’s hair before visiting hours, giving information about the availability of a cosmetician to enhance appearance, and teaching the patient ways to direct attention away from a disfigured body to the self within. Consultants such as psychologists, social workers, vocational counsellor, and teachers are valuable participants in assisting burn patients to regain their self-esteem.

Monitoring and Managing Potential Complications CONTRACTURES. With early and aggressive physical and occupational therapy, contractures are rarely a long-term complication. However, surgical intervention is indicated if a full range of motion in the burn patient is not achieved. (Refer to Chapter 12 for a discussion of prevention of contractures.) IMPAIRED PSYCHOLOGICAL ADAPTATION TO THE BURN INJURY. Some patients, particularly those with

limited coping skills or psychological function or a history of psychiatric problems before the burn injury, may not achieve adequate psychological adaptation to the burn injury. Psychological counselling or psychiatric referral may be made to assess the patient’s emotional status, to help the patient develop coping skills, and to intervene if major psychological issues or ineffective coping is identified.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. As the inpatient phase of recovery becomes shorter, the focus of rehabilitative interventions is directed toward outpatient care or care in a rehabilitation centre. In the long term, much of the care of healing burns will be

CHAPTER 58

performed by the patient and others at home. Throughout the phases of burn care, efforts are made to prepare the patient and family for the care that will continue at home. Thus, they are instructed about the measures and procedures that they will need to perform. For example, patients commonly have small areas of clean, open wounds that are healing slowly. They are instructed to wash these areas daily with mild soap and water, and to apply the prescribed topical agent or dressing. In addition to instructions about wound care, patients and families require careful written and verbal instructions about prevention of complications, pain management, and nutrition. Information about specific exercises and use of pressure garments and splints is reviewed with both the patient and family; written instructions are provided for reference. They are taught to recognize abnormal signs and instructed to report them to the physician. All of this information will enable patients to progress successfully through the rehabilitative phase of burn management. The patient and family are assisted in planning for the patient’s continued care by identifying and acquiring supplies and equipment that are needed at home (Chart 58-9). CONTINUING CARE. Follow-up care by an interdisciplinary burn care team will be necessary. Preparations should begin during the early stages of care. Patients who receive care in a burn centre usually return to the burn clinic or centre periodically for evaluation by the burn team, modification of home care instructions, and planning for reconstructive surgery. Other patients receive ongoing care from the general or plastic surgeon who cared for them during the acute phase of their management. Still other patients require the services of a rehabilitation centre and may be transferred to such a centre for aggressive rehabilitation before going home. Many patients require outpatient physical or occupational therapy, often several times weekly. It is often the nurse who is responsible for coordinating all aspects of care and ensuring that the patient’s needs are met. Such coordination is an important aspect in assisting a burn victim to achieve independence. Patients who return home after a severe burn injury, those who cannot manage their own burn care, and those with inadequate support systems will need referral for home care. During visits to the patient at home, the home care nurse assesses the patient’s physical and psychological status as well as the adequacy of the home setting for safe and adequate care. The nurse monitors the patient’s progress and adherence to the plan of care and notes any problems that interfere with the patient’s ability to carry out the care. During the visit, the nurse assists the patient and family with wound care and exercises. Patients with severe or persistent depression or difficulty adjusting to changes in their social and/or occupational roles are identified and referred to the burn team for possible referral to a psychologist, psychiatrist, or vocational counsellor.

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The burn team or home care nurse identifies community resources that may be helpful for the patient and family. Several burn patient support groups and other organizations offer services for burn victims. They provide caring people (often recovered burn victims) who can visit a burn patient in the hospital or home or telephone the patient and family periodically to provide support and counselling about skin care, cosmetics, and problems related to psychosocial adjustment. Such organizations sponsor group meetings and social functions at which outpatients are welcome. Some also provide school reentry programs and are active in burn prevention activities. If more information is needed regarding burn prevention, the American Burn Association can help to locate the nearest burn centre (including locations in Canada) and offer current burn prevention tips (see Chart 58-2). Because so much attention is given to the burn wound and the treatments that are necessary to treat the burn wound and to prevent complications, the patient, family, and health care providers may inadvertently ignore the patient’s ongoing needs for health promotion and screening. Thus, the patient and family are reminded of the importance of periodic health screening and preventive care (e.g., gynecologic examinations, dental care).

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Demonstrates activity tolerance required for desired daily activities a. Obtains sufficient sleep daily b. Reports absence of nightmares or sleep disturbances c. Shows gradually increasing tolerance and endurance in physical activities d. Can concentrate during conversations e. Has energy available to sustain desired daily activities 2. Adapts to altered body image a. Verbalizes accurate description of alterations in body image and accepts physical appearance b. Demonstrates interest in resources that may improve body appearance and function c. Uses cosmetics, wigs, and prostheses as desired to achieve acceptable appearance d. Socializes with significant others, peers, and usual social group e. Seeks and achieves return to role in family, school, and community as a contributing member 3. Demonstrates knowledge of required self-care and follow-up care a. Describes surgical procedures and treatments accurately b. Verbalizes detailed plan for follow-up care c. Demonstrates ability to perform wound care and prescribed exercises

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CHART 58-9

HOME CARE CHECKLIST •

The Patient With a Burn Injury

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

✔ ✔ ✔ ✔ ✔ ✔ ✔

✔

Mental Health Identify strategies to promote own mental health; for example: • Remember that changes in lifestyle take time. • Resume previous interests and activities gradually. • Take one day at a time to regain physical and mental strength. • Be aware of own feelings and fears and discuss them with selected others. • Expect concerns, frustrations, and depression about changes in appearance. • Be honest with self, family, and friends about needs, hopes, and fears. • Realize that emotional adjustment to the burn injury will occur with time.

✔ ✔ ✔ ✔

Burn Skin Precautions and Wound Care Identify the following skin precautions and wound care: • Cover burned skin with light clothing or wear sun block with the highest sun protection factor (SPF) possible to protect burned skin from the sun. • Avoid further trauma to burned skin; leave unbroken blisters that may form. • Lubricate healed burned skin with mild nonperfumed lotion (as prescribed); avoid scratching. • Wear wide-brimmed hats if face has been burned to protect the area from the sun. • Use only mild soap and lotion (i.e., products without perfume) on burned areas.

✔ ✔ ✔ ✔ ✔

✔

✔

Exercise Describe the following guidelines for exercise: • Do as much for self as possible. • Adhere to the exercise regimen given by the therapist. • Participate in exercise every day, several times a day, even when “not feeling like it.”

✔ ✔ ✔

Nutrition Identify the following guidelines for nutrition: • Eat a diet high in calories and protein. • Drink adequate volume of fluids to prevent constipation associated with use of analgesic medications.

✔ ✔

Pain Management Describe the following steps for managing pain: • Take analgesic medication as prescribed. • Avoid situations that require alertness (analgesic agents may produce drowsiness). • Use analgesic medication as prescribed (30 minutes before painful procedures such as dressing changes). • Use relaxation and distraction to relieve pain and discomfort.

✔ ✔ ✔

✔

✔

Thermoregulation Identify strategies to compensate for inability to regulate body temperature: • Dress to accommodate cold and hot weather or environment. • Avoid extremes of temperature.

✔ ✔

Clothing Considerations State the following strategies in selection of clothing to wear: • Avoid tight clothing over burned areas. • Select white cotton, loose-fitting clothing so that dyes in coloured clothes does not irritate healing skin. • Wear clothing and gloves to protect healing skin from unnecessary bruises, bumps, and scratches.

✔ ✔ ✔

Management of Burn Scar Describe the following strategies to manage burn scar: • Massage and stretch skin to maintain/increase its elasticity. • Use lotion for massage as recommended by therapist. • Wear compression garments 23 hours a day.

✔ ✔ ✔

✔ ✔

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CHART 58-9

HOME CARE CHECKLIST •

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The Patient With a Burn Injury, continued Patient

Caregiver

Resumption of Sexual Relations Identify the following guidelines regarding resumption of sexual relationships: • Realize that resumption of sexual relationships is the rule rather than the exception. • Expect sensitivity of and around the genital area for several months if these areas were burned. • Resume sexual activity slowly; endurance will increase with time.

✔ ✔ ✔

✔

Adapted with permission from Orlando Regional Medical Center Burn Unit’s Personal Guide to Burn Care.

d. Returns for follow-up appointments as scheduled e. Identifies resource people and agencies to contact for specific problems 4. Exhibits no complications a. Demonstrates full range of motion b. Shows no signs of withdrawal or depression c. Displays no psychotic behaviours

BURN CARE IN THE HOME More and more burns are being treated exclusively in outpatient settings, including wound clinics, physicians’ offices, and emergency department clinics. The outpatient setting is appropriate for the care of minor burns. However, a number of factors must be considered in determining the appropriate site of care. These factors include the age of the patient, the extent and depth of the burn, the availability of family support systems and community resources to assist the patient, the patient’s adherence to the prescribed plan of care, and the distance from home to the outpatient setting. Initially, looking at and touching the burn wound may be difficult and even frightening to some family members and patients. However, with encouragement and support, most can handle burn wound care with little need for daily professional care. Instructions, both verbal and written, are given to the patient about burn wound care, pain management strategies, the need for adequate nutrition, and the importance of exercise and rest. Instruction is also given about signs and symptoms of infection that should be reported to the physician. The importance of notifying the physician about complications early and of keeping follow-up appointments is emphasized to the patient and family.

Gerontologic Considerations Nursing assessment of the older burn patient should include particular attention to pulmonary function, response to fluid resuscitation, and signs of mental confusion or disorientation. A careful history of preburn medications and pre-existing illnesses is essential. Nursing care promotes early mobilization, aggressive pulmonary care, and attention to preventing com-

plications. Because of lowered resistance, burn wound sepsis and lethal systemic septicemias are more likely in older patients. Moreover, fever may not be present in the older to signal such events. Therefore, surveillance for other signs of infection becomes even more important. Rehabilitation must take into account pre-existing functional abilities and limitations, such as arthritis and low activity tolerance. Older patients commonly lack family members who can provide home care, so social services and community nursing services must be contacted to provide optimal care and supervision after hospital discharge.

Critical Thinking Exercises 1

A 60-year-old man weighing 70 kg is transferred to the emergency department after his truck caught on fire. He has circumferential burns on both of his legs, his anterior chest, and his entire right upper extremity. He was unable to extricate himself from the truck and suffered inhalation burns as well. Using the rule of nines chart, estimate the percent of TBSA burned. What are the emergent priorities for this patient? What are the fluid resuscitation requirements for this patient based on his percent burn and his weight? What assessment parameters would you be monitoring closely? What pain management strategies would be indicated for this patient? What is the evidence for the use of pharmacologic and nonpharmacologic pain management strategies for this patient? How strong is that evidence, and what criteria would you use to evaluate the strength of that evidence? How would you use that evidence in providing care for this patient?

2 Your 25-year-old patient received burns over 60% of her body, including the upper extremities and face, as a result of a kitchen fire 2 weeks ago. She is depressed and distraught about the pain associated with wound care and the changes in her appearance. What assessments are important in her care, and what nursing interventions would be appropriate for her at this time?

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3 Your 26-year-old burn patient is scheduled for surgery. The burn physician plans on using Integra on his upper extremity burns after débridement as well as application of Acticoat to the superficial partial-thickness burns. What patient education would you give this patient about Integra and Acticoat? Explain what these two products are, their purpose, and the benefits of their use. Explain how the implications for nursing care differ for the two products. 4 Your 41-year-old patient, an attorney, is expected to be discharged from the hospital in a week following 6 weeks of treatment for severe burns to the lower part of her body. She has used a wheelchair for the last 20 years as a result of a spinal cord injury. The burns occurred when she was lighting a candle at home and it fell onto her clothing. What preparation would be important in making arrangements for referral and home care if she lives alone? What specific safety precautions should be included in discharge teaching for her?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS AND DOCUMENTS American Burn Association. (2000). Scalds: A Burning Issue. A Campaign Kit for Burn Awareness Week. Retrieved January 25, 2013 from: http:// www.ameriburn.org/Preven/2000Prevention/Scald2000PrevetionKit. pdf American Burn Association. (2006). Burn center referral criteria. Retrieved December 17, 2008, from http://www.ameriburn.org/ American Burn Association. (2013). National burn repository: 2013 report. Report data from 2003–2012. Retrieved August 15, 2013, from http://www.ameriburn.org/2013NBRAnnualReport.pdf Appleby, T. (2005). Burns. In P. G. Morton, D. K. Fontaine, C. M. Hudak, et al. (Eds.), Critical care nursing: A holistic approach. Philadelphia, PA: Lippincott Williams & Wilkins. Calne, S. (2004). Minimising pain at wound dressing-related procedures: A consensus document. In S. Calne (Ed.), Principles of best practice: A World Union of Wound Healing Societies’ initiative. London: Medical Education Partnership/Viking Print Services. Centers for Disease Control and Prevention. (2011). Guidelines for the prevention of intravascular catheter-related infections, 1–83. Centers for Disease Control and Prevention, & National Center for Injury Prevention and Control. (2003). 10 leading causes of death, United States 2003. Atlanta, GA: Author. Centers for Disease Control and Prevention (CDC) & National Center for Injury Prevention and Control. (2011). Fire deaths and injuries: Fact sheet. Retrieved June 17, 2013, from www.cdc.gov/HomeandRecreationalSafety/Fire-Prevention/fires-factsheet.html Dudek, S. G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Wolters, Kluwer Health/Lippincott Williams & Wilkins. Fitzpatrick, J. C., & Cioffi, W. G. (2002). Diagnosis and treatment of inhalation injury. In D. N. Herndon (Ed.), Total burn care (2nd ed.). Philadelphia, PA: WB Saunders. Fontaine, D. K., & Morton, P. G. (2005). Critical care nursing: A holistic approach. Philadelphia, PA: Wolters, Kluwer Health/Lippincott Williams & Wilkins. Herndon, D. N. (2002). Total burn care. Philadelphia, PA: WB Saunders. Hess, C. T. (2005). Wound care (5th ed.). Lippincott Williams & Wilkins. LaBorde, P. J., & Willis, J. M. (2013). Burns. In M. L. Sole, D. Klein, & M. Moseley (Eds.), Introduction to critical care nursing (6th ed.). Philadelphia, PA: WB Saunders. Micak, R., & Buffalo, M. (2007). Pre-hospital management, transportation, and emergency care. In D. N. Herndon (Ed.), Total burn care (2nd ed.). Philadelphia, PA: Saunders Elsevier.

Morton, P. G., Fontaine, D. K., Hudak, C. M., et al. (2005). Burn depth. Critical Care Nursing: A Holistic Approach (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. National Association of State Fire Marshalls (NASFM) Cooking Fires Taskforce and Association of Home Appliance Manufacturers (AHAM) Safety Cooking Campaign (1996). Ten–Community Study of Behaviors and Profiles of People Involved in Residential Cooking Fires Executive Summary. Washington, DC: Author. Retrieved Aug 19, 2013 from: www. aham.org/ht/a/GetDocumentAction/i/2316 Regional Wound Care Guidelines. (2009). Thermal Injuries. In Regional Wound Care Guidelines 8.9. Edmonton, AB: Alberta Health Services. Siegel, J. D., Rhinehart, E., Jackson, M., et al. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved Aug 19, 2013 from: http://www.cdc.gov/ ncidod/dhqp/pdf/isolation2007.pdf U.S. home product report, 1993–1997: Flammable or combustible liquids. (2000). Quincy, MA: National Fire Protection Association, Fire Analysis and Research Division.

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CHAPTER 58 DuBose, C., Groher, M. G., Mann, G. C., et al. (2005). Pattern of dysphagia recovery after thermal burn injury. Journal of Burn Care and Rehabilitation, 26(3), 233–237. Dyster-Aas, J., Kildal, M., & Willebrand, M. (2007). Return to work and health-related quality of life after burn injury. Journal of Rehabilitation Medicine, 39(1), 49–55. Dyster-Aas, J., Willebrand, M., Wikehult, B. et al. (2008). Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. Journal of Trauma-Injury Infection and Critical Care, 64(5), 1349–1356. Edwards, J. (2011). Management of minor burn injuries. Journal of Community Nursing, 25(5), 21–28. Ehrlich, H. P. (2004). Understanding experimental biology of skin equivalent: From laboratory to clinical use in patients with burns and chronic wounds. American Journal of Surgery, 187(5A), 29S–33S. Embil J. M., McLeod, J. A., Al-Barrak, A. M., et al. (2001). An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: Potential role of contaminated hydrotherapy equipment. Burns, 27(7), 681–688. Fauerbach, J. A., Lezotte, D., Hills, R. A., et al. (2005). Burden of burn: A norm-based inquiry into the influence of burn size and distress on recovery of physical and psychosocial function. Journal of Burn Care and Rehabilitation, 26(1), 21–32. Ferguson, S. L., & Voll, K. V. (2004). Burn pain and anxiety: The use of music relaxation during rehabilitation. Journal of Burn Care and Rehabilitation, 25(1), 8–14. *Flynn, M. B. (1999). Identifying and treating inhalation injuries in fire victims. Dimensions of Critical Care Nursing, 18(4), 18–23. *Flynn, M. B. (2004). Nutritional support for the burn-injured patient. Critical Care Nursing Clinics of North America, 16(1), 139–144. Forjuoh, S. N. (1998). The mechanisms, intensity of treatment, and outcomes of hospitalized burns: Issues for prevention. Journal of Burn Care and Rehabilitation, 19(5), 456–460. Fowler, A. (1998). Nursing management of minor burn injuries. Emergency Nurse, 6(6), 31–39. Fratianne, R. B., & Brandt, C. P. (1997). Determining when care for burns is futile. Journal of Burn Care and Rehabilitation, 18(3), 262– 267. Garvin, C. G., & Brown, R. O. (2001). Nutritional support in the intensive care unit: Are patients receiving what is prescribed? Critical Care Medicine, 29(1), 204–205. Gilboa, D. (2001). Long-term psychosocial adjustment after burn injury. Burns, 27(4), 335–341. Gordon, M., & Goodwin, C. W. (1997). Burn management: Initial assessment, management and stabilization. Nursing Clinics of North America, 32(2), 237–249. Gordon, M., Greenfield, E., Marvin, J., et al. (1998). Use of pain assessment tools: Is there a preference? Journal of Burn Care and Rehabilitation, 19(5), 451–454. Gosain, A., & Gamelli, R. (2005a). A primer in cytokines. Journal of Burn Care and Rehabilitation, 26(1), 7–12. Gosain, A., & Gamelli, R. (2005b). Role of the gastrointestinal tract in burn sepsis. Journal of Burn Care and Rehabilitation, 26(1), 85–91. Greenfield, E., & McManus, A. T. (1997). Infectious complications: Prevention and strategies for their control. Nursing Clinics of North America, 32(2), 297–309. Gueugniaud, P. Y., Carsin, H., Bertin-Maghit, M., et al. (2000). Current advances in the initial management of major thermal injuries. Intensive Care Medicine, 26(7), 848–856. Hart, D. W., Wolf, S. E., Chinkes, D. L., et al. (2000). Determinants of skeletal muscle catabolism after severe burn. Annals of Surgery, 232(4), 455–456. Hedderich, R., & Ness, T. J. (1999). Analgesia for trauma and burns. Critical Care Clinics, 15(1), 167–184. Heimbach, D. M., Warden, G. D., Luterman, A., et al. (2003). Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment. Journal of Burn Care and Rehabilitation, 24(1), 42–48. Helvig, E. I. (2002). Managing thermal injuries within WOCN practice. The Journal of Wound Ostomy and Continence Nursing, 29(2), 76–82. Holm, C., Melcer, B., Horbrand, F., et al. (2000). The relationship between oxygen delivery and oxygen consumption during fluid resuscitation of burn related shock. Journal of Burn Care and Rehabilitation, 21(2), 147–154. Hunt, J. L., Calvert, C. T., Peck, M. D., et al. (2000). Occupationrelated burn injuries. Journal of Burn Care and Rehabilitation, 21(4), 327–332.

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Istre, G. R., McCoy, M. A., Osborn, L., et al. (2001). Deaths and injuries from house fires. New England Journal of Medicine, 344(25), 1911– 1916. Jaffe, S. E., & Patterson, D. R. (2004). Treating sleep problems in patients with burn injuries: Practical considerations. Journal of Burn Care and Rehabilitation, 25(3), 294–305. Jain, S., & Bandi, V. (1999). Electrical and lightning injuries. Critical Care Clinics, 15(2), 319–331. Jonsson, C. E., Holmsten, A., Dahlstrom, L., et al. (1998). Background pain in burn patients: Routine measurement and recording of pain intensity in burn unit. Burns, 24(5), 448–454. Jordan, R. B., Daher, J., & Wasil, K. (2000). Splints and scar management for acute and reconstructive burn care. Clinics in Plastic Surgery, 27(1), 71–85. Kagan, R. J., & Smith, S. C. (2000). Evaluation and treatment of thermal injuries. Dermatology Nursing, 12(5), 334–335, 338–344, 347–350. Katz, W. A. (1998). The needs of a patient in pain. American Journal of Medicine, 105(1B), 2S–7S. *Keane, A., Brennan, A. M., & Pickett, M. (2000). A typology of residential fire survivors’ multidimensional needs. Western Journal of Nursing Research, 22(3), 263–278. *Keane, A., Jepson, C., Pickett, M., et al. (1996). Demographic characteristics, fire experiences, and distress of residential fire survivors. Issues in Mental Health Nursing, 17(5), 487–501. Kildal, M., Willebrand, M., Andersson, G., et al. (2004). Personality characteristics and perceived health problems after burn injury. Journal of Burn Care and Rehabilitation, 25(3), 228–235. Koschel, M. J. (2002). Where there’s smoke, there may be cyanide. American Journal of Nursing, 102(8), 39–42. Koupil, J., Brychta, P., Rihova, H., et al. (2001). Special features of burn injuries in elderly patients. Acta Chirurgiae Plasticae, 43(2), 57–60. Latenser, B. (2009). Critical care of the burn patient: The first 48 hours. Critical Care Medicine, 37(10), 2819–2826. Leistikow, B. N., Martin, D. C., & Milano, C. E. (2000). Fire injuries, disasters, and costs from cigarettes and cigarette lights: A global overview. Preventive Medicine, 31, 91–99. Lim, J. J., Rehmar, S. G., & Elmore, P. (1998). Rapid response: Care of burn victims. AAOHN Journal, 46(4), 169–178. Linneman, P. K., Terry, B. E., & Burd, R. S. (2000). The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries. Journal of Burn Care and Rehabilitation, 21(6), 519–522. Long, T. D., Cathers, T. A., Twillman, R., et al. (2001). Morphine-infused silver sulfadiazine (MISS) cream for burn analgesia: A pilot study. Journal of Burn Care and Rehabilitation, 22(2), 118–123. Loss, M., Wedler, V., Kunzi, W., et al. (2000). Artificial skin, split-thickness autograft and cultured autologous keratinocytes combined to treat a serious burn injury of 93% TBSA. Burns, 26(7), 644–652. Low, A. J., Dyster-Aas, J., Kildal, M., et al. (2006). The presence of nightmares as a screening tool for symptoms of posttraumatic stress disorder in burn survivors. Journal of Burn Care and Research, 27(5), 727–733. Martin-Herz, S. P., Patterson, D. R., Honari, S., et al. (2003). Pediatric pain control practices of North American burn centers. Journal of Burn Care and Rehabilitation, 24(1), 26–36. Martin-Herz, S. P., Thurber, C. A., & Patterson, D. R. (2000). Psychological principles of burn wound pain in children. II: Treatment application. Journal of Burn Care and Rehabilitation, 21(5), 458–472. Matheson, J. D., Clayton, J., & Muller, J. (2001). The reduction of itch during burn wound healing. Journal of Burn Care and Rehabilitation, 22(1), 76–81. McCall, J., & Cahill, T. (2005). Respiratory care of the burn patient. Journal of Burn Care and Rehabilitation, 26(3), 200–206. Mertens, D. M., Jenkins, M. E., & Warden, G. D. (1997). Outpatient burn management. Nursing Clinics of North America, 32(2), 343–364. Muller, M. J., Pegg, S. P., & Rule, M. R. (2001). Determinants of death following burn injury. British Journal of Surgery, 88(4), 583–587. Neely, A., Fowler, L. A., Kagan, R. J., et al. (2004). Procalcitonin in pediatric burn patients: An early indicator of sepsis? Journal of Burn Care and Rehabilitation, 25(1), 76–80. Noordenbos, J., Dore, C., & Hansbrough, J. F. (1999). Safety and efficacy of TransCyte for the treatment of partial-thickness burns. Journal of Burn Care and Rehabilitation, 20(4), 275–281. O’Keefe Gatewood, M., & Zane, R. (2004). Lightning injuries. Emergency Medical Clinics of North America, 22(2), 369–403. Pal, S. K., Cortiella, J., & Herndon, D. (1997). Adjunctive methods of pain control in burns. Burns, 23(5), 404–412.

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Parsons, L. (1997). Office management of minor burns. Lippincott’s Primary Care Practice, 1(1), 40–49. Patterson, D. R. (1996). Non-opioid-based approaches to burn pain. Journal of Burn Care and Rehabilitation, 17(4), 372–375. Patterson, D. R., Ptacek, J. T., Cromes, F., et al. (2000). The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors. Journal of Burn Care and Rehabilitation, 21(6), 490–498. Pereira, C., Murphy, K., & Herndon, D. (2005). Altering metabolism. Journal of Burn Care and Rehabilitation, 26(3), 194–199. Pessina, M., & Ellis, S. M. (1997). Rehabilitation. Nursing Clinics of North America, 32(2), 365–374. Pham, T. N., & Gibran, N. S. (2007). Thermal and electrical injuries. Surgical Clinics of North America, 87(1), 1–18. Polko, L. E., & McMahon, M. J. (1998). Burns in pregnancy. Obstetrical and Gynecological Survey, 53(1), 50–56. Ptacek, J. P., Patterson, D. R., & Doctor, J. (2000). Describing and predicting the nature of procedural pain after thermal injuries: Implication for research. Journal of Burn Care and Rehabilitation, 21(4), 318–326. Ramzy, P. I., Barret, J. P., & Herndon, D. N. (1999). Thermal injury. Critical Care Clinics, 15(2), 333–352. Raymond, I., Nielsen, T. A., Lavigne, G., et al. (2001). Quality of sleep and its relationship to pain intensity in hospitalized adult burn patients. Pain, 92, 381–388. Saffle, J. R. (2003). What’s new in general surgery: Burns and metabolism. Journal of the American College of Surgeons, 196(20), 267–289. Santos, A. P., Wilson, A. K., Hornung, C. A., et al. (2005). Methamphetamine laboratory explosions: A new and emerging burn injury. Journal of Burn Care and Rehabilitation, 26(3), 228–232. Schiller, W. R., Bay, R. C., Garren, R. L., et al. (1997). Hyperdynamic resuscitation improves survival in patients with life-threatening burns. Journal of Burn Care and Rehabilitation, 18(1), 10–16. Sgroi, M. I., Willebrand, M., Ekselius, L., et al., (2005). Fear-avoidance in recovered burn patients: Association with psychological and somatic symptoms. Journal of Health Psychology, 10(4), 491–502. Shehata, M., Youssef, F., & Pater, A. (2013). Handling facial burns at an emergency setting (Editorial). Emergency Medicine, 3, 1. Sheridan, R., & Tompkins, R. (2004). What’s new in burns and Metabolism. Journal of the American College of Surgeons, 198(2), 243–263. Sheridan, R. L., & Moreno, C. (2001). Skin substitutes in burns. Burns, 27(1), 92. Sheridan, R. L., Ryan, C. M, Yin, L. M., et al. (1998). Death in burn unit: Sterile multiple organ failure. Burns, 24(4), 307–311. Shrivastava, P., & Goel, A. (2010). Pre-hospital care in burn injury. Indian Journal of Plastic Surgery, 43(Suppl), S15–S22. Sibbald, R. G., Orsted, H. L., Coutts, P. M., et al. (2006). Best practice recommendations for preparing the wound bed: Update 2006. Wound Care Canada, 4(1), 15–29. Snyder, C., & Ubben, P. (2003). Use of speech pathology services in the burn unit. Journal of Burn Care and Rehabilitation, 24(4), 217–221. Spinks, A., Wasiak, J., Cleland, H., et al. (2008). Ten-year epidemiological study of pediatric burns in Canada. Journal of Burn Care and Research, 29(3), 482–488. Stewart, R., Bhagwanjee, A. M., Mbakaza, Y., et al. (2000). Pressure garment adherence in adult patients with burn injuries: An analysis of patient and clinician perceptions. American Journal of Occupational Therapy, 54(6), 598–606. Still, J. M., & Law, E. J. (2000). Primary excision of the burn wound. Clinics in Plastic Surgery, 27(1), 23–47. Supp, D.M., Karpinski, A., & Boyce, S., (2004). Vascular endothelial growth factor overexpression increases vascularization by murine but not human endothelial cells in cultured skin substitutes grafted to athymic mice. Journal of Burn Care and Rehabilitation, 25(4), 337–345. Supple, K. G. (2004). Physiologic response to burn injury. Critical Care Nursing Clinics of North America, 16(1), 119–126. Thornton, J. F., & Gosman, A. A. (2004). Skin grafts and skin substitutes and principles of flaps. Selected Readings in Plastics Surgery, 10(1), 1–78. Thurber, C. A., Martin-Herz, S. P., & Patterson, D. R. (2000). Psychological principles of burn wound pain in children. I: Theoretical framework. Journal of Burn Care and Rehabilitation, 21(4), 376–387. Tredget, E. E., Shankowsky, H. A., Joffe, A. M., et al. (1992). Epidemiology of infections with Pseudomonas aeruginosa in burn patients: The role of hydrotherapy. Clinical Infectious Diseases, 15(6), 941–949.

Tredget, E. E., Shankowsky, H. A., Taerum, T. V., et al. (1990). The role of inhalation injury in burn trauma. A Canadian experience. Annals of Surgery, 212, 720–727. *Turner, J. G., Clark, A. J., Gauthier, D. K., et al. (1998). The effect of therapeutic touch on pain and anxiety in burn patients. Journal of Advanced Nursing, 28(1), 10–20. U.S. Fire Administration/National Fire Data Center. (2005a). Fatal fires. Topical Fire Research Series, 5(1), 1–6. U.S. Fire Administration/National Fire Data Center. (2005b). Residential smoking fires and casualties. Topical Fire Research Series, 5(5), 1–6. U.S. Fire Administration/National Fire Data Center. (2005c). Structure cooking fires. Topical Fire Research Series, 5(6), 1–4. U.S. Fire Administration/National Fire Data Center. (2010). Fatal fires in residential buildings. Topical Fire Research Series, 11(2), 1–11. Wahl, W. L., Ahrns, K. S., Brandt, M. M., et al. (2005). Bronchoalveolar lavage in diagnosis of ventilator-associated pneumonia in patients with burns. Journal of Burn Care and Rehabilitation, 26(1), 57–61. Wainright, D., Madden, M., Luterman, A., et al. (1996). Clinical evaluation of an acellular allograft dermal matrix in full-thickness burns. Journal of Burn Care and Rehabilitation, 17(2), 124–136. Wall-Alonso, E., Schoeller, D. A., Schecter, L., et al. (1999). Measured total energy requirements of adult patients with burns. Journal of Burn Care and Rehabilitation, 20(4), 329–337. Weber, J., McManus, A., & Nursing Committee of the International Society for Burn Injuries. (2004). Infection control in burn patients. Burns, 30(8), A16–A24. Weibelhaus, P., & Hansen, S. L. (2001). What should you know about managing burn emergencies? Nursing, 31(1), 36–41. Weinbren, M. J. (1999). Pharmacokinetics of antibiotics in burn patients. Journal of Antimicrobial Chemotherapy, 44(3), 319–327. Wibbenmeyer, L. A., Amelon, M. J., Morgan, L. J., et al. (2001). Predicting survival in an elderly burn population. Burns, 27(6), 583–590. Wikehult, B., Hedlund, M., Marsenic, M., et al. (2008). Evaluation of negative emotional care experiences in burn care. Journal of Clinical Nursing, 17(14), 1923–1929. Willebrand, M., Andersson, G., & Ekselius, L. (2004). Prediction of psychological health after an accidental burn. Journal of Trauma, 57(2), 367–374. Winfree, J., & Barillo, D. J. (1997). Nonthermal injuries. Nursing Clinics of North America, 32(2), 275–296. Wisplinghoff, H., Perbix, W., & Seifert, H. (1999). Risk factors for nosocomial bloodstream infections due to Acinetobacter baumannii: A case-control study of adult burn patients. Clinical Infectious Diseases, 28(1), 59–66. Wysocki, A. B. (1999). Skin anatomy, physiology, and pathophysiology. Nursing Clinics of North America, 34(4), 777–797. Yin, H. Q., Langford, R., & Burrell, D. E. (1999). Comparative evaluation of the antimicrobial activity of Acticoat Antimicrobial Barrier dressing. Journal of Burn Care and Rehabilitation, 20(3), 195–200. Yowler, C. J., & Fratianne, R. B. (2000). Current status of burn resuscitation. Clinics in Plastic Surgery, 27(1), 1–10. Yu, Y. M., Tompkins, R. G., Ryan, C. M., et al. (1999). The metabolic basis of the increase in energy expenditure in severely burned patients. Journal of Parenteral and Enteral Nutrition, 23(3), 160–168.

RESOURCES AND WEB SITES Alisa Ann Ruch Burn Foundation, 20944 Sherman Way, Suite 115, Canoga Park, CA 91303, (818) 883–7700; http://www.aarbf.org. American Burn Association, 625 North Michigan Avenue, Suite 1530, Chicago, IL 60611, (800) 548-BURN; http://www.ameriburn.org. Association of Home Appliance Manufacturers, 111 19th Street NW, Suite 402, Washington, DC 20036, (202) 872–5955; http://www.aham.org. Burned Children Recovery Foundation, 409 Wood Place, Everett, WA 98203; (800) 799-BURN; http://www.burnedchildrenrecovery.org. Burn Foundation, 1128 Walnut Street, Philadelphia, PA 19107, (215) 629–9200, e-mail: [email protected]. Burn Institute, 8825 Aero Drive, Suite 200, San Diego, CA 92123-2269; (858) 541-2277; http://www.burninstitute.org. Burn Prevention Foundation, (610) 481-9810; http://www.burnprevention.org. Canadian Patient Safety Institute. 1150 Cyrville Road, Suite 410, Ottawa, Ontario K1J 7S9; (613) 730–7322. http://www.patientsafetyinstitute. ca/English/Pages/default.aspx# Chemical Educational Foundation, 1560 Wilson Boulevard, Suite 1250, Arlington, VA 22209, (703) 527-6223; http://www.chemed.org.

CHAPTER 58 Cool the Burn; http://www.regionshospital.com/rh/specialties/burncenter/index.html Firefighters Burn Institute, 3823 V Street, Suite #4, Sacramento, CA 95817, (916) 739-8525; http://www.ffburn.org. Integra Life Sciences Corporation, PO Box 688, 105 Morgan Lane, Plainsboro, NJ 08536, (800) 654-2873, fax (609) 799-3297; http:// www.integralife.com/ International Association of Fire Fighters Burn Foundation, 1750 New York Avenue NW, Washington, DC 20006, (202) 737-8484; http:// www.iaff.org.

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International Society for Burn Injuries, Dr. Keith Judkins, ISBI Secretary/ Treasurer, Medical Director for Burn Care, Pinderfields Hospital, Aberford Road, Wakefield, UK WFI 4DG,+44 1924 212331; http://www. worldburn.org. LifeCell Corporation, 3606 Research Forest Drive, The Woodlands, TX 77381, (800) 367-5737; http://www.lifecell.com. Phoenix Society for Burn Survivors, 11 Rust Hill Road, Levittown, PA 19056, (215) 946-BURN, (800) 888-BURN; http://www.phoenixsociety.org. Also see issues of The Journal of Burn Care and Rehabilitation and Burns—The Journal of the International Society for Burn Injuries.

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Case Study Applying Concepts From NANDA, NIC, and NOC A Patient With Impaired Vision and Decreased Attention to One Side of the Body Mr. Razniak is a 64-year-old man who has had several strokes. Ophthalmologic testing reveals that he has homonymous hemianopsia of the left visual field and visual spatial neglect; as a result, he has limited vision in the left visual fields of both eyes. He has difficulty in many areas, such as bumping into objects and ignoring the left side of his body.

Sensorineural Function

A patient with impaired vision and decreased attention to one side of the body receives the nursing diagnoses Disturbed Sensory Perception: Visual

will benefit from

requires nursing interventions Communication Enhancement: Visual Deficit

requires and

Unilateral Neglect

outcomes should show improvement in may lead to

may enhance the patient’s

Vision Compensation Behaviour

and

and

requires

Unilateral Neglect Management

may help achieve

Safe Home Environment

may help achieve

and

Risk for Injury

which may improve

and

requires

Positioning

may help protect

Physical Injury Severity

Nursing Classifications and Languages NANDA Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes Return to functional baseline status, stabilization of, or improvement in

Disturbed Sensory Perception: Visual—Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Communication Enhancement: Visual Deficit—Use of strategies augmenting communication capabilities for a person with diminished vision

Vision Compensation Behaviour— Personal actions to compensate for visual impairment

Unilateral Neglect—Impairment in sensory and motor response, mental representation, and spatial attention of the body and the corresponding environment characterized by inattention to one side or overattention to the opposite side

Unilateral Neglect Management— Protecting and safely reintegrating the affected part of the body while helping the patient adapt to disturbed perceptual abilities

Safe Home Environment—Physical arrangements to minimize environmental factors that might cause physical harm or injury in the home

Risk for Injury—At risk for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources

Positioning—Deliberative placement of the patient or a body part to promote physiologic and/or psychological well-being

Physical Injury Severity—Signs and symptoms of bodily injuries

From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier/Mosby; Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions & classification 2012–2014. Oxford, UK: Wiley Blackwell; Moorhead, S., Johnson, M., Mass, M. L., et al. (Eds.). (2013). Nursing outcomes classification. Measurement of health outcomes. (5th ed.). St. Louis, MO: Elsevier/Mosby.

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CHAPTER

59 Assessment and Management of Patients With Eye and Vision Disorders Adapted by Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify significant eye structures and describe their functions. 2. Identify diagnostic tests for assessment of vision and evaluation of visual disorders. 3. Discuss clinical features, diagnostic assessment and examinations, medical or surgical management, and nursing management for patients with ocular disorders. 4. Describe therapeutic effects of ophthalmic medications. 5. Define low vision and blindness and differentiate between functional and visual impairment. 6. List and describe assessment and management strategies for patients with low vision. 7. Demonstrate orientation and mobility techniques for patients with low vision in a health care setting. 8. Demonstrate instillation of eye drops and ointment. 9. Discuss general discharge instructions for patients after ocular surgery. 10. Discuss strategies for patient safety in ophthalmology.

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The ability to see the world clearly can easily be taken for granted. “There are 161 million people worldwide who are visually impaired—37 million are blind and 124 million have partial vision loss that cannot be corrected, . . . Without intervention, the number of people with impaired vision could double by 2020.” (Carroll, Jens, & Curtis, 2010, p. 1328). The eye is a sensitive, highly specialized sense organ subject to various disorders, many of which lead to impaired vision. Impaired vision affects an individual’s independence in self-care, work and lifestyle choices, sense of self-esteem, safety, ability to interact with society and the environment, and overall quality of life. Many of the leading causes of visual impairment are associated with aging (e.g., cataracts, glaucoma, macular degeneration),

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and two thirds of the population with impaired vision is older than 65 years of age. Younger people are also at risk for eye disorders, particularly traumatic injuries. Everyday 700 Canadians sustain eye injuries at work (Canadian National Institute for the Blind [CNIB], 2014a). The rapidly changing technological advances of ophthalmic surgery affect all age groups. These include refractive procedures as well as implantation of intraocular lenses (IOLs) and telescopic devices. Although most people with eye disorders are treated in an ambulatory care setting, many patients receiving health care have an eye disease as a comorbid condition. In addition to understanding the prevention, treatment, and consequences of eye disorders, nurses in all settings should assess visual acuity in those at risk (e.g., patients who are

Glossary accommodation: process by which the eye adjusts for near distance (e.g., reading) by changing the curvature of the lens to focus a clear image on the retina anterior chamber: space in the eye bordered anteriorly by the cornea and posteriorly by the iris and pupil aphakia: absence of the natural lens aqueous humour: watery fluid that fills the anterior and posterior chambers of the eye astigmatism: refractive error in which light rays are spread over a diffuse area rather than sharply focused on the retina; a condition caused by differences in the curvature of the cornea and lens binocular vision: ability of both eyes to focus on one object and fuse the two images into one blindness: inability to see, usually defined as corrected visual acuity of 20/400 or less, or a visual field of no more than 20 degrees in the better eye chemosis: edema of the conjunctiva cones: retinal photoreceptor cells essential for visual acuity and colour discrimination diplopia: seeing one object as two; double vision emmetropia: absence of refractive error enucleation: complete removal of the eyeball and part of the optic nerve evisceration: removal of the intraocular contents through a corneal or scleral incision; the optic nerve, sclera, extraocular muscles, and sometimes, the cornea are left intact exenteration: surgical removal of the entire contents of the orbit, including the eyeball and lids glaucoma: an abnormal condition of elevated pressure within an eye because of obstruction of the outflow of aqueous humour, resulting in loss of vision hyperemia: “red eye” resulting from dilation of the vasculature of the conjunctiva hyperopia: farsightedness; a refractive error in which the focus of light rays from a distant object is behind the retina hyphema: blood in the anterior chamber hypopyon: collection of inflammatory cells that has the appearance of a pale layer in the inferior anterior chamber of the eye

injection: congestion of blood vessels keratoconus: cone-shaped deformity of the cornea limbus: junction of the cornea and sclera miotics: medications that cause pupillary constriction mydriatics: medications that cause pupillary dilation myopia: nearsightedness; a refractive error in which the focus of light rays from a distant object is anterior to the retina neovascularization: growth of abnormal new blood vessels nystagmus: involuntary oscillation of the eyeball papilledema: swelling of the optic disc due to increased intracranial pressure photophobia: ocular pain on exposure to light posterior chamber: space between the iris and vitreous proptosis: downward displacement of the eyeball resulting from an inflammatory condition of the orbit or a mass within the orbital cavity ptosis: drooping eyelid refraction: determination of the refractive errors of the eye and correction by lenses rods: retinal photoreceptor cells essential for bright and dim light scotomas: blind or partially blind areas in the visual field strabismus: a condition in which there is deviation from perfect ocular alignment sympathetic ophthalmia: an inflammatory condition created in the fellow eye by the affected eye (without useful vision): the condition may become chronic and result in blindness (of the fellow eye) trachoma: a bilateral chronic follicular conjunctivitis of childhood that leads to blindness during adulthood, if left untreated uveitis: inflammation of part or all of the uvea (sclera, cornea, and retina) vitreous humour: gelatinous material (transparent and colourless) that fills the eyeball behind the lens Safety Note: To reduce risk of medical and medication errors DO NOT USE these abbreviations related to vision and eye health: OD (ocular dexter, right eye), OS (ocular sinister, left eye), and OU (ocular uterque, both eyes). Instead use “right eye”, “left eye”, or “both eyes” to document findings (Stephen, 2012).

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Sensorineural Function Superior oblique

Upper lid

Brow Inner canthus

Lacrimal gland

Caruncle

Lacrimal sac

Outer canthus

Lateral rectus Inferior rectus

Conjunctiva Sclera

Superior rectus

Limbus Iris

Pupil

Lower lacrimal canal

Near lower lacrimal punctum

Nasolacrimal duct

FIGURE 59-1. External structures of the eye and position of the

lacrimal structures.

older, those with diabetes or acquired immunodeficiency syndrome [AIDS]), refer patients to eye care specialists as appropriate, implement health promotion measures such as wearing sunglasses to prevent further visual loss, and help patients adapt to impaired vision.

ANATOMIC AND PHYSIOLOGIC OVERVIEW Unlike most organs of the body, the eye is available for external examination, and its anatomy is more easily assessed than many other body parts (Fig. 59-1). The eyeball, or globe, sits in a protective bony structure known as the orbit. Lined with muscle and connective and adipose tissues, the orbit is about 4 cm high, wide, and deep, and it is shaped roughly like a four-sided pyramid, surrounded on three sides by the sinuses: ethmoid (medially), frontal (superiorly), and maxillary (inferiorly). The optic nerve and the ophthalmic artery enter the orbit at its apex through the optic foramen. The eyeball is moved though all fields of gaze by the extraocular muscles. The four rectus muscles and two oblique muscles (Fig. 59-2) are innervated by cranial nerves (CNs) III, IV, and VI. Usually, the movements of the two eyes are coordinated, and the brain perceives a single image. The eyelids, composed of thin elastic skin that covers striated and smooth muscles, protect the anterior portion of the eye. The eyelids contain multiple glands, including sebaceous, sweat, and accessory lacrimal glands, and they are lined with conjunctival material. The upper lid usually covers the uppermost portion of the iris and is innervated by the oculomotor nerve (CN III). The lid margins contain meibomian glands, the inferior and superior

Inferior oblique

FIGURE 59-2. The extraocular muscles responsible for eye movement. The medial rectus muscle (not shown) is responsible for opposing the movement of the lateral rectus muscle.

puncta, and the eyelashes. The triangular spaces formed by the junction of the eyelids are known as the inner or medial canthus and the outer or lateral canthus. With every blink of the eyes, the lids wash the cornea and conjunctiva with tears. Tears are vitally important to eye health. They are formed by the lacrimal gland and the accessory lacrimal glands. A healthy tear is composed of three layers: lipoid, aqueous, and mucoid. If there is a defect in the composition of any of these layers, the integrity of the cornea may be compromised. Tears are secreted in response to reflex or emotional stimuli. The conjunctiva, a mucous membrane, provides a barrier to the external environment and nourishes the eye. The goblet cells of the conjunctiva secrete lubricating mucus. The bulbar conjunctiva covers the sclera, whereas the palpebral conjunctiva lines the inner surface of the upper and lower eyelids. The junction of the two portions is known as the fornix. The sclera, commonly known as the white of the eye, is a dense, fibrous structure that comprises the posterior five sixths of the eye (Fig. 59-3). The sclera helps to maintain the shape of the eyeball and protects the intraocular contents from trauma. The sclera may have a slightly bluish tinge in young children, a dull white colour in adults, and a slightly yellowish colour in older adults. Externally, it is overlaid with conjunctiva, which is a thin, transparent, mucous membrane that contains fine blood vessels. The conjunctiva meets the cornea at the limbus on the outermost edge of the iris. The cornea (Fig. 59-4), a transparent, avascular, domelike structure, forms the most anterior portion of the eyeball and is the main refracting surface of the eye. It is composed of five layers: epithelium, Bowman’s membrane, stroma, Descemet’s membrane, and endothelium. The epithelial cells are capable of rapid replication and are completely replaced every 7 days. Behind the cornea lies the anterior chamber, filled with a continually replenished supply of clear aqueous humour, which nourishes the cornea. The aqueous humour is produced by the ciliary body, and its production is related to the intraocular pressure (IOP). Usual pressure is 15 mm Hg (Standring, 2008). The uvea consists of the iris, the ciliary

CHAPTER 59

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Assessment and Management of Patients With Eye and Vision Disorders Vitreous humour

Central retina vein and artery

Macula Conjunctiva Ciliary body Canal of Schlemm Iris Pupil

Optic nerve

Lens Cornea

Sclera

Choroid Retina Posterior chamber filled with aqueous humour

FIGURE 59-3. Three-dimensional cross-section of

the eye.

body, and the choroid. The iris, or coloured part of the eye, is a highly vascularized, pigmented collection of fibres surrounding the pupil. The pupil is a space that dilates and constricts in response to light. Pupils are usually round and constrict symmetrically when a bright light shines on them. About 20% of the population has pupils that are slightly unequal in size but that respond equally to light. Dilation and constriction are controlled by the sphincter and dilator pupillae muscles. The dilator muscles are controlled by the sympathetic nervous system, whereas the sphincter muscles are controlled by the parasympathetic nervous system.

Anterior chamber filled with aqueous humour

Directly behind the pupil and iris lies the lens, a colourless and almost completely transparent, biconvex structure held in position by zonular fibres. It is avascular and has no nerve or pain fibres. The lens enables focusing for near vision and refocusing for distance vision. The ability to focus and refocus is called accommodation. The lens is suspended behind the iris by the zonules and is connected to the ciliary body. The ciliary body controls accommodation through the zonular fibres and the ciliary muscles. The aqueous humour is anterior to the lens; posterior to the lens is the vitreous humour. All cells formed throughout life are retained by the lens, which makes the cell structure Epithelium Bowman’s membrane Stroma Descemet’s membrane Endothelium

Trabecular meshwork Canal of Schlemm Conjunctiva

of the eye. From Goldblum, K. (Ed.). (1997). Core curriculum for ophthalmic nursing, American Society of Ophthalmic Registered Nurses. Dubuque, IA: Kendall/Hall Publishing.

Iris

Lens

Sclera

FIGURE 59-4. Internal structures

Dilator muscle Pigment layer Sphincter muscle

Zonular fibres Ciliary process Ciliary muscle Ciliary epithelium

Cornea

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Sensorineural Function

of the lens susceptible to the degenerative effects of aging. The lens continues to grow throughout life, laying down fibres in concentric rings. This gradual thickening becomes evident in the fifth decade of life and eventually results in an increasingly dense core or nucleus, which can limit accommodative powers. The posterior chamber is a small space between the vitreous humour and the iris. Aqueous fluid is manufactured in the posterior chamber by the ciliary body. This aqueous fluid flows from the posterior chamber into the anterior chamber, from which it drains through the trabecular meshwork into the canal of Schlemm. The choroid lies between the retina and the sclera. It is a vascular tissue, supplying blood to the portion of the sensory retina closest to it. The ocular fundus is the largest chamber of the eye and contains the vitreous humour, a clear, gelatinous substance, composed mostly of water and encapsulated by a hyaloid membrane. The vitreous humour occupies about two thirds of the eye’s volume and helps maintain the shape of the eye. As the body ages, the gel-like characteristics are gradually lost, and various cells and fibres cast shadows that the patient perceives as “floaters.” The vitreous is in continuous contact with the retina and is attached to the retina by scattered collagenous filaments. The vitreous shrinks and shifts with age. The innermost surface of the fundus is the retina. The retina is composed of 10 microscopic layers and has the consistency of wet tissue paper. It is neural tissue, an extension of the optic nerve. Viewed through the pupil, the landmarks of the retina are the optic disc, the retinal vessels, and the macula. The point of entrance of the optic nerve into the retina is the optic disc. The optic disc is oval or circular, is pink, and has sharp margins. In the disc, a physiologic depression or cup is present centrally, with the retinal blood vessels emanating from it. The retinal tissues arise from the optic disc and line the inner surface of the vitreous chamber. The retinal vessels also enter the eye through the optic nerve, branching out through the retina and forming superior and inferior arcades. The macula is the area of the retina responsible for central vision. The rest of the retina is responsible for peripheral vision. In the centre of the macula is the most sensitive area, the fovea, which is avascular and surrounded by the superior and inferior vascular arcades. Two important layers of the retina are the retinal pigment epithelium (RPE) and the sensory retina. A single layer of cells constitutes the RPE, and these cells have numerous functions, including the absorption of light. The sensory retina contains the photoreceptor cells: rods and cones. Rods and cones are long, narrow cells shaped like rods or cones. The rods are mainly responsible for night vision or vision in low light, whereas the cones provide the best vision for bright light, colour vision, and fine detail. Cones are distributed throughout the retina, with their greatest concentration in the fovea. Rods are absent in the fovea (Carroll et al., 2010). Visual acuity depends on a healthy, functioning eyeball and an intact visual pathway (Fig. 59-5). This pathway is made up of the retina, optic nerve, optic chiasm, optic tracks, lateral geniculate bodies, optic radiations, and the visual cortex area of the brain. The pathway is an extension of the central nervous system.

Optic nerve

Optic chiasm

Optic tract Optic radiations Lateral geniculate body

Occipital lobe

Visual cortex

FIGURE 59-5. The visual pathway. From Goldblum, K. (Ed.). (1997). Core curriculum for ophthalmic nursing, American Society of Ophthalmic Registered Nurses. Dubuque, IA: Kendall/Hall Publishing.

The optic nerve is also known as the second cranial nerve (CN II). Its purpose is to transmit impulses from the retina to the occipital lobe of the brain. The optic nerve head, or optic disc, is the physiologic blind spot in each eye. The optic nerve leaves the eye and then meets the optic nerve from the other eye at the optic chiasm. The chiasm is the anatomic point at which the nasal fibres from the nasal retina of each eye cross to the opposite side of the brain. The nerve fibres from the temporal retina of each eye remain uncrossed. Fibres from the right half of each eye, which would be the left visual field, therefore carry impulses to the right occipital lobe. Fibres from the left half of each eye, or the right visual field, carry impulses to the left occipital lobe. Beyond the chiasm, these fibres are known as the optic tract. The optic tract continues on to the lateral geniculate body. The lateral geniculate body

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Assessment and Management of Patients With Eye and Vision Disorders

leads to the optic radiations and then to the cortex of the occipital lobe of the brain.

ASSESSMENT Ocular History The eye care professional, through careful questioning, elicits the necessary information that can lead to the diagnosis of an ophthalmic condition. Pertinent questions to ask during the interview can be found in Chart 59-1.

Visual Acuity After the patient’s chief concern has been identified and the history has been obtained, visual acuity is assessed. This is an essential part of the eye examination and a measure against which all therapeutic outcomes are based. Most people are familiar with the standard Snellen chart. This chart is composed of a series of rows of progressively smaller letters and is used to test distance vision. The fraction 20/20 is considered the standard of “normal” vision. Most people can see the letters on the line designated as 20/20 from a distance of 6.1 m (20 ft). A person whose vision is 20/200 can see an object from 20 ft away (6.1 m) that a person whose vision is 20/20 can see from 200 ft (61 m) away (Stephen, 2012). The patient is positioned at the prescribed distance, usually 6.1 m (20 ft), from the chart and is asked to read the smallest line that he or she can see. The patient should wear distance correction (eyeglasses or contact lenses) if required, and each eye is tested separately. The right eye is

CHART 59-1

Taking an Ocular History • What does the patient perceive to be the problem? • Is visual acuity diminished? • Does the patient experience blurred, double, or distorted vision?

• Is there pain? Is it sharp? Or dull? Is it worse when blinking?

• Is the discomfort an itching sensation? Or more of a foreign body sensation?

• Are both eyes affected? • Is there a history of discharge? If so, question colour, • • • • • • • • •

consistency, odour. What is the duration of the problem? Is this a recurrence of a previous condition? How has the patient self-treated? What makes the symptoms improve or worsen? Has the condition affected performance of activities of daily living (ADLs)? Are there any systemic diseases? What medications are used in their treatment? What concurrent ophthalmic conditions does the patient have? Is there an ophthalmic surgery history? Have other family members had the same symptoms or condition?

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commonly tested first. The patient is asked to cover the left eye with an opaque card while the right eye is being tested. Patients are encouraged to read every letter possible and to guess, if necessary. If the patient successfully reads the line, the examiner encourages the patient to attempt the next line of smaller letters. The smallest line in which the patient can successfully identify more than half the letters is recorded as the visual acuity for the eye being tested. This procedure is then repeated for the left eye, with the right eye covered, and then both eyes are tested together. If a patient is unable to read the English alphabet, a Snellen E Chart is available. The visual acuity (VA) is recorded in the following way. If the patient reads all five letters from the 20/20 line with the right eye and three of the five letters on the 20/15 line with the left eye, the examiner writes right eye 20/20, left eye 20/15-2, or VA 20/20, 20/15-2. If the patient is unable to read the largest letter on the chart (the 20/200 line), the patient should be moved toward the chart or the chart moved toward the patient, until the patient is able to identify the largest letter on the chart. If the patient can recognize only the letter E on the top line at a distance of 10 ft (3 m), the visual acuity would be recorded as 10′/200. If the patient is unable to see the letter E at any distance, the examiner should determine if the patient can count fingers (CF). The examiner holds up a random number of fingers and asks the patient to count the number he or she sees. If the patient correctly identifies the number of fingers at 3 ft (1 m), the examiner would record CF/3′. If the patient is unable to count fingers, the examiner raises one hand up and down or moves it side to side and asks in which direction the hand is moving. This level of vision is known as hand motions (HM). A patient who can perceive only light is described as having light perception (LP). The vision of a patient who is unable to perceive light is described as no light perception (NLP).

External Eye Examination After the visual acuity has been recorded, an external eye examination is performed. The position of the eyelids is noted. Commonly, the upper 2 mm of the iris is covered by the upper lid. The patient is examined for ptosis (i.e., drooping eyelid) and for lid retraction (i.e., too much of the eye is exposed). Sometimes, the upper or lower lid turns out, affecting closure. The lid margins and lashes should have no edema, erythema, or lesions. The examiner looks for scaling or crusting, and the sclera is inspected. The sclera is opaque and white. Lesions on the conjunctiva, discharge, and tearing or blinking are noted. The room is darkened so that the pupils can be examined. Examine the pupils directly. Observe the size and shape of each pupil. Next, shine a penlight on right pupil; watch for right pupil to constrict. Repeat for the other eye. Check for consensual response by shining light on the right eye and watching for the left pupil to constrict. Repeat by shining light on the left eye and watching for the right pupil to constrict. Check accommodation by having the patient stare with both eyes at a distant object (an object on the opposite wall) and then at an object up close (a pen held about 30 cm from the eyes). Pupils should dilate with distance and constrict with closeness. Record that the

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FIGURE 59-6. Testing extraocular movements.

pupils are equal, round, and react to light and accommodation, abbreviated as PERRLA (Stephen, 2012). A pupil is usually black. An irregular pupil may result from trauma, previous surgery, or a disease process. The patient’s eyes are observed in primary or direct gaze, and any head tilt is noted. A tilt may indicate cranial nerve palsy. The patient is asked to stare at a target; each eye is covered and uncovered quickly while the examiner looks for any shift in gaze. The examiner observes for nystagmus (i.e., oscillating movement of the eyeball). Using the patient’s shoulders as outer edges, the extraocular movements of the eyes are tested by having the patient follow the examiner’s finger through the six cardinal directions of gaze (right, right upward, right downward, left, left upward, and left downward) (Fig. 59-6). This is especially important when screening patients for ocular trauma or for neurologic disorders.

Diagnostic Evaluation Direct Ophthalmoscopy An ophthalmoscope is a handheld instrument with various plus and minus lenses. The lenses can be rotated into place, enabling the examiner to bring the cornea, lens, and retina into focus sequentially. The examiner holds the ophthalmoscope in the right hand and uses the right eye to examine the patient’s right eye. The examiner switches to the left hand and left eye when examining the patient’s left eye. During this examination, the room is darkened, and the patient’s eye is on the same level as the examiner’s eye. The patient and the examiner should be comfortable, and both should breathe quietly. The patient is given a target to gaze on and is encouraged to keep both eyes open and steady. When the fundus is examined, the vasculature comes into focus first. The veins are larger in diameter than the arteries. The examiner focuses on a large vessel and then follows it toward the midline of the body, which leads to the optic nerve. The central depression in the disc is known as the cup which is about one third of the disc. The size of the physiologic optic cup is estimated and the disc margins described as sharp or blurred. A silvery or coppery

appearance, which indicates arteriolosclerosis, is noted. The periphery of the retina can be examined by having the patient shift his or her gaze. The last area of the fundus to be examined is the macula, because this area is the most sensitive to light. The healthy fundus is free of any lesions. The examiner looks for intraretinal hemorrhages, which may appear as red smudges or, if the patient has hypertension, may look somewhat flame shaped. Lipid may be present in the retina of patients with hypercholesterolemia or diabetes. This lipid has a yellowish appearance. Soft exudates that have a fuzzy, white appearance (i.e., cotton-wool spots) are noted. The examiner looks for microaneurysms, which look like little red dots, and nevi. Drusen (small, hyaline, globular growths), commonly found in macular degeneration, appear to be yellowish areas with indistinct edges. Small drusen have a more distinct edge. The examiner sketches the fundus and documents any abnormalities.

Indirect Ophthalmoscopy The indirect ophthalmoscope is an instrument commonly used by eye care professionals (ophthalmologists or optometrists) to see larger areas of the retina, although in an unmagnified state. It produces a bright and intense light. The light source is affixed with a pair of binocular lenses, which are mounted on the examiner’s head. The ophthalmoscope is used with a handheld, 20-diopter lens.

Slit-Lamp Examination The slit lamp is a binocular microscope mounted on a table. This instrument enables the user to examine the eye with magnification of 10 to 40 times the real image. The illumination can be varied from a broad to a narrow beam of light for different parts of the eye. For example, by varying the width and intensity of the light, the anterior chamber can be examined for signs of inflammation. Cataracts may be evaluated by changing the angle of the light. When a handheld contact lens, such as a three-mirror lens, is used with the slit lamp, the angle of the anterior chamber may be examined, as may the ocular fundus.

Colour Vision Testing The ability to differentiate colours has a dramatic effect on the activities of daily living (ADLs). For example, the inability to differentiate between red and green can compromise traffic safety. Some careers (e.g., commercial art, colour photography, airline pilot, electrician) may be closed to people with significant colour deficiencies. The photoreceptor cells responsible for colour vision are the cones, and the greatest area of colour sensitivity is in the macula, the area of densest cone concentration. A screening test, such as the polychromatic plates discussed in the next paragraph, can be used to establish whether a person’s colour vision is within expected range. Colour vision deficits can be inherited. For example, red/ green colour deficiencies are inherited in an X-linked manner, affecting approximately 8% of men and 0.4% of women. Acquired colour vision losses may be caused by medications (e.g., digitalis toxicity) or pathology such as

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cataracts. A simple test, such as asking a patient if the red top on a bottle of eye drops appears redder to one eye than the other, can be an effective tool. A difference in the perception of the intensity of the colour red between the two eyes can be a symptom of a neurologic issue and may provide information about the location of the lesion. Because alteration in colour vision is sometimes indicative of conditions of the optic nerve, colour vision testing is often performed in a neuro ophthalmologic workup. The most common colour vision test is performed using Ishihara polychromatic plates. These plates are bound together in a book. On each plate of this booklet are dots of primary colours that are integrated into a background of secondary colours. The dots are arranged in simple patterns, such as numbers or geometric shapes. Patients with diminished colour vision may be unable to identify the hidden shapes. Patients with central vision conditions (e.g., macular degeneration) have more difficulty identifying colours than those with peripheral vision conditions (e.g., glaucoma) because central vision identifies colour.

dilated during the procedure, and visual acuity is diminished for about 30 minutes due to retinal “bleaching” by the intense flashing lights. The resulting fundus photographs can be viewed stereoscopically so that elevations such as macular edema can be identified.

Amsler Grid

Indocyanine Green Angiography

The Amsler grid is a test often used for patients with macular concerns, such as macular degeneration. It consists of a geometric grid of identical squares with a central fixation point. The grid should be viewed by the patient wearing usual reading glasses. Each eye is tested separately. The patient is instructed to stare at the central fixation spot on the grid and report any distortion in the squares of the grid itself. For patients with macular concerns, some of the squares may look faded, or the lines may be wavy. Patients with age-related macular degeneration (AMD) are commonly given these Amsler grids to take home. The patient is encouraged to check them frequently, as often as daily, to detect any early signs of distortion that may indicate the development of a neovascular choroidal membrane, an advanced stage of macular degeneration characterized by the growth of abnormal choroidal vessels.

Indocyanine green angiography is used to evaluate abnormalities in the choroidal vasculature, conditions often seen in macular degeneration. Indocyanine green dye is injected intravenously (IV), and multiple images are captured using digital videoangiography over a period of 30 seconds to 20 minutes. The dye is generally well tolerated, but some patients experience nausea and vomiting. Allergic reactions are rare; however, indocyanine green angiography is contraindicated in patients with a history of iodide reactions.

Ultrasonography Lesions in the globe or the orbit may not be directly visible and are evaluated by ultrasonography. Ultrasonography is a very valuable diagnostic technique, especially when the view of the retina is obscured by opaque media such as cataract or hemorrhage. Ultrasonography can be used to identify orbital tumours, retinal detachment, and changes in tissue composition.

Optical Coherence Tomography Optical coherence tomography is an emerging technology that involves low coherence interferometry. Light is used to evaluate retinal and macular diseases as well as anterior segment conditions. This method is noninvasive and involves no physical contact with the eye.

Colour Fundus Photography Fundus photography is a technique used to detect and document retinal lesions. The patient’s pupils are widely

Fluorescein Angiography Fluorescein angiography evaluates clinically significant macular edema, documents macular capillary nonperfusion, and identifies retinal and choroidal neovascularization (CNV) (i.e., growth of abnormal new blood vessels) in AMD. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital area vein. Within 10 to 15 seconds, this dye can be seen coursing through the retinal vessels. Over a 10-minute period, serial black-and-white photographs are taken of the retinal vasculature. The dye may impart a gold tone to the skin of some patients, and urine may turn deep yellow or orange. This discolouration usually disappears in 24 hours.

Tonometry Tonometry measures IOP by determining the amount of force necessary to indent or flatten (applanate) a small anterior area of the globe of the eye. The principle involved is that a soft eye is dented more easily than a hard eye. Pressure is measured in millimetres of mercury (mm Hg). High readings indicate high pressure; low readings, low pressure. The three most common types of tonometers are indentation, applanation, and noncontact. The procedure is noninvasive and is usually painless. Two of the most commonly used tonometers are the applanation tonometer and the Tono-Pen. The applanation tonometer is generally used by the more skilled examiner. A drop of fluorescein dye and an anesthetic drop are instilled in the eye. The applanation tip is pressed against the cornea and the examiner, looking through the slit lamp, obtains the IOP reading. The Tono-Pen is a portable, battery-operated, handheld tonometer that is commonly used in many clinical settings. A disposable cover is placed over the tip of the instrument, and it is held against the anesthetized cornea for a few seconds. The tension reading is displayed in a liquid crystal display window. A third method of assessing IOP uses the noncontact (“air puff”) tonometer. The “rebound force of a small puff of air blown against the cornea” is used to determine IOP (Carroll et al., 2010, p. 1339). It may not be as accurate as other methods, but as no instrument

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touches the eye it is easily used by technicians and in screening programs (Carroll et al., 2010).

A Normal

Perimetry Testing Perimetry testing evaluates the field of vision. A visual field is the area or extent of physical space visible to an eye in a given position. Its average extent is 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees outward when the eye is in the primary gaze (i.e., looking directly forward). It is a three-dimensional contour representing areas of relative retinal sensitivity. Visual acuity is sharpest at the very top of the field and declines progressively toward the periphery. Visual field testing (i.e., perimetry) helps to identify which parts of the patient’s central and peripheral visual fields have useful vision. It is most helpful in detecting central scotomas (i.e., blind areas in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa. The two methods of perimetric testing are manual and automated perimetry. Manual perimetry involves the use of moving (kinetic) or stationary (static) stimuli or targets. An example of kinetic manual perimetry is the tangent screen. A tangent screen is a black felt material mounted on a wall that has a series of concentric circles dissected by straight lines emanating from the centre. It tests the central 30 degrees of the visual field. Automated perimetry uses stationary targets, which are harder to detect than moving targets. In this test, a computer projects light randomly in different areas of a hollow dome while the patient looks through a telescopic opening and depresses a button whenever he or she detects the light stimulus. Automated perimetry is more accurate than manual perimetry.

IMPAIRED VISION Refractive Errors In refractive errors, vision is impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on the retina. Blurred vision from refractive error can be corrected with eyeglasses or contact lenses. The appropriate eyeglass or contact lens is determined by refraction. Refraction ophthalmology consists of placing various types of lenses in front of the patient’s eyes to determine which lens best improves the patient’s vision. The depth of the eyeball is important in determining refractive error (Fig. 59-7). Patients for whom the visual image focuses precisely on the macula and who do not need eyeglasses or contact lenses are said to have emmetropia (normal vision). People who have myopia are said to be nearsighted. They have deeper eyeballs; the distant visual image focuses in front of, or short of, the retina. People with myopia experience blurred distance vision. When people have a shorter depth to their eyes, the visual image focuses beyond the retina; the eyes are shallower and are called hyperopic. People with hyperopia are farsighted. These patients experience near-vision blurriness, whereas their distance vision is excellent.

X

B Myopic eye

X

C Hypermetropic eye

X

FIGURE 59-7. Eyeball shape determines visual acuity in refractive

errors. A, Normal eye. B, Myopic eye. C, Hypermetropic eye.

Another important cause of refractive error is astigmatism, an irregularity in the curve of the cornea. Because astigmatism causes a distortion of the visual image, acuity of distance and near vision can be decreased. Eyeglasses with a cylinder correction may be used for correction. Hard contact lenses, which by means of their tear film correct astigmatic errors, or soft toric contact lenses with a cylinder correction may be used in place of eyeglasses for patients with astigmatism. Ophthalmology has entered the era of customized vision correction in its desire to achieve “super-normal vision.” A new method of measuring refractive error that includes sphere, cylinder, and higher-order aberrations is called wavefront technology. The most promising application for this technology is wavefront-guided refractive surgery. A customized laser ablation pattern is generated to reshape the cornea.

Low Vision and Blindness Low vision is a general term describing visual impairment that requires patients to use devices and strategies in addition to corrective lenses to perform visual tasks. Low vision is defined as a best corrected visual acuity (BCVA) of 20/70 to 20/200. Blindness is defined as a BCVA of 20/400 to NLP. The clinical definition of absolute blindness is the absence of LP. Legal blindness is a condition of impaired vision in which an individual has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less. This definition does not equate with functional ability, nor does it classify the degrees of visual impairment. Legal blindness ranges

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from an inability to perceive light to having some vision remaining. An individual who meets the criteria for legal blindness may obtain government financial assistance. There are approximately 1 million Canadians who are blind, with the largest portion of this group being over 65 years of age. Someone in Canada begins to lose his or her vision every 12 minutes (Canadian National Institute for the Blind [CNIB], 2014b). Impaired vision is often accompanied by difficulty in performing functional activities. People with visual acuity of 20/80 to 20/100 with a visual field restriction of 60 degrees to greater than 20 degrees can read at a nearly usual level with optical aids. Their visual orientation is near normal but requires increased scanning of the environment (i.e., systematic use of head and eye movements). In a visual acuity range of 20/200 to 20/400 with a 20-degree to greater than 10-degree visual field restriction, the person can read slowly with optical aids. His or her visual orientation is slow, with constant scanning of the environment. People in this category may have the ability to negotiate their environment without auxiliary aids. This ability is termed “travel vision.” People with HM vision or no vision may benefit from the use of mobility devices (e.g., cane, guide dog) and should be encouraged to learn Braille and to use computer aids. The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts (CNIB, 2014c). Macular degeneration is more prevalent among Caucasians, whereas glaucoma is more prevalent among African Canadians. Age-related changes in the eye are described in Table 59-1.

Assessment and Diagnostic Testing The assessment of low vision includes a thorough history and the examination of distance and near visual acuity, visual field, contrast sensitivity, glare, colour perception, and refraction. Specially designed, low-vision visual acuity charts are used to evaluate patients. TABLE 59-1

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Patient Interview During history taking, the cause and duration of the patient’s visual impairment are identified. Patients with retinitis pigmentosa, for example, have a genetic abnormality (Chart 59-2). Patients with diabetic macular edema typically have fluctuating visual acuity. Patients with macular degeneration have central acuity issues. Central acuity concerns cause difficulty in performing activities that require finer vision, such as reading. People with peripheral field defects have more difficulties with mobility. The patient’s customary ADLs, medication regimen, habits (e.g., smoking), acceptance of the physical limitations brought about by the visual impairment, and realistic expectations of low-vision aids must also be identified and included in the plan of care, including provision of guidelines for safety and referrals to social services.

Contrast-Sensitivity Testing and Glare Testing Contrast-sensitivity testing measures visual acuity in different degrees of contrast. The initial test may take the form of simply turning on the lights while testing the distance acuity. If the patient can read better with the lights on, the patient can benefit from magnification. Glare testing enables the examiner to obtain a more realistic evaluation of the patient’s ability to function in his or her environment. Glare can reduce a person’s ability to see, especially in patients with cataracts. Devices that test glare, such as the Brightness Acuity Tester, produce three degrees of bright light to create a dazzle effect while the patient is viewing a target, such as Snellen letters on the wall. The lights have been calibrated to imitate certain objects that create glare, such as the brightness of a car’s headlights at night.

Medical Management Managing low vision involves magnification and image enhancement through the use of low-vision aids and strategies and through referrals to social services and community agencies serving those with visual impairment.

Age-Related Changes in the Eye

The External Eye

Structural Change

Functional Change

History & Physical Findings

Eyelids and lacrimal structures

Loss of skin elasticity and orbital fat, decreased muscle tone; wrinkles develop

Reports of burning, foreign body sensation, increased tearing (epiphoria); injection, inflammation, and ulceration may occur

Refractive changes; presbyopia Cataract

Loss of accommodative power in the lens with age

Lid margins turn in causing lashes to irritate cornea and conjunctiva (entropian); or lid margins may turn out, resulting in increased corneal exposure (ectropian) Reading materials must be held at increasing distance in order to focus Interference with the focus of a sharp image on the retina

Posterior vitreous detachment Age-related macular degeneration (AMD)

Liquefaction and shrinkage of vitreous body Drusen (yellowish aging spots in the retina) appear and coalesce in the macula. Abnormal choroidal blood vessels may lead to formation of fibrotic disciform scars in the macula

Opacities in the normally crystalline lens

May lead to retinal tears and detachment Central vision is affected; onset is more gradual in dry AMD, more rapid in wet AMD; distortion and loss of central vision may occur

Patient reports, “Arms are too short!”; need for increased light; reading glasses or bifocals needed Patients report increased glare, decreased vision, changes in colour values (blue and yellow especially affected) Reports light flashes, cobwebs, floaters Reading vision is affected; words may be missing letters, faded areas appear on the page, straight lines may appear wavy; drusen, pigmentary changes in retina; abnormal submacular choroidal vessels

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GENETICS IN NURSING PRACTICE

Chart 59-2. Eye and Vision Disorders SELECTED EYE AND VISION DISORDERS INFLUENCED BY GENETIC FACTORS • Albinism: partial or total absence of pigment of eyes, hair and skin, can include astigmatism, photophobia • Aniridia: congenital absence of all or a part of the iris • Colour blindness • Glaucoma • Homocystinuria: absence of enzyme needed to metabolize homocystine, involves mental retardation, subluxated lenses, clotting disorders • Isolated familial congenital cataracts • Leber hereditary optic neuropathy • Marfan syndrome: long lean body and other signs including dislocation of optic lens and other ocular issues • Retinitis pigmentosa NURSING ASSESSMENTS Family History Assessment • Assess history of family members with glaucoma, cataracts, night blindness (retinitis pigmentosa), colour blindness, or other vision impairment. • Inquire about the age of onset of symptoms (the onset of Leber Hereditary optic neuropathy is in young adulthood). • Inquire about family members with other disorders that may include visual impairment, such as cutaneous, metabolic, connective tissue disorders, and hearing loss. Physical Assessment

• Assess for other systemic and/or clinical features such as cutaneous or skeletal conditions, or hearing loss.

MANAGEMENT ISSUES SPECIFIC TO GENETICS

• Inquire whether DNA gene mutation or other genetic testing has been performed on any affected family members.

• If indicated, refer for further genetic counselling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions.

The goals are to enhance visual function and assist patients with low vision to perform customary activities. Lowvision aids include optical and nonoptical devices (Table 59-2). The optical devices include convex lens aids, such as magnifiers and glasses; telescopic devices; antireflective lenses that diminish glare; and electronic reading systems, such as closed-circuit television and computers with large print. Continuing advances in computer software provide very useful products for patients with low vision. Scanners with the appropriate software enable the user to scan printed data into the computer and have it read by computer voice or to enlarge the print for reading. Magnifiers can be handheld or attached to a stand with or without illumination. Telescopic devices can be spectacle telescopes or clip-on or handheld loupes. Nonoptical aids include large-print publications and a variety of writing aids. The Internet continues to expand, and a telephone system has been developed that allows access to the Internet and e-mail using voice commands (Chart 59-3).

• Offer appropriate genetics information and resources. • Assess patient’s understanding of genetics information. • Provide support to families with newly diagnosed geneticrelated sensorineural disorders.

• Participate in management and coordination of care of patients with genetic conditions and individuals predisposed to develop or pass on a genetic condition

GENETICS RESOURCES Canadian Association of Genetic Counsellors (CAGC)—a listing of genetic centres across Canada; www.cagc-accg.ca Canadian Cancer Society—information on the genetic factors/risk and genetic testing; www.cancer.ca Canadian Directory of Genetic Support Groups—a resource guide for families and professionals; www.lhsc.on.ca/ programs/medgenet Canadian Genetic Disease Network—its stated mission is to be the primary catalyst in advancing Canada’s scientific and commercial competitiveness in genetic research and the application of genetic discoveries to the prevention, diagnosis, and treatment of human disease; www.cgdn.ca Canadian Organization for Rare Disorders (CORD)—information on over 6,000 rare disorders and links individuals/ families together with the same rare disorder; www. cord.ca Genetic Alliance—increases the capacity of genetic advocacy groups to achieve their missions and leverages the voices of millions of individuals and families living with genetic conditions; www.geneticalliance.org Genetics Society of Canada (GSC)—promotes research and communicates the results and implications of genetics to the public; http://life.biology.mcmaster.ca/GSC GeneTests—a publicly funded medical genetics information resource developed for physicians, other health care providers, and researchers; http://www.genetests.org OMIM Online Mendelian Inheritance in Man—a catalogue of human genes and genetic disorders; www.ncbi.nlm.nih. gov/omim

CHART 59-3

Web Access for the Visually Impaired People with impaired vision need not be left behind in the computer age. Various technologies are available. A list of general equipment needs follows: • Computer: typically with IBM- or MAC-compatible software and a Windows operating system • Internet service provider (e.g., AOL, Netscape, Earthlink, Hotmail) • Screen-reader program: converts text on the computer screen to synthesized speech (e.g., JAWS for Windows, Window Eyes, Slimware Window Bridge, ProTalk 32, Hal Screen Reader, WinVision, WYNN, outSPOKEN for Windows) • Browser program to navigate the World Wide Web (e.g., Microsoft Internet Explorer, IBM Home Page Reader)

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Activities Affected by Visual Impairment and Visual Aids

Activity

Optical Aids

Nonoptical Aids

Shopping Fixing a snack Eating out Identifying money Reading print Writing Using a telephone

Hand magnifier Bifocals Hand magnifier Bifocals, hand magnifier High-power spectacle, bifocals, hand magnifier, stand magnifier, closed-circuit television Hand magnifier, focusable telescope, closed-circuit television Hand magnifier

Crossing streets Finding taxis and bus signs Reading medication labels Reading stove dials Adjusting the thermostat Using a computer Reading signs Watching sporting event

Telescope Telescope Hand magnifier Hand magnifier Hand magnifier Spectacles Spectacles Telescope

Lighting, colour cues Colour cues, consistent storage plan Flashlight, portable lamp Arrange paper money in wallet compartments Lighting, high-contrast print, large print, reading slit Lighting, bold-tip pen, black ink Large print dial or touch tone buttons, handprinted directory Cane, ask directions Colour codes, large print Colour codes, raised dots Enlarged print model High-contrast colour, large-print program Move closer Sit in front rows

Adapted from Riordan-Eva, P., & Whitcher, J. P. (2008). Vaughn and Asbury’s general ophthalmology. New York, NY: McGraw-Hill.

Strategies that enhance the performance of visual tasks include modification of body movements and illumination and training for independent living skills. Head movements and positions can be modified to place images in functional areas of the visual field. Illumination is an added feature in magnifiers. Adjusting the lighting helps with reading and other activities. Simple optical and nonoptical aids are available in lowvision clinics. Referrals to community agencies may be necessary for patients with low vision living alone who are unable to self-administer their medications. Community agencies offer services to patients with low vision that include training in independent living skills and the provision of occupational and recreational activities and a wide variety of assistive devices for vision enhancement and orientation and mobility. Lam and Leat (2013) examined patients’ perspectives of accessing a low-vision care program. Their reasons for not accessing low-vision programs included: “didn’t know what it was,” “vision is not bad enough,” “wanted to appear independent,” stigma attached to using aids, admitting they have a disability, other health issues, transportation, and education level. The irony is that lowvision care programs help people with low vision to be more independent.

Vision Restoration for the Blind Ophthalmologists have worked for years toward visual restoration for people who are blind, and computer technology now provides opportunities for restoring sight. Research is ongoing all over the world. Retinal implants for those whose optic nerves are functional as well as cortical implants for those whose optic nerves are diseased are being developed. For example, an experimental artificial silicon retina microchip is being developed for the treatment of patients with retinitis pigmentosa (Chow, Chow, Packo, et al., 2004). The rapid changes in technology and miniaturization of computer chips may enable dramatic advances in synthetic vision in the future.

Nursing Management Coping with blindness involves three types of adaptation: emotional, physical, and social. The emotional adjustment to blindness or severe visual impairment determines the success of the physical and social adjustments of the patient. Successful emotional adjustment means acceptance of blindness or severe visual impairment.

Promoting Coping Efforts Effective coping may not occur until the patient recognizes the permanence of the blindness. Clinging to false hopes of regaining vision hampers effective adaptation to blindness. A patient who is newly blind and his or her family members (especially those who live with the patient) undergo the various steps of grieving: denial and shock, anger and protest, restitution, loss resolution, and acceptance. The ability to accept the changes that must come with visual loss and willingness to adapt to those changes influence the successful rehabilitation of the patient who is blind. Additional aspects to consider are value changes, independence–dependence conflicts, coping with stigma, and learning to function in social settings without visual cues and landmarks.

Promoting Spatial Orientation and Mobility A person who is blind or severely visually impaired requires strategies for adapting to the environment. ADLs, such as walking to a chair from a bed, require spatial concepts. The person needs to know where he or she is in relation to the rest of the room, to understand the changes that may occur, and to know how to approach the desired location safely. This requires a collaborative effort between the patient and the responsible adult who serves as the sighted guide. A patient whose visual impairment results from a chronic progressive eye disorder, such as glaucoma, has better cognitive mapping skills than the patient who becomes blind suddenly. Patients with progressive eye disorders develop the use of spatial and topographic concepts

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early and gradually; hence, remembering a room layout is easier for them. Patients who become blind suddenly have more difficulty in adjusting, and emotional and behavioural issues of coping with blindness may hinder their learning. These patients require intensive emotional support. The nurse assesses the degree of physical assistance the person with vision loss requires and communicates this to other health care personnel. In the hospital, the bedside table and the call button must always be within reach. The parts of the call button are explained, and the patient is taught to touch and press the buttons or dials until the activity is mastered. The patient is familiarized with the location of the telephone, water pitcher, and other objects on the bedside table. The food tray’s composition is likened to the face of a clock; for example, the main plate may be described as being at 12 o’clock or the coffee cup at 3 o’clock. All articles and furniture must remain in the same positions throughout the patient’s hospitalization. Nurses should always introduce themselves upon entering a patient’s room and alert the patient to their departure. Such habits are always polite and help in the care of a patient with vision loss. The nurse should be aware of the importance of techniques in providing physical assistance, encouraging independence, and ensuring safety. Specific guidelines for interacting with the patient with vision loss are presented in Chart 59-4. The readiness of the patient and his or her family to learn are assessed before initiating orientation and mobility training.

Promoting Home and Community-Based Care The nurse, social workers, family, and others collaborate to assess the patient’s home condition and support system. If available, a low-vision specialist should be consulted before discharge, particularly for patients for whom identifying and administering medications pose a challenge. The level of visual acuity and patient preference help to determine appropriate interventions. For example, a plastic pill container with dividers that has been prefilled with a week’s supply of medication can make medication administration easier for some patients, whereas others may prefer to have medication bottles marked with textured paints. Many patients require referral to social services. Patients with habits that may jeopardize safety, such as smoking, need to be cautioned and assisted to make their environment safe. Other interventions that are appropriate for some people with low vision or blindness include Braille and guide dogs. Recent rapid advances in technology have led to the erroneous conclusion by some that Braille is an outmoded communication tool. There has been an ever-increasing reliance on print magnification technology as well as computer-assisted speech output. However, although the use of Braille may be less important for adults who have already learned language and grammar skills, educators and low-vision specialists have continued to advocate that children who are legally blind be given the opportunity to learn Braille.

CHART 59-4

GUIDELINES for Interacting With People Who Are Blind or Have Low Vision • Remember that the only difference between you and people

•

•

• • •

•

who are blind or have low vision is that they are not able to see through their eyes what you are able to see through yours. Do not be uncomfortable when in the company of a person who is blind or has low vision. Talk with the person as you would talk with any other individual, honestly and without pity; do not be concerned about using words like “see” and “look.” There is no need to raise your voice unless the person asks you to do so. Identify yourself as you approach the person and before you make physical contact. Tell the person your name and your role. If another person approaches, introduce him or her. When you leave the room, be sure to tell the person that you are leaving and if anyone else remains in the room. It is often appropriate to touch the person’s hand or arm lightly to indicate that you are about to speak. When talking, face the person and speak directly to him or her using a normal tone of voice. Be specific when communicating direction. Mention a specific distance or use clock cues when possible (e.g., walk left about 2 metres; walk about 6 metres to the right; the telephone is at 2 o’clock). Avoid using phrases such as “over there.” When you offer to assist someone, allow the person to hold onto your arm just above the elbow and to walk a half-step behind you.

• When offering the person a seat, place the person’s hand on the back or the arm of the seat.

• When you are about to go up or down a flight of stairs, tell the person and place his or her hand on the banister.

• Make sure that the environment is free of obstacles; close doors and cabinets so they are not in the path.

• Offer to read written information, such as a menu. • If you serve food to the person, use clock cues to specify where everything is on the plate.

• When the person who is blind or who has low vision is a

patient in a health care facility: • Make sure all objects the person will need are close at hand. • Identify the location of objects that the person may need (e.g., “The call light is near your right hand”; “The telephone is on the table on the left side of your bed.”) • Remove obstacles that may be in the person’s pathway and could cause a fall. • Place all assistive devices the person uses close at hand; let the person feel the devices so that he or she knows their location. • Do not distract the service animal unless the owner has given permission. • Ask the person, “How can I help you?” At some times the person needs help, but at other times help may not be needed.

This material is adapted from and based in part on Achieving Physical and Communication Accessibility, a publication of the National Center for Access Unlimited; Community Access Facts, an Adaptive Environments Center publication; and The Ten Commandments of Interacting with People with Mental Health Disabilities, a publication of The Ability Center of Greater Toledo.

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Guide dogs, also known as seeing-eye dogs, are dogs that are specially bred, raised, and rigourously trained to assist people who are blind. The guide dog is a constant companion to the person who is blind (also referred to as the animal’s handler) and is allowed on airplanes and in restaurants, stores, hotels, and other public places. With the assistance of the guide dog, the person who is blind can be extremely mobile and accomplish usual activities both within and outside of the home and workplace. A dog in harness is a working dog, not a pet. The dog should not be distracted from his job by wellintentioned strangers who want to pet, feed, or play with him. The dog’s handler should always be consulted before approaching the working guide dog. Most health care facilities have a service animal policy that outlines the responsibilities of the handler with regard to the care of the animal. In Canada, laws such as the Canadian Charter of Human Rights and Freedoms, Access to Information Act, and Canadian Human Rights Act support assistance of people who are blind. Governmental services include income assistance and health insurance through Family and Community Services, support services through programs such as the Canadian National Institute for the Blind and the Alliance for Equality of Blind Canadians, tax exemptions and tax deductions, educational services through programs such as the Canadian Association Disability Service Providers in Post Secondary Education and National Educational Association of Disabled Students, reduced or free postage for Braille materials through the Canada Post Corporation Act, and assistance for veterans through Veteran Affairs Canada. Other resources and services are identified in “Resources and Web Sites” at the end of this chapter.

GLAUCOMA The term glaucoma is used to refer to a group of ocular conditions characterized by optic nerve damage. In the past, glaucoma was seen more as a condition of elevated IOP than of optic neuropathy. Increasingly, that is no longer the case. There is no doubt that increased IOP damages the optic nerve and nerve fibre layer, but the degree of harm is highly variable (McKinnon, Goldberg, Peeples, et al., 2008). The optic nerve damage is related to the IOP caused by congestion of aqueous humour in the eye. A range of IOPs are considered “normal,” but these may be associated with vision loss in some patients. Glaucoma is the second most common cause of irreversible blindness in the world and affects more than 250,000 Canadians over the age of 40 (CNIB, 2014d). It usually occurs in older people but can occur in people of any age. It is estimated that glaucoma affects at least 300,000 Canadians, with approximately half of them unaware of their disease. Glaucoma is more prevalent among people older than 40 years of age, and again after the age of 60 the incidence increases with age (CNIB, 2014d). It is also more prevalent among men than women and in the African Canadian and Asian Canadian populations (Chart 59-5). There is no cure for glaucoma, but research continues.

CHART 59-5

Risk Factors for Glaucoma • • • • • • • • •

Family history of glaucoma African Canadians Older age Diabetes Cardiovascular disease Migraine syndromes Nearsightedness (myopia) Eye trauma Prolonged use of topical or systemic corticosteroids

Physiology Aqueous humour flows between the iris and the lens, nourishing the cornea and lens. Most (90%) of the fluid then flows out of the anterior chamber, draining through the spongy trabecular meshwork into the canal of Schlemm and the episcleral veins (Fig. 59-8). About 10% of the aqueous fluid exits through the ciliary body into the suprachoroidal space and then drains into the venous circulation of the ciliary body, choroid, and sclera. Unimpeded outflow of aqueous fluid depends on an intact drainage system and an open angle (about 45 degrees) between the iris and the cornea. A narrower angle places the iris closer to the trabecular meshwork, diminishing the angle. The amount of aqueous humour produced tends to decrease with age, in systemic diseases such as diabetes, and in ocular inflammatory conditions. IOP is determined by the rate of aqueous production, the resistance encountered by the aqueous humour as it flows out of the passages, and the venous pressure of the episcleral veins that drain into the anterior ciliary vein. When aqueous fluid production and drainage are in balance, the IOP is 15 mm Hg (Standring, 2008). When aqueous fluid is inhibited from flowing out, pressure builds up within the eye. Fluctuations in IOP occur with

B

A

FIGURE 59-8. Normal outflow of aqueous humour. A, Trabecular

meshwork. B, Uveoscleral route. From Kanski, J. J. (1999). Clinical ophthalmology. Oxford: Butterworth-Heinemann Ltd.

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Pathophysiology

CHART 59-6

Stages of Glaucoma 1. Initiating events. Precipitating factors include illness, emotional stress, congenital narrow angles, long-term use of corticosteroids, and use of mydriatics (i.e., medications causing pupillary dilation). These events lead to the second stage. 2. Structural alterations in the aqueous outflow system. Tissue and cellular changes caused by factors that affect aqueous humour dynamics lead to structural alterations and to the third stage. 3. Functional alterations. Conditions such as increased intraocular pressure or impaired blood flow create functional changes that lead to the fourth stage. 4. Optic nerve damage. Atrophy of the optic nerve is characterized by loss of nerve fibres and blood supply. This fourth stage inevitably progresses to the fifth stage. 5. Visual loss. Progressive loss of vision is characterized by visual field defects.

time of day, exertion, diet, and medications. It tends to increase with blinking, tight lid squeezing, and upward gazing. Systemic conditions such as hypertension and intraocular conditions such as uveitis and retinal detachment have been associated with elevated IOP. Exposure to cold weather, alcohol, a fat-free diet, heroin, and marijuana have been found to lower IOP. TABLE 59-3 Types of Glaucoma

There are two accepted theories regarding how increased IOP damages the optic nerve in glaucoma. The direct mechanical theory suggests that high IOP damages the retinal layer as it passes through the optic nerve head. The indirect ischemic theory suggests that high IOP compresses the microcirculation in the optic nerve head, resulting in cell injury and death. Some glaucomas appear as exclusively mechanical, and some are exclusively ischemic types. Typically, most cases are a combination of both. Regardless of the cause of damage, glaucomatous changes typically evolve through clearly discernible stages (Chart 59-6).

Classification of Glaucoma There are several types of glaucoma. Although glaucoma classification is changing as knowledge increases, current clinical forms of glaucoma are identified as open-angle glaucoma (accounting for 90% of all cases in Canada [CNIB, 2014d]), angle-closure glaucoma (also called pupillary block), congenital glaucoma, and glaucoma associated with other conditions, such as developmental anomalies or corticosteroid use. Glaucoma can be primary or secondary, depending on whether associated factors contribute to the rise in IOP. The two common clinical forms of glaucoma encountered in adults are open-angle and angle-closure glaucoma, which are differentiated by the mechanisms that cause impaired aqueous outflow.

Glaucoma Types, Clinical Manifestation, and Treatment Clinical Manifestations

Treatment

Open-Angle Glaucomas Usually bilateral, but one eye may be more severely affected than the other. In all three types of open-angle glaucoma, the anterior chamber angle is open and appears normal. Chronic open-angle glauOptic nerve damage, visual field defects, IOP Decrease IOP 20%–50%. Additional topical and oral coma (COAG) >21 mm Hg. May have fluctuating IOPs. Usually agents added as necessary. no symptoms but possible ocular pain, headache, If medical treatment is unsuccessful, laser trabeculoplasty and halos. (LT) can provide a 20% drop in IOP. Glaucoma filtering surgery if continued optic nerve damage despite medication therapy and LT. Normal tension glaucoma Treatment similar to COAG, however, the best manageIOP ≤ 21 mm Hg. Optic nerve damage, visual field ment for normal tension glaucoma management is yet to defects. be established. Goal is to lower the IOP by at least 30%. Ocular hypertension Elevated IOP. Possible ocular pain or headache. Lower IOP by at least 20%. Angle-Closure (Pupillary Block) Glaucomas Obstruction in aqueous humour 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 glauRapidly progressive visual impairment, periocular Ocular emergency; administration of hyperosmotics, acetcoma (AACG) pain, conjunctival hyperemia, and congestion. Pain azolamide, and topical ocular hypotensive agents, such may be associated with nausea, vomiting, bradyas pilocarpine and beta-blockers (betaxolol). Possible cardia, and profuse sweating. Reduced central laser incision in the iris (iridotomy) to release blocked visual acuity, severely elevated IOP, corneal edema. aqueous and reduce IOP. Other eye is also treated with Pupil is vertically oval, fixed in a semi-dilated posipilocarpine eye drops and/or surgical management to tion, and unreactive to light and accommodation. avoid a similar spontaneous attack. Subacute angle-closure Transient blurring of vision, halos around lights; Prophylactic peripheral laser iridotomy. Can lead to acute glaucoma temporal headaches and/or ocular pain; pupil may or chronic angle-closure glaucoma if untreated. be semi-dilated. Chronic angle-closure Progression of glaucomatous cupping and significant Management similar to that for COAG: includes laser iriglaucoma visual field loss; IOP may be normal or elevated; dotomy and medications. ocular pain and headache. IOP, intraocular pressure.

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Table 59-3 summarizes the characteristics of the different types of open-angle and angle-closure glaucoma. I-40

Clinical Manifestations Glaucoma is often called the silent thief of sight because most patients are unaware that they have the disease until they have experienced visual changes and vision loss (Sharts-Hopko & Glynn-Milley, 2009). The patient may not seek health care until he or she experiences blurred vision or “halos” around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

Assessment and Diagnostic Findings Access to ophthalmologists is limited, especially in Northern Canada. Eye examinations via a University of Alberta teleglaucoma program in northern Alberta found that only 27% of patients needed an in-person assessment by an ophthalmologist while the remainder could be managed by their referral optometrist (Verma, Arora, Kassam, et al., 2014). 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 are 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 fibres 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 (i.e., 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 59-9 shows the progression of visual field defects caused by glaucoma.

Medical Management The aim of all glaucoma treatment is prevention of optic nerve damage through pharmacologic therapy, laser procedures, 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.

I-20

A

V-40

C

B

D

V-40

E

F

FIGURE 59-9. Progression of glaucomatous visual field defects. A cen-

tral 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.)

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 Canada, medical management is utilized in conjunction with surgical treatment, depending on the severity and type of glaucoma.

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. For patients who react to the preservative in their eye drops, preservative-free dorzolamide HCl/timolol maleate is now available in Canada. In considering a therapeutic regimen, the ophthalmologist/optometrist aims for the greatest effectiveness with the least side

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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 59-4), including miotics (i.e., cause pupillary constriction), adrenergic agonists (i.e., sympathomimetic agents), beta-blockers, alpha2-agonists (i.e., adrenergic agents), carbonic anhydrase inhibitors, and prostaglandins. Cholinergics (i.e., miotics) increase the outflow of the aqueous humour 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

TABLE 59-4

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 promoting outflow of aqueous humour 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 humour from the anterior chamber to the subconjunctival space into a bleb, thereby bypassing the usual drainage structures. This allows the aqueous humour to flow and exit by different routes (i.e., absorption by the conjunctival vessels or mixing with tears). Trabeculectomy

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 humour and increases outflow

Teach patients punctal occlusion to limit systemic effects (described in Chart 59-11)

Beta-blockers (betaxolol, timolol)

Decreases aqueous humour 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 humour production

Eye redness, dry mouth and nasal passages

Decreases aqueous humour 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

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

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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 glaucoma treatment is to achieve incomplete healing of the surgical wound. The outflow of aqueous humour 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 follow-up; 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 humour to an attached plate in the conjunctival space. A fibrous capsule develops around the episcleral plate and filters the aqueous humour, thereby regulating the outflow and controlling IOP.

CHART 59-7

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 • • • •

Nursing Management

•

Promoting Home and Community-Based Care

•

TEACHING PATIENTS SELF-CARE. The medical and surgi-

cal 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 are explained to help ensure compliance. A thorough 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 glaucoma-control 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 59-7 contains points to review with patients with glaucoma. CONTINUING CARE. 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 low-vision and rehabilitation services. Patients who meet the criteria for legal blindness should be offered referrals to agencies that assist in obtaining federal/territorial assistance. Reassurance and emotional support are important aspects of care. A lifelong disease involving a possible loss

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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/optometrist to send a report to your physician after each appointment. Keep all follow-up appointments.

of sight has psychological, physical, social, and vocational ramifications. The family is integrated into the plan of care, and because the disease has a familial tendency, family members is encouraged to undergo examinations at least once every 2 years to detect glaucoma early.

CATARACTS A cataract is a lens opacity or cloudiness (Fig. 59-10). Cataracts rank only behind arthritis and heart disease as a

FIGURE 59-10. 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, PA: Lippincott Williams & Wilkins.)

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leading cause of disability in older adults. More than 2.5 million Canadians have cataracts (CNIB, 2014e). In Canada, cataract surgery is the most commonly performed surgical procedure (CNIB, 2014e). According to the World Health Organization, cataract is the leading cause of blindness in the world (WHO, 2009).

Pathophysiology Cataracts can develop in one or both eyes at any age for a variety of causes (Chart 59-8). Cataract risk is related to lower income and educational levels, smoking history for 35 or more pack-years, diabetes, excessive sun exposure, medications, and high triglyceride levels in men (CNIB, 2014e). Visual impairment normally progresses at the same rate in both eyes over many years or in a CHART 59-8

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 (e.g., 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

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 (i.e., nearsightedness), which worsens when the cataract progresses. If dense, the cataract severely blurs vision. Periodic changes in prescription eyeglasses help manage this condition. 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 centre of the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is worse in very bright light. People with the highest levels of sunlight exposure have twice the risk of developing cortical cataracts than those with low-level sunlight exposure. Occupational sun exposure in people between 20 and 29 years of age is associated with nuclear cataract formation. 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 (e.g., sunlight, headlights).

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 (i.e., double vision), colour shift (i.e., the aging lens becomes progressively more absorbent at the blue end of the spectrum), brunescens (i.e., colour 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 slit-lamp 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 usual activities despite clinically significant cataracts. Others with less lens opacification have a disproportionate decrease in visual acuity; hence, visual acuity is an imperfect measure of visual impairment.

Medical Management No nonsurgical (medications, eyedrops, eyeglasses) treatment cures cataracts or prevents age-related cataracts. However, cigarette smoking; long-term use of corticosteroids, especially at high doses; sunlight and ionizing

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radiation; diabetes; obesity; and eye injuries can increase the risk for cataracts. In the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision.

Surgical Management In general, if reduced vision from cataract does not interfere with usual activities (e.g., able to drive legally), surgery may be delayed. 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 59-5). 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 (i.e., clear TABLE 59-5

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cornea incision), and lens design (i.e., foldable and more accurate IOL measurements). Injection-free topical and intraocular anesthesia, such as 1% lidocaine gel applied to the surface of the eye, eliminates the hazards of regional (retrobulbar and peribulbar) anesthesia, such as ocular perforation, retrobulbar hemorrhage, optic injuries, diplopia, and ptosis, and is ideal for patients receiving anticoagulants. Furthermore, patients can communicate and cooperate during surgery. IV moderate sedation may be used to minimize anxiety and discomfort. 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.

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. Broad-spectrum 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 Results in astigmatism, sensitivity to glare, or appearance of halos Persistent, low-grade inflammation and granuloma

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 are necessary for severe cases.

Early Postoperative Complications Acute bacterial endophthalmitis: devastating complication that occurs in about 1 in 1,000 cases; the most common causative organisms are Staphylococcus epidermidis, Staphylococcus 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) IOP, intraocular pressure.

Visual acuity is diminished.

Corticosteroids and antibiotics are administered systematically. 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.

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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 (i.e., nucleus, cortex, and capsule) is removed, and fine sutures close the incision. ICCE is infrequently performed today; but, it is still indicated when there is a need to remove the entire lens, such as with a subluxated cataract (i.e., 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 IOL. After the pupil has been dilated and the surgeon has made 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. With increasing frequency, self-sealing (sutureless) clear corneal incisions (temporal part of the cornea) are performed with phacoemulsification, minimizing postoperative astigmatism and thus decreasing bleeding and subconjunctival hemorrhage and speeding recovery of visual acuity. However, studies have revealed an increased incidence of postoperative endophthalmitis, or inflammation of ocular tissue (Taban, Behrens, Newcomb, et al., 2005). An in vitro study concluded that the transient reduction of IOP might result in poor wound apposition with the potential fluid flow across the cornea and into the anterior chamber increasing the risk of endophthalmitis. Innovations are under way for laser phacoemulsification with low heat generation and smaller incision size, minimizing induced astigmatism, improving wound integrity, and promoting the use of injectable IOLs. LENS REPLACEMENT. After removal of the crystalline lens, the patient is referred to as aphakic (i.e., 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 (i.e., 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. 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 (e.g., 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. The most common IOL is the single-focus lens. Eyeglasses are still needed for distant or close vision, because the single-focus lens, unlike the natural lens of the eye, cannot alter its shape to bring objects at different distances into focus. Multifocal IOLs reduce the need for eyeglasses but patients can experience halos and glare. In the future, older patients may benefit from a combined surgical approach using customized IOLs and refractive surgery for a customized vision correction.

Toxic Anterior Segment Syndrome Also known as toxic endothelial cell destruction or sterile endophthalmitis, toxic anterior segment syndrome is a noninfectious inflammation caused by a toxic agent after an uncomplicated and uneventful surgery. This relatively newly recognized disorder is a complication of anterior chamber surgery. Investigations have shown that it may be caused by toxins from improperly rinsed surgical instruments soaked in enzymatic detergents, residue from instruments sterilized with plasma gas, abnormalities in the pH or ionic composition of irrigation solutions, ophthalmic viscoelastic devices, intraocular medications, or even the finish of the IOL. Toxic anterior segment syndrome is characterized by corneal edema less than 24 hours after surgery, compared to the classic endophthalmitis, which appears 48 to 72 hours after surgery and is bacterial in nature. Like the classic endophthalmitis, the symptoms include reduction in visual acuity and pain. In the absence of microorganism growth, improvement has occurred with topical steroid treatment alone.

Nursing Management The patient with cataracts should receive the usual preoperative care for ambulatory surgical patients undergoing eye surgery. The standard battery of preoperative tests (complete blood count, ECG, and urinalysis) should be

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Assessment and Management of Patients With Eye and Vision Disorders

prescribed only when they would have been indicated by the patient’s medical history.

Providing Preoperative Care Increasing numbers of older patients are taking oral anticoagulants because of increasing prevalence of atrial fibrillation and other cardiovascular conditions (Ing & Doukeris, 2014). It has been common practice to withhold any anticoagulant therapy (e.g., aspirin, warfarin [Coumadin]) to reduce the risk for retrobulbar hemorrhage (after retrobulbar injection) for 5 to 7 days before surgery. However, a recent study showed that the risk of adverse events for patients who continued anticoagulant therapy before cataract surgery was very low (0.1% to 0.8%). The researchers speculated that regular users of aspirin or warfarin are already at higher risk for transient ischemic attacks or angina and suggest that patients may not need to discontinue these medications prior to surgery (Katz, Feldman, Bass, et al., 2003). 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 nonsteroidal antiinflammatory drug (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 complica-

tions, and obtain emergency care. Activities to be avoided are identified in Chart 59-9. The nurse also explains that there is minimal discomfort after surgery and instructs 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.

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 (i.e., dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. CONTINUING CARE. The eye patch is removed after the first follow-up 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

CHART 59-9

HOME CARE CHECKLIST •

Intraocular Lens Implant

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

• 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

✔

✔

• 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 (e.g., walking, reading, watching television). Resume the following activi-

✔

• Remember not to lift, push, or pull objects heavier than 7 kg.

✔

• Avoid bending or stooping for an extended period.

✔

• Be careful when climbing or descending stairs.

✔

• Know when to call the physician.*

✔

the inner canthus outward.

ties only as directed by the physician: driving, sexual activity, unusually strenuous activity.

✔

*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.

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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 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 open-angle 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.

Keratoconus Keratoconus is a condition characterized by a conical protuberance of the cornea with progressive thinning on protrusion and irregular astigmatism. This 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. The success rate of ocular surface transplantation using autologous oral mucosal epithelium or amniotic membrane recipient–derived bone stem cells is now reasonable. Tissue rejection remains a major cause of failure.

Phototherapeutic Keratectomy PTK is a laser procedure that is used to treat diseased corneal tissue by removing or reducing corneal opacities and smoothening 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 reepithelialization (particularly in patients with diabetes) and bacterial keratitis. Postoperative management consists of oral analgesic agents for eye pain. Reepithelialization 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 (i.e., 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 (e.g., 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 cornea with functionally compromised endothelium is typically not used for grafting (Chart 59-10), 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 (i.e., deviation in ocular alignment) can negatively influence the outcome. 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

CHART 59-10

Contraindications to the Use of Donor Tissue for Corneal Transplantation: Donor Characteristics Systemic Disorders • • • • •

Death from unknown cause Creutzfeldt–Jakob disease AIDS or high risk for HIV infection Hepatitis Eye infection, systemic infection

Intrinsic Eye Disease • • • •

Retinoblastoma Ocular inflammation Malignant tumours 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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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 colours 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 long-term 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 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 recontour corneal tissue and correct refractive errors so that eyeglasses or contact lenses are no longer needed. Both photorefractive keratectomy (PRK) and LASIK use an excimer laser (193-nm wavelength argon fluoride laser), which can evaporate corneal tissue very cleanly with almost no damage to the epithelial cells. Newer excimer lasers have a smaller spot size, a robust tracking system for eye movements, and wavefront custom ablation technology. These advances have minimized or eliminated aberrations induced by conventional laser vision correction as well as pre-existing aberrations; they have improved treatment accuracy and therefore have provided for better vision. Postoperative night vision problems also have been reduced. Laser vision correction alters the major optical function of the eye and thereby carries certain surgical risks. The patient must fully understand the benefits, potential risks and complications, common side effects, and limitations of the procedure. Refractive surgery does not alter the usual aging process of the eye. If the reason for the

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procedure is to meet vision requirements for the patient’s occupation, the results must satisfy both the patient and the employer. Precise visual outcome cannot be guaranteed. Typically, patients must be at least 18 years of age. The corneal structure must be normal and the refractive error must be stable. The patient is required to discontinue using contact lenses for a period before the procedure (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 (e.g., 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. Patient satisfaction is the ultimate goal; therefore, patient education and counselling about potential risks, complications, and postoperative follow-up are critical. Minimal postoperative care includes topical corticosteroid or NSAID and antibiotic drops.

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.

Laser Vision Correction Photorefractive Keratectomy Laser vision correction 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 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

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Implantable Devices Laser pulse

“Flap”

FIGURE 59-11. Laser-assisted in situ keratomileusis (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.

according to calculated measurements (Fig. 59-11). 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. However, with LASIK, the cornea has been invaded at a deeper level, and any complications are more significant than those that can occur with PRK. With the increasing success and popularity of LASIK, PRK is now reserved for patients who are unsuitable for LASIK, such as people with very thin corneas.

Perioperative Complications ABLATION-RELATED COMPLICATIONS. Ablation com-

plications of LASIK include an elevated area within the corneal treatment ablation zone (i.e., 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 visionthreatening 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 the first week after surgery. Studies suggest that, because no single agent appears to be solely the cause of DLK, the cause is multifactorial (Randleman & Shah, 2012). 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 DECENTRED ABLATIONS.

Decentred or eccentric ablation involves a shift of the centre 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 lowlight settings.

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 IOL implantation in patients who retain their natural lens. These phakic IOLs may be used in either the anterior or posterior chamber, and design improvements continue to be made. The implantation of such devices is reversible because the natural lens is left in place and the normal architecture of the cornea is preserved. This procedure may provide more predictable refractive results than procedures that alter the corneal curvature. Potential complications include cataract, iritis or uveitis, endothelial cell loss, and increased IOP. Although phakic IOL implantation provides a more predictable alternative to corneal refractive surgery, more controlled, longitudinal multicentre trials are needed to evaluate its long-term safety.

Conductive Keratoplasty A recent innovation in refractive surgery for the correction of low to mild hyperopia uses the principles of thermal keratoplasty by applying radiofrequency current to the peripheral cornea using a thin, handheld probe. It does not involve the removal of cornea tissue. Clinical trials have shown that postprocedure visual acuity, predictability, and stability are as good as, if not better than, with other refractive procedures (Du, Fan, & Asbell, 2007).

Nursing Management Patient satisfaction is the ultimate goal; therefore, patient education and counselling 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 DISORDERS Although the retina is composed of multiple microscopic layers, the two innermost layers, the sensory retina and the 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.

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

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Assessment and Management of Patients With Eye and Vision Disorders

Detached retina

Retinal tear

Lens

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Increasingly, optical coherence tomography and ultrasound are used for the complete retinal assessment, especially if the view is obscured by a dense cataract or vitreal hemorrhage. All retinal breaks, all fibrous bands that may be causing traction on the retina, and all degenerative changes must be identified.

Surgical Management Fluid

Vitreous humour

FIGURE 59-12. Retinal detachment.

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. 59-12). 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 Chapter 42). 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.

In rhegmatogenous detachment, an attempt is made to surgically reattach the sensory retina to the RPE. In traction detachment, the source of traction must be removed and the sensory retina reattached. New surgical techniques as well as advances in instrumentation have led to an increased rate of success of surgical reattachment and better visual outcomes. The most commonly used surgical interventions are the scleral buckle, the pars plana vitrectomy, and pneumatic retinopexy.

Scleral Buckle The retinal surgeon compresses the sclera (often with a scleral buckle or a silicone band; Fig. 59-13) to indent the scleral wall from the outside of the eye and bring the two retinal layers in contact with each other. This type of surgery has a high success rate in the hands of experienced retinal surgeons. It causes less damage to the lens of the eye in phakic patients, and there is a low risk of endophthalmitis. However, there is an increased incidence of diplopia and other complications, such as induced myopia and increased postoperative pain.

Pars Plana Vitrectomy A vitrectomy is an intraocular procedure in which 1- to 4-mm incisions are made at the pars plana. One incision allows the introduction of a light source, 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. Scleral buckle encircles globe

Clinical Manifestations

Repaired tear

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 report pain.

Assessment and Diagnostic Findings After visual acuity is determined, the patient must have a dilated fundus examination using an indirect ophthalmoscope as well as slit-lamp biomicroscopy. Stereo fundus photography and fluorescein angiography are commonly used during the evaluation.

Buckle holds sclera against the retina

FIGURE 59-13. Scleral buckle.

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This surgical technique was originally introduced as a treatment for eyes with conditions that were previously inoperable (e.g., vitreous hemorrhage, proliferative diabetic retinopathy). Technologic improvements, including the use of operating microscopes, microinstrumentation, and instruments that combine vitreous cutting, aspiration, and illumination capabilities in one device, have advanced 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.

Pneumatic Retinopexy This technique is used for the repair of a rhegmatogenous retinal detachment. It is the least invasive of the three procedures described. A gas bubble, silicone oil, or perfluorocarbon and liquids may be injected into the vitreous cavity to help push the sensory retina up against the RPE. Postoperative positioning of the patient is critical, because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. Argon laser photocoagulation or cryotherapy is also used to “spot-weld” small holes.

Nursing Management For the most part, nursing interventions consist of educating the patient and providing supportive care.

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 are 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. Associated risk factors include diabetes mellitus, glaucoma, and aging.

Central Retinal Vein Occlusion Blood supply to and from the ocular fundus is provided by the central retinal artery and vein. Central retinal vein occlusions (CRVOs) are relatively common and found most often in people older than 50 years of age. Patients who have suffered a CRVO report decreased visual acuity, which may range from mild blurring to vision that is severely limited. Direct ophthalmoscopy of the retina shows optic disc swelling, venous dilation and tortuousness, retinal hemorrhages, cotton-wool spots, and a “blood and thunder” (extremely bloody) appearance of the retina. The better the initial visual acuity, the better the general prognosis is. Fluorescein angiography may show extensive areas of capillary closure. The patient is 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. Macular edema, macular nonperfusion, and vitreous hemorrhage from the neovascularization are among the potential complications of CRVO.

Branch Retinal Vein Occlusion Some patients with branch retinal vein occlusions are symptom free, whereas others report 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 CRVO; 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 CRVO. Potential complications are similar. Potential associated conditions include glaucoma, systemic hypertension, diabetes mellitus, hyperlipidemia, and hyperviscosity syndrome.

Central Retinal Artery Occlusion The patient with central retinal artery occlusion, a relatively rare disorder, 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. Most visual loss associated with central retinal artery occlusion is severe and permanent.

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Assessment and Management of Patients With Eye and Vision Disorders

FIGURE 59-14. Retina showing drusen and age-related macular degen-

eration (AMD).

Age-Related Macular Degeneration Macular degeneration is the leading cause of severe vision loss in Canadians, especially among older adults, and is responsible for one in three cases of reported vision loss (CNIB, 2014f). Commonly called AMD, it is characterized by tiny, yellowish spots called drusen (Fig. 59-14) 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. At present, more than one million Canadians have AMD (CNIB, 2014f). Of those, about 100,000 have blindness or partial sight. Central vision is mainly affected, with most patients retaining peripheral vision (Fig. 59-15). 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. 59-16). 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,

FIGURE 59-15. Visual loss associated with macular degeneration.

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there is a gradual blurring of vision that patients may notice when they try to read. There is no known treatment that can cure this type of AMD. The Age-related Eye Disease Study (2001), a multicentre clinical trial, has provided promising information about the prevention and treatment of AMD. The study was designed to determine whether large doses of macronutrients were effective in preventing or slowing the course of AMD. The study revealed that use of antioxidants (vitamin C, vitamin E, and beta-carotene) and minerals (zinc oxide) in megadoses can slow the progression of AMD and vision loss for people at high risk for developing advanced AMD. On the other hand, the results from a recent meta-analysis indicated a “small but statistically significant association between aspirin use and early ARMD” (Kahawita & Casson, 2014, p. 35). The second type of AMD, the wet or exudative type, may have an abrupt onset. Patients report 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 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 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 an increasing problem. With the growth of these new vessels from the choriocapillary 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. PDT is a two-step process (Fig. 59-17). 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. Overall, some patients may experience an improvement in vision, but most often the result has been to stabilize or slow visual loss. Verteporfin is a light-activated dye, and patient education is important preoperatively. 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 concern. The patient is instructed to bring dark sunglasses, gloves, a wide-brimmed hat, long-sleeved shirt, and slacks to the PDT setting. The patient is cautioned to avoid exposure to direct sunlight or

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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 59-16. Progression of age-related macular degeneration (AMD): pathways to vision loss.

bright light for 5 days after treatment. If a patient must go outdoors during daylight hours within the first 5 days after treatment, he or she should be counselled to wear long-sleeved shirts, slacks made of tightly woven fabrics, gloves, shoes, socks, sunglasses, and a wide-brimmed hat. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn that may require plastic surgery.

Nursing Management Nursing management is primarily educational. Most patients benefit from the use of bright lighting and magnification devices and from referral to a low-vision centre. Some low-vision centres send representatives to 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 are 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 (e.g., if the lines or squares appear distorted or faded), the patient should notify the ophthalmologist immediately and should arrange to be seen promptly.

Ongoing Research Angiogenesis An important component of the effort against neovascular AMD is research into the development and progression of angiogenesis (abnormal blood vessel formation). Studies continue toward identification of agents that can be used to inhibit angiogenesis. This has implications for ocular

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Assessment and Management of Patients With Eye and Vision Disorders

MACULAR DEGENERATION Leaky new vessels form in macula.

Retinal vessels

Optic nerve head The leaky new vessels retain vertiporfin dye.

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CNV. Laser treatment can then be applied to the abnormal neovascular network with minimal damage occurring to the macula. This surgical technique is being refined.

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 59-11 details safety measures to prevent orbital and ocular trauma.

Fovea

PHOTODYNAMIC THERAPY Red laser is aimed at new vessels for 83 seconds.

The dye is activated by the laser, leading to the closure of the new vessels.

LA S E R FIGURE 59-17. 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.

neovascularization and the treatment of other disorders, such as solid tumours. Vasoproliferation in exudative AMD is believed to be caused by an underlying angiogenic stimulus known as vascular endothelial growth factor (VEGF). Research is ongoing in phase III trials on two intravitreal agents designed to inhibit angiogenesis. Macugen (pegaptanib sodium) is designed to inhibit the ability of VEGF to bind to cellular receptors. Thus far Macugen has been shown to be safe and more effective than a placebo (Eyetech Study Group, 2003). Lucentis (ranibizumab) is designed to bind and inactivate all isoforms of VEGF. The results of animal studies and a small study of 64 patients have been promising. A larger phase III trial is under way.

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 condition 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 area of

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 The signs and symptoms of soft tissue injury from blunt or penetrating trauma include tenderness, ecchymosis, lid swelling, proptosis (i.e., 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.

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CHART 59-11

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 par-

ticles, 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/Yard • Wear safety glasses when mowing grass or trimming hedges, shrubs, trees, etc.

• Do not let anyone stand at the side of or in front of a moving lawn mower.

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. 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 (i.e., enophthalmos). Computed tomography (CT) can clearly 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 ball. 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 usual facial contours, interference with 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. Surgical repair is primarily

• Pick up rocks and stones before going over them with the

lawn mower. These stones can be hurled out of the rotary 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.

directed at freeing the entrapped ocular structures and restoring the integrity of the orbital floor.

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 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.

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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 (e.g., construction industry), sports (e.g., baseball, basketball, hockey, racket sports, boxing), weapons (e.g., air guns, BB guns), assault, motor vehicle crashes (e.g., broken windshields), and war (e.g., blast fragments). There are two types of ocular trauma in which the first response is critical: chemical burn and foreign object in the eye. With a chemical burn, the eye must be immediately irrigated with copious amounts of tap water or normal saline. With a foreign body, no attempt should be made to remove the foreign object. The object is protected from jarring or movement to prevent further ocular damage. No pressure or patch is applied to the affected eye. All traumatic eye injuries should be protected using a metal shield if available or a stiff paper cup until medical treatment can be obtained (Fig. 59-18).

Assessment and Diagnostic Findings 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 (i.e., 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 (i.e., agents that paralyze the ciliary

FIGURE 59-18. 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, PA: Lippincott-Raven.

A

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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, broad-spectrum antibiotics are initiated. Tetanus antitoxin is administered, if indicated, as well as analgesic agents. (Tetanus prophylaxis is recommended for full-thickness ocular and skin wounds.) Any topical medication (e.g., anesthetic agents, 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 (i.e., 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 lead to permanent corneal scarring. Corticosteroids are avoided while the epithelial defect exists.

Penetrating Injuries and Contusions of the Eyeball Sharp penetrating injury or blunt contusion force can rupture the eyeball. When the eyeball, 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 (i.e., edema of the conjunctiva), conjunctival laceration, shallow anterior chamber with or without an eccentrically placed pupil, hyphema (i.e., 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

B

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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 (i.e., complete removal of the eyeball and part of the optic nerve) is considered only if the globe is irreparable and has NLP. 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 uninjured eye by the affected eye that can result in blindness of the uninjured eye.

Intraocular Foreign Bodies A patient who reports blurred vision and discomfort is 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, grinding-wheel work, and an explosion. 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 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 (i.e., 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 (e.g., 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 (e.g., 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 (i.e., 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 agent is instilled, and a lid speculum is applied to overcome blepharospasm (i.e., spasms of the eyelid muscles that result in closure of the lids). Particulate matter must be removed from the fornices using moistened, cotton-tip 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 reepithelialization. Intense lubrication using nonpreserved (i.e., without preservatives to avoid allergic reactions) tears is essential. Reepithelialization 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 (e.g., curling iron, tobacco, ash), whereas photochemical injury results from ultraviolet irradiation or infrared exposure (e.g., 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 (i.e., 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 59-6 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 (e.g., thyroid disorders, Parkinson’s disease), infection, injury, or complications of medications (e.g., antihistamines, oral contraceptives, phenothiazines).

Clinical Manifestations The most common concern in dry eye syndrome is a scratchy or foreign body sensation. Other symptoms include itching, excessive mucous secretion, inability to produce tears, a burning sensation, redness, pain, and difficulty moving the lids.

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TABLE 59-6

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Common Infections and Inflammatory Disorders of Eye Structures

Disorder

Description

Management

Hordeolum (stye) Chalazion

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.

Blepharitis

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.

Bacterial keratitis

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 to 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.

Herpes simplex keratitis

Leading cause of corneal blindness. 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.

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, and 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 has been the usual regimen to hydrate and lubricate the eye through stimulating tears and preserving a moist ocular surface. Antiinflammatory medications have also been used, along with moisture chambers (e.g., moisture chamber spectacles, swim goggles) to provide additional relief. Restasis (cyclosporine ophthalmic emulsion, 0.05% w/v with no preservative) is now available in Canada. These eye drops are used every 12 hours. These drops are different from other treatments in that they promote actual healing of the ocular surface, with improvement continuing for a number of months.

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 (i.e., 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 on a repeated Schirmer’s test of 2 mm or less (filter paper is used to measure tear production).

Conjunctivitis Conjunctivitis (i.e., 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.

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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 (i.e., watery, mucoid, purulent, or mucopurulent), type of conjunctival reaction (i.e., follicular or papillary), presence of pseudomembranes or true membranes, and presence or absence of lymphadenopathy (i.e., 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 slitlamp 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 (e.g., 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.

Microbial Conjunctivitis BACTERIAL 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.

Chlamydial conjunctivitis includes trachoma (a bilateral chronic follicular conjunctivitis of childhood that leads to blindness during adulthood if left untreated) 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 with fomites, and the vectors can be insects such as flies and gnats. The onset of trachoma 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 (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 oral–genital 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. VIRAL CONJUNCTIVITIS. Viral conjunctivitis (Fig. 59-19) 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 (i.e.,

FIGURE 59-19. Conjunctival hyperemia in viral conjunctivitis.

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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. EKC is most often accompanied by preauricular lymphadenopathy and occasionally periorbital pain. There are marked follicular and papillary formations. EKC can lead to keratopathy.

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 (i.e., 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 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 is 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.

Bacterial Conjunctivitis Acute bacterial conjunctivitis is almost always selflimiting, lasting 2 weeks if left untreated. If treated with antibiotics, it may last a few days, except for gonococcal and staphylococcal conjunctivitis. For trachoma, usually broad-spectrum antibiotics are administered topically and systemically. Surgical management

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includes the correction of trichiasis (eyelashes growing inward toward the conjunctiva and cornea) to prevent conjunctival scarring. Adult inclusion conjunctivitis requires 1 week of antibiotics. Prevention of reinfection is important, and affected individuals and their sexual partners must seek treatment for sexually transmitted disease, if indicated.

Viral Conjunctivitis Viral conjunctivitis is not responsive to any treatment. Cold compresses may alleviate some symptoms. It is 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 the garbage. 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 59-12). During outbreaks of conjunctivitis caused by adenovirus, it is necessary that health care facilities CHART 59-12

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 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 usual. • 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 professional for an examination.

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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.

Allergic Conjunctivitis 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.

Toxic Conjunctivitis 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 humour (i.e., cell and flare). If severe, a hypopyon (i.e., 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 (i.e., peripheral iris adheres to the cornea and impedes outflow of aqueous humour). The development of posterior synechia (i.e., 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 greyish. 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. In Manitoba, Roy (2014) completed a retrospective chart review of uveitis in 43 First Nations (FN) patients and a control group of 45 non-FN patients in Manitoba. Significant differences were found in age of onset (FN 30.4 years vs. non-FN 40.2 years); bilateral uveitis (FN 86% vs. non-FN 51%); granulomatous uveitis (FN 53% vs. non-FN 11%); panuveitis (FN 67% vs. non-FN 16%); and anterior uveitis (FN 26% vs. non-FN 73%). The result

was that FN patients needed more aggressive therapies but had an increased complication rate, and ended up with poorer vision. There is a need across Canada to “improve uveitis management and visual outcomes in this rapidly growing Canadian population” (Hooper, 2014, p.119).

Management Because photophobia is a common symptom, patients should wear dark glasses outdoors. Ciliary spasm and synechia are best avoided through mydriasis; cyclopentolate (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 is 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 (ANAs), Venereal Disease Research Laboratories (VDRL), and Lyme disease titre. 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 foreign bodies and from a pre-existing 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 symptoms include pain, lid swelling, conjunctival edema, proptosis, and decreased ocular motility. With such edema, optic nerve compression can occur and IOP may increase. 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 (e.g., nausea, vomiting, fever, level of consciousness), displacement of the globe, extraocular movements, pupillary signs, and the fundus is extremely important. Consultation with

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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 TUMOURS Benign Tumours of the Orbit Benign tumours can develop from infancy and grow rapidly or slowly and present themselves in later life. Some benign tumours 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 tumours are masses characterized by the lack of infiltration in the surrounding tissues. Examples are cystic dermoid cysts and mucocele, hemangiomas, lymphangiomas, lacrimal tumours, 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 tumours that intertwine with other orbital structures, such as optic nerve meningiomas. Complete removal of the tumour may endanger visual function.

Benign Tumours of the Eyelid Benign tumours 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 tumours that may be bright, superficial, strawberry-red lesions (i.e., 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 concerns rather than visual function problems. Surgical excision, or electrocautery,

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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 Tumours 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 tumour 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 Tumours of the Orbit Rhabdomyosarcoma is the most common malignant primary orbital tumour in childhood, but it can also develop in older 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 tumours 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 tumours 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 Tumours of the Eyelid Basal cell carcinoma is the most common malignant tumour of the eyelid. Squamous cell carcinoma occurs less frequently but is considered the second most common malignant tumour. Malignant melanoma is rare. Malignant eyelid tumours occur more frequently 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

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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 Tumours 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 pre-existing nevus or acquired melanosis during middle age. Squamous cell carcinoma is also rare but invasive.

Management The management is surgical incision. Some benign tumours and most malignant tumours recur. To avoid recurrences, patients usually undergo radiation therapy and cryotherapy after the excision of malignant tumours. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumour is involved.

Malignant Tumour of the Globe: Ocular Melanoma A malignant tumour 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 tumour 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 report blurred vision or a change in eye colour. A number of such tumours 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 Tumours are classified according to size (i.e., small, medium, and large). Small tumours are generally monitored, whereas medium and large tumours require treatment. Treatment consists of radiation, enucleation, or both. Radiation therapy is achieved by external beam performed in repeated doses over several days or through the surgical implantation of a small plaque that contains radioactive iodine pellets (I125) over the tumour.

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 (i.e., 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. 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 is elevated to a comfortable position (30 to 45 degrees). Discharge teaching includes medication instructions for oral antibiotics, instillation of ophthalmic medications, and application of ocular compresses.

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Enucleation Enucleation is the removal of the entire eye and part of the optic nerve. It may be performed for the following conditions: • 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 tumours 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 (i.e., 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 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 Orbital implants and conformers (i.e., 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. 59-20) 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.

FIGURE 59-20. Eye prostheses. (Left) Anophthalmic ocular prosthesis.

(Right) Scleral shell.

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.

Medical Management 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 includes 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. Then an ophthalmic topical antibiotic ointment is applied in the socket three times daily. After the removal of an eye, there is a loss of depth perception. Patients are 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 is advised that conformers may accidentally fall out of the socket. If this happens, the conformer is 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 are taught how to insert, remove, and care for the prosthetic eye. Thorough handwashing must be observed before inserting

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and removing an ocular prosthesis. A suction cup may be used if there are issues with manual dexterity. Precautions, such as draping a towel over the sink and closing the sink drain, are 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 are identified by locating the identifying marks, such as a reddish colour 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 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 is 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

Canada in people younger than 50 years of age (CNIB, 2014g). The condition is called diabetic retinopathy, and it affects 500,000 Canadians. Regular eye examinations by optometrists and ophthalmologists can detect the condition early and treatment may prevent further loss of vision. Chapter 42 provides a detailed discussion of diabetic retinopathy.

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 report 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 burnedout 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.

Medical Management 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, Kuppermann, Wolitz, 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 deoxyribonucleic acid (DNA) replication. It may be the medication of choice when ganciclovir is ineffective. It may be administered intravenously

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Assessment and Management of Patients With Eye and Vision Disorders

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 is 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. In the late 1990s, the routine management of patients with AIDS, including those with CMV retinitis, changed with the introduction of highly active antiretroviral therapy (HAART). HAART is a combination of two or three medications of different categories. For example, a nucleoside analog such as zidovudine administered in combination with one or more protease inhibitors such as ritonavir has led to a suppression of human immunodeficiency virus (HIV) replication for sustained periods. The immune system can then recover to a functional level. Several patients who had been treated for CMV retinitis have been able to discontinue treatment for CMV retinitis as their immune systems rebounded. However, some patients develop immune recovery uveitis, characterized by intraocular inflammation, cystoid macular edema, and the formation of epiretinal membranes. Immune recovery uveitis is managed by corticosteroids or by injection of corticosteroids into the sub-Tenon’s area of the eye.

Hypertension-Related Eye Changes Hypertension, known as the silent killer, can shorten the life span by as many as 20 years. An estimated 7.4 million Canadians have hypertension (Hypertension Canada, 2014), and more than 9 in 10 Canadians will develop hypertension unless they follow a healthy lifestyle. Endorgan 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 colouration 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 fibre 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 vasoconstric-

1931

tion, and ischemia may result in serous retinal detachments and infarction of the RPE. Ischemic optic neuropathy and papilledema (i.e., swelling of the optic disc due to increased IOP) may also result. Blood pressure in these more severe stages should be lowered in a controlled gradual fashion to avoid ischemia of the optic nerve and brain secondary to a too-rapid fall in blood pressure. For further information about hypertension, see Chapter 33.

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 humour through the different routes of ocular drug administration. The rate and extent of aqueous humour 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 mL, and any excess is wasted. The volume of one eye drop from commercial topical ocular solutions typically ranges from 20 to 35 mL. • 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

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Sensorineural Function

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 medication 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.

TABLE 59-7

Drug Phenylephrine

Atropine Scopolamine Homatropine Cyclopentolate

Tropicamide

Commonly Used Ocular Medications Common ocular medications include topical anesthetic, mydriatic, and cycloplegic agents that reduce IOP; antiinfective medications; corticosteroids; NSAIDs; antiallergy medications; eye irrigants; and lubricants.

Topical Anesthetics Agents 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. Patients must never be allowed to take topical anesthetic agents home. Prolonged use can delay wound healing and can lead to permanent corneal opacification and scarring, resulting in visual loss. Topical anesthetic medication is also used for severe eye pain to allow the patient to open his or her eyes for examination or treatment (e.g., eye irrigation for chemical burns). Anesthesia occurs within 20 seconds to 1 minute and lasts 10 to 20 minutes. The nurse instructs patients not to rub their eyes while anesthetized because this may result in corneal damage.

Mydriatic and Cycloplegic Agents Mydriasis, or pupil dilation, is the main objective of the administration of mydriatic and cycloplegic agents (Table 59-7). These two medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations

Mydriatics and Cycloplegics Available Preparation/ Concentration Solution (2.5%, 10%)

Ointment (0.5%–2%) Solution (0.5%–3%) Solution (0.25%) Solution (5%–2.5%) Solution (0.5%–2%)

Solution (0.25%–1%)

Peak

Recovery Time

Indication/Dosage

Mydriasis

Cycloplegia

Mydriasis

Cycloplegia

Administered with cycloplegics in pupillary dilation for ophthalmoscopy and surgical procedures every 5–10 minutes × 3 or until the pupils are fully dilated In glaucoma, uveitis, or after surgery, 2× to 4× daily

10–60 minutes

—

3–6 hours

—

30–40 minutes

60–180 minutes

7–10 days

6–12 days

The same as atropine

20–30 minutes

30–60 minutes

3–7 days

3–7 days

The same as atropine and scopolamine

40–60 minutes

30–60 minutes

1–3 days

1–3 days

Administered with mydriatics q5–10 minutes × 3 or until the pupils are fully dilated for ophthalmoscopy and surgical procedures

30–60 minutes

25–75 minutes

1 days

6–24 hours

20–40 minutes

20–35 minutes

6 hours

BC). The Rinne test distinguishes between conductive and sensorineural hearing losses. With a conductive hearing loss, bone-conducted sound is heard as long as or longer than air-conducted sound; with a sensorineural hearing loss,

Comparison of Weber and Rinne Tests

Hearing Status

Weber

Rinne

Hearing intact

Sound is heard equally in both ears.

Conductive hearing loss

Sound heard best in affected ear (hearing loss).

Sensorineural hearing loss

Sound heard best in normal hearing ear.

Air conduction is audible longer than bone conduction. AC>BC Bone conduction as long or longer in affected ear (hearing loss). BC>AC Air conduction is audible longer than bone conduction in affected ear. AC>BC

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Assessment and Management of Patients With Hearing and Balance Disorders

1947

A thorough assessment of the inner ear function will likely require several diagnostic tests guided by the history obtained (e.g., vertigo, dizziness, impaired spatial orientation, visual difficulties, response to sudden loud noises) and assessment of the various integrated systems in the vestibular system (VEDA, n.d.).

DIAGNOSTIC EVALUATION OF HEARING AND BALANCE Many diagnostic procedures are available to measure the auditory and vestibular systems indirectly. These tests are usually performed by an audiologist or speech-language pathologist who is recognized by SAC.

Audiometry

FIGURE 60-6. The Rinne test assesses both bone and air conduction

of sound. (Photo © Day, R. A., Stephen, T., & Day, L. W. (2005). Faculty of Nursing, University of Alberta.)

air-conducted sound is audible longer than bone-conducted sound.

Vestibular Dysfunction Testing to Assess Balance Vestibular dysfunction is only one condition that contributes to impaired balance. For example, a positive Romberg test would indicate proprioceptive difficulty. (See Chapter 67 for assessment of muscle weakness, Chapter 60 for cerebellar assessment, and Chapter 59 for visual alterations.)

In detecting hearing loss, audiometry is the most important diagnostic instrument. Audiometric testing is of two kinds: pure-tone audiometry, in which the sound stimulus consists of a pure or musical tone (the louder the tone before the patient perceives it, the greater the hearing loss), and speech audiometry, in which the spoken word is used to determine the ability to hear and discriminate sounds and words. When evaluating hearing, three characteristics of sound pressure waves are important: pitch (frequency), duration, and intensity. A fourth characteristic of audible sound, timbre, (musical quality) is not assessed. Pitch refers to the frequency of sound pressure waves emanating from a source per second, measured as wave cycles per second (cps) commonly expressed in Hertz (Hz). The human ear perceives sounds ranging in frequency from 20 to 20,000 Hz. The frequencies from 500 to 2,000 Hz are important for understanding everyday speech and are referred to as the speech range (speech frequencies). Pitch is the term used to describe frequency; a tone with 100 Hz is considered to be a low pitch and a tone of 10,000 Hz is considered to be a high pitch. The duration of sound is the unit of time in seconds, minutes, or hours that a sound is heard. The unit for measuring intensity (loudness of sound) is the decibel (dB), the pressure exerted by sound. The physiological perception of sound is detected by an instrument that is calibrated for the human hearing curve: the “A” scale (Skillen, 2010). Hearing loss as measured in decibels is a logarithmic function of intensity that is not easily converted into a percentage. The critical level of loudness is approximately 30 dB(A). The shuffling of papers in quiet surroundings is about 15 dB; a low conversation, 40 dB; and a jet plane 30 m away, about 150 dB. Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner ear. Table 60-2 classifies hearing loss based on decibel level. In surgical treatment of patients with hearing loss, the aim is to improve the hearing level to 30 dB or better within the speech frequencies. During audiometry, the patient wears earphones and signals to the audiologist or occupational health nurse when a tone is heard. When the tone is applied directly over the external auditory canal, air conduction is

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Electronystagmography

TABLE 60-2

Severity of Hearing Loss

Loss in Decibels

Interpretation

0–15 >15–25 >25–40 >40–55 >55–70 >70–90 >90

Expected (intact) hearing Slight hearing loss Mild hearing loss Moderate hearing loss Moderate to severe hearing loss Severe hearing loss Profound hearing loss

measured. When the stimulus is applied to the mastoid bone, bypassing the conductive mechanism (i.e., ossicles), nerve conduction is tested. For accuracy, audiometric evaluations are computerized and performed in a soundproof room. Responses are plotted on a graph known as an audiogram, which differentiates conductive from sensorineural hearing loss. Speech discrimination is also measured (Fig. 60-7).

Tympanogram A tympanogram, or impedance audiometry, measures middle ear muscle reflex to sound stimulation and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal. Compliance is impaired with middle ear disease.

Auditory Brain Stem Response The auditory brain stem response is a detectable electrical potential from cranial nerve VIII and the ascending auditory pathways of the brain stem in response to sound stimulation. Electrodes are placed on the patient’s forehead. Acoustic stimuli, usually in the form of clicks, are made in the ear. The resulting electrophysiologic measurements can determine at which decibel level a patient hears and whether there are any impairments along the nerve pathways (e.g., tumour on the vestibulocochlear) (Pagana & Pagana, 2010).

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 60-7. 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.

Electronystagmography is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous, positional, or calorically evoked nystagmus. It identifies degree, velocity, and direction of nystagmus. It is also used to assess the oculomotor and vestibular systems and their corresponding interaction. Electronystagmography differentiates peripheral from central pathologic conditions. It helps in diagnosing conditions such as Ménière’s disease and tumours 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. No solid food is eaten prior to the test in case of vomiting. The test is contraindicated in the presence of perforations or an implanted pacemaker (Pagana et al., 2010).

Platform Posturography Platform posturography is used to investigate postural control capabilities, such as vertigo. The integration of visual, vestibular, and proprioceptive cues (i.e., 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. The same patient preparation is required as for electronystagmography. Although such testing cannot identify the side of the lesion in unilateral disease, it helps to identify disease (e.g., Ménière’s disease and tumours of the auditory canal) and evaluate the course of recovery. Ahmed, Goebel, and Sinks (2009) compared rotary chair versus caloric testing and concluded that the combination of testing had the strongest predictive value for identifying peripheral vestibular disorder.

Middle Ear Endoscopy Using 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

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Assessment and Management of Patients With Hearing and Balance Disorders

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.

HEARING LOSS More than 3 million Canadians have some form of hearing impairment. The Canadian Association of the Deaf (CAD) (2012) estimates that there are 350,000 Canadians who are culturally deaf and 3.15 million Canadians who are hard of hearing. Culturally deaf refers to Canadians who do not consider themselves disabled because of the absence of hearing (CAD). Many hearing impaired individuals can be helped with medical or surgical therapies, or with a hearing aid. By the year 2026, Canada’s population is expected to be approximately 35 million people, with 20% of the population being 65 years or older (Statistics Canada, 2008). The cost of hearing loss to the Canadian economy is estimated at $18 billion per year (Hearing Foundation of Canada, 2010). Of concern internationally is the evidence for early hearing loss in young people (The Hearing Foundation of Canada, 2010). 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 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, thus affecting the person’s quality of life. In a classroom, a student with impaired hearing may be disinterested, inattentive, and have failing grades. A person at home may feel isolated because of an inability to hear the clock chime, doorbell ring, refrigerator hum, birds sing, or traffic pass. A pedestrian with a hearing impairment may attempt to cross the street and fail to hear an approaching car. People with hearing impairments may miss parts of a conversation. Many people are unaware of their gradual hearing impairment. Often, it is the people with whom the individual communicates who recognize the impairment first (Chart 60-3).

1949

CHART 60-3

Symptoms & Signs 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 hearingimpaired people tend to dominate the conversation, knowing that as long as it is centred on them and they can control it, they are not so likely to be embarrassed by some mistake.

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 people generally ask those with whom they are trying to communicate to let them know whether difficulties in communication exist. These attitudes and behaviours are be taken into account when counselling patients who need hearing assistance. The decision to wear a hearing aid is a personal one that is affected by attitudes and behaviours.

Prevention Many environmental factors have an adverse effect on the auditory system and over time result in permanent sensorineural hearing loss. The World Health Organization (WHO) (2014) estimates that there are 360 million people with disabling hearing impairment and that worldwide, about a third of all people who are over 65 years of age are affected negatively by hearing impairment. Half of hearing loss and deafness is preventable. Noise exposure is the major preventable cause of hearing impairment.

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Sensorineural Function

Noise (unwanted, unavoidable sound) has been identified as one of the environmental hazards of the 21st 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. Noise-induced hearing loss (NIHL) is increasing in Canadians, especially in younger persons. 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 unequivocal that a quiet environment would be more conducive to peace of mind. A person who is ill feels more at ease when noise is kept to a minimum. Numerous factors contribute to hearing loss (Chart 60-4). The term noise-induced hearing loss is used to describe hearing loss that results from excessive exposure to loud sounds (both intensity and length of time exposed), such as heavy machinery, engines, and artillery. Acoustic trauma refers to the hearing loss caused by a single exposure to an extremely intense noise, such as an explosion. Usually, NIHL occurs at a high frequency (around 4,000 Hz). With continued noise exposure, hearing loss can become more severe and include adjacent frequencies. The minimum noise level known to cause NIHL regardless of duration, is about 85 to 90 dB. In Canadian jurisdictions, the exposure limit to noise for 8 hours/day for 5 days/week is 85 dB in all jurisdictions except two which permit somewhat higher levels (Canadian Centre for Occupational Health and Safety [CCOHS], 2014). Several industries (e.g., carpentry, plumbing, printing, and mining) and workplaces (e.g., shipyards, airports, breweries, and paper mills) have exposures close to or higher than these levels. Musicians and hunters are also at risk. Some equipment, such as power tools, woodworking saws, engines, and compressors, exceeds the exposure limit. For example, the sound levels from cutting machines in sawmills can reach 105 dB (Health and Safety Executive, 2007). The CCOHS requires that workers wear ear protection to prevent NIHL when exposed to noise above the legal limits. No medications protect against NIHL; hearing loss is permanent because the hair cells in the organ of Corti are destroyed. Ear pro-

CHART 60-4

Risk Factors for Hearing Loss • • • • • • • •

Family history of sensorineural impairment Congenital malformations of the cranial structure (ear) Low birth weight (40 mmol/d

Increased

Increased

Increased

SIADH, Syndrome of inappropriate secretion of antidiuretic hormone; CSW, cerebral salt wasting; DI, diabetes insipidus; WNL, within expected limits.

blood pressure and oxygenation, and reducing cellular metabolic demands. Judicious use of hyperventilation is recommended only if the ICP is not responding to other measures (AANN, 2012). Management of increased ICP is discussed in Chapter 64.

Monitoring Intracranial Pressure and Cerebral Oxygenation The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of ICP elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. ICP can be monitored with the use of an intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fibreoptic transducer-tipped catheter placed in the subdural space or in the ventricle (Fig. 62-3). When a ventriculostomy or ventricular catheter monitoring device is used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle, preferably in the

B A

To monitor

Subarachnoid screw

C Intraparenchymal sensor Intraventricular catheter Scalp Skull

D Subdural bolt

FIGURE 62-3. Intracranial pressure monitoring. A device may be placed in (A) the ventricle, (B) the subarachnoid space, (C) the intraparenchymal space, or (D) the subdural space.

CHAPTER 62

nondominant hemisphere of the brain (Hickey, 2013). The catheter is connected by a fluid-filled 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 increases in pressure. The ventriculostomy can also be used to drain blood from the ventricle. Also, continuous drainage of CSF under pressure control is an effective method of treating intracranial hypertension. Another advantage of a ventricular catheter is access for the intraventricular administration of medications and the occasional instillation of air or a contrast agent for ventriculography. Complications associated with its use include ventricular infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with the monitoring system (Stewart-Amidei & Klein, 2013). The subarachnoid screw or bolt is a hollow cylindrical device that is inserted through the skull and dura mater so that the tip protrudes into the cranial subarachnoid space (Hickey, 2013). 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 also has the advantage of avoiding complications from brain shift and small ventricle size. Complications include infection and 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 to detect ICP. The epidural ICP monitoring 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 fibre optic monitor, or transducer-tipped catheter, is a newer alternative to other intraventricular, subarachnoid, and subdural systems (Slazinski, 2011; StewartAmidei & Klein, 2013). 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.

Interpreting Intracranial Pressure Waveforms 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. 62-4). 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 (AANN, 2011). Plateau waves have clinical significance and indicate changes in vascular volume within the intracranial compartment that are beginning to compromise cerebral perfusion. The 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

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2015

Management of Patients With Neurologic Dysfunction

INTRACRANIAL PRESSURE WAVES

mm Hg

100 A Waves

75 B Waves

20

15

10

50 C Waves

5

25

0

Minutes FIGURE 62-4. 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.

shorter (30 seconds to 2 minutes) and have smaller amplitude (up to 50 mm Hg). They have less clinical significance, but if seen in a series 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. The clinical significance of C waves is unknown (AANN, 2011).

New Trends in Monitoring Additional trends in neurologic monitoring include microdialysis of the patient with a brain injury (Hickey, 2013; Stewart-Amidei & Klein, 2013; Timofeev, Czosnyka, Carpenter, et al., 2011). Cortical probes are placed near the injured area and are used to measure levels of glutamate, lactate, pyruvate, and glucose, which are substances that reflect the metabolic function of the brain. Some researchers theorize that direct measurements of glucose and energy byproducts in the brain will lead to better management of these patients and, ultimately, to improved outcomes. In order to determine optimal blood glucose parameters, microdialysis has been shown to provide insight into cerebral glucose metabolism, which is missed by simply investigating serum glucose (Meierhans et al., 2010). An additional new trend is monitoring of cerebral oxygenation through monitoring of the oxygen saturation in the jugular venous bulb (SjvO2) or via a catheter in the brain. Cerebral oxygenation is thought to be important because changes in cerebral perfusion may reflect an increase in ICP. Readings taken from a catheter residing in the jugular outflow tract 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 before an increase in ICP occurs. Minimizing cerebral desaturations can potentially improve outcomes (Mattar, 2011). This type of monitoring is now widely available and has been successfully used to identify secondary brain insults. A limiting factor is that this

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A

B

FIGURE 62-5. LICOX catheter system. A: The brain tissue oxygen catheter and monitor. B: Placement of

the catheter in brain white matter. Redrawn with permission of Integra NeuroSciences, Plainsboro, NJ.

saturation reflects overall perfusion of the brain rather than that of a specific injured area (Bhatia & Gupta, 2013). Another method of measuring cerebral oxygenation and temperature is by inserting a fibre optic catheter into the brain matter. Cerebral oxygenation can provide critical information on brain tissues, metabolic demands that ICP and CPP values do not always capture (Wilensky & Bloom, 2014). The most common system is LICOX (manufactured by Integra NeuroSciences, Plainsboro, NJ; Fig. 62-5). The system includes a monitor with a screen for the display of oxygen and temperature values and cables that connect to the monitoring probes in the brain (Hickey, 2013).

Decreasing Cerebral Edema According to AANN (2012), the following measures are recommended to reduce cerebral edema and to maximize outcomes in patients suffering a traumatic brain injury. The primary brain injury damages brain tissue and vessels; these damages can lead to secondary injury, which involves multiple metabolic mechanisms. Interruption of blood and oxygen to undamaged cells as well as damaged cells, which cause electrolyte shifts and loss of ion transportation controls, produce a cytotoxic edema that initiates an inflammatory response that will extend the damage to the brain. Goal: Maintain ICP less than 20 mm Hg 1. Interventions: 75 mm Hg (remember: CPP = MAP − ICP). Vasopressors may be used to increase the patient’s MAP to reach target CPP values. 2. Monitor for hyperthermia (defined as a temperature greater than 38°C) as it has been shown to contribute to increased poor neurologic outcomes. 3. Initiate adequate nutrition within 72 hours of injury and using continuous feeding to improve tolerance to feeds. 4. Prevent DVT formation with the use of low-molecularweight heparin (LMWH), sequential compression stocking or thigh-high compression stockings. 5. Administer IV insulin to maintain blood glucose levels within the prescribed range.

6. Administer anti-epileptic, as prescribed, to reduce postinjury seizures. If the above prove to be inadequate in reducing the patient’s ICP, additional measures such as: 1. Inducing moderate hypothermia (32–34°C) by using cooling blankets and IV cooling devices, will reduce the oxygen and metabolic requirements of the brain, and protect the brain from continued ischemia. However, complications of hypothermia include infection, coagulopathy, cardiac arrhythmias, and electrolyte abnormalities. 2. The administration of hypertonic saline (from 2% to 23.4%) to decrease ICP needs to be closely monitored. 3. The administration of high-dose barbiturates is meant to suppress cerebral metabolic demand and blood volume. No recent studies have been confirmed that examine the effect of barbiturates and patient outcomes. When using this treatment, continuous EEG monitoring should be used to guide barbiturate dosing. Patients must be hemodynamically stable prior to receiving barbiturates. 4. Hyperventilation is recommended as a temporary measure to reduce ICP, when all other measures have been exhausted, and should not be used within the first 24 hours of injury. All of the above interventions are not independently initiated by nurses, but nurses are responsible for implementing and monitoring the outcomes of these activities. These interventions to reduce ICP are evidence-based and provide the nurse with a framework, with which to advocate for best practice in patient care (AANN, 2012; Hickey, 2013).

Maintaining Oxygenation and Reducing Metabolic Demands Arterial blood gases and pulse oximetry are monitored to ensure that systemic oxygenation remains optimal. Metabolic demands may be reduced through the administration of high doses of barbiturates if the patient is

CHAPTER 62

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 cerebral protection (Mattar, 2011; Urden, Stacy, & Lough, 2013). Another method of reducing cellular metabolic demand and improving oxygenation is the administration of pharmacologic sedative, analgesic, or 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. The administration of paralyzing medication such as propofol (Diprivan) may also be appropriate. The patient who receives these agents cannot move; this decreases the metabolic demands and results in a decrease in cerebral oxygen demand. Paralyzing agents do not produce either sedation or analgesia, which must be provided, because the patient cannot respond to or report pain. Common sedative and analgesic agents include morphine sulfate, midazolam, fentanyl, and sufentanil. Common agents used for barbiturate or paralytic therapy are pentobarbital and propofol (Baird and Bethel, 2011). If barbiturates or paralyzing agents are used, the ability to perform serial neurologic assessments is lost. 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 the patient’s response to ventilator therapy (e.g., “bucking the ventilator”). The level of pharmacologic paralysis is adjusted based on serum levels of the medications administered and the assessed parameters. Potential complications include hypotension caused by decreased sympathetic tone and myocardial depression. Patients receiving high doses of barbiturates or pharmacologic paralyzing agents require continuous cardiac monitoring, endotracheal intubation, mechanical ventilation, and arterial pressure monitoring, as well as ICP monitoring. In addition, serum barbiturate levels must be routinely monitored (Baird & Bethel, 2011). Barbiturates are withdrawn gradually as the patient’s condition improves.

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Management of Patients With Neurologic Dysfunction

2017

function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Because the patient is critically ill, ongoing assessment is more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and ICP, and use of the Glasgow Coma Scale. Assessment of the patient with altered LOC is summarized in Table 62-1.

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 dysfunction (brain stem compression, structural displacement) • Ineffective cerebral tissue perfusion related to the effects of increased ICP • Risk for hemodynamic disturbance • Risk for imbalanced body temperature • Deficient fluid volume related to fluid restriction • Risk for infection related to ICP monitoring system (fibre optic or intraventricular catheter) Other relevant nursing diagnoses are included in the section on altered LOC.

Collaborative Problems/ Potential Complications Based on the assessment data, potential complications include: • • • • •

Brain stem herniation DI Infection SIADH CSW

Planning and Goals !!"##

Nursing Process

The Patient With Increased Intracranial Pressure

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

Assessment

Maintaining a Patent Airway

Initial assessment of the patient with increased ICP includes obtaining a history of events leading to the present illness and the pertinent past medical history. Due to the patient’s altered LOC it is usually 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

Airway patency is assessed regularly. Secretions that are obstructing the airway must be suctioned with care, and coughing is discouraged as transient elevations of ICP occur with coughing and suctioning (Hickey, 2013). Hypoxia caused by poor oxygenation leads to cerebral ischemia and subsequent edema. Coughing is discouraged because it increases ICP. The lung fields are auscultated at least every 8 hours

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to determine the presence of adventitious sounds or any areas of congestion. Elevating the head of the bed may aid in lung expansion and in clearing secretions and improve 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 can cause hyperventilation. If 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 therapist in monitoring the PaCO2, which is usually maintained at less than 30 to 35 mm Hg (Hickey, 2013). A neurologic observation record (Fig. 62-6) 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 62-3).

TABLE 62-3

Proper positioning of the patient’s head helps reduce ICP. The patient’s head is kept in a neutral (midline) position, maintained with the use of a soft cervical collar if necessary, to promote intracranial venous drainage. Elevation of the head is maintained at 30 to 45 degrees unless contraindicated or otherwise prescribed (AANN, 2012). 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 having a patient in this position causes an increase in intra-abdominal and intrathoracic pressures, which can produce an increase in ICP. The Valsalva manoeuvre, which can be produced by straining at defecation, moving in bed, or sneezing contribute to spikes in ICP and are avoided. Stool softeners may be prescribed if the patient is alert and able to eat; a diet high in fibre may be indicated. Abdominal distention, which increases intraabdominal and intrathoracic pressure and ICP, are 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 manoeuvre. Mechanical ventilation presents unique challenges for the patient with increased ICP. Before suctioning, the patient is preoxygenated and briefly hyperventilated using 100% oxygen on the ventilator. Suctioning should not last longer than 10 to 15 seconds and is limited to no more than two passes. High levels of positive end-expiratory pressure (PEEP) are avoided, because they may decrease venous return to the heart and decrease venous

Increased Intracranial Pressure and Interventions

Factor

Physiology

Interventions

Rationale

Cerebral edema

Can be caused by contusion, tumour, or abscess; water intoxication (hypoosmolality); alteration in the blood– brain barrier (protein leaks into the tissue, causing water to follow)

Administer osmotic diuretics as prescribed (monitor serum osmolality) Maintain head of bed elevated 30 degrees Maintain alignment of the head

Promotes venous return Prevents impairment of venous return through the jugular veins

Hypoxia

A decrease in the PaO2 causes cerebral vasodilation at 60 mm Hg Maintain oxygen therapy Monitor arterial blood gas values Suction when needed Maintain a patent airway

Prevents hypoxia and vasodilation

Hypercapnia (elevated PaCO2)

Causes vasodilation

Maintain PaCO2 (normally 35–45 mm Hg) by establishing ventilation

Normalizing PaCO2 minimizes vasodilation and thus reduces the cerebral blood volume

Impaired venous return

Increases the cerebral blood volume

Maintain head alignment Elevate head of bed 30 degrees

Hyperextension, rotation, or hyperflexion of the neck causes decreased venous return

Increase in intrathoracic or abdominal pressure

An increase in these pressures due to coughing, PEEP, or Valsalva manoeuvre 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 keep secretions loose and easy to suction or expectorate Soft bowel movements will prevent straining or Valsalva manoeuvre

CHAPTER 62

NURSING NEUROLOGIC CRITICAL CARE FLOWSHEET

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2019

Management of Patients With Neurologic Dysfunction

ADDRESSOGRAPH Date Time Initials

Person Level of orientation (✓)

Place Date and time No orientation Voice

Awakens to (✓)

Touch 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 verbal response ETT/TRACH Moves all extremities purposefully

Best motor response (✓)

Withdraws and lifts to painful stimuli Moves to painful stimuli Decorticates (spinal reflex) Decerebrates (spinal reflex) No motor response

Best motor strength upper extremities (✓) Best strength lower extremities (✓) Seizure activity (✓) Ataxia (✓) ICP monitoring

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 motor 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

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 Fine motor ataxia Does not apply Ventriculostomy mL ICP mm Hg Not applicable

*= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT FIGURE 62-6. A neurologic assessment flow chart.

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 above 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

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L L

R R R R R R

L L L L L 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

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

III, IV, VI, Extraocular movements Cranial nerves (+)=Present (–)=Absent

VII – Peripheral facial droop (R/L)

R

XII – Tongue deviation (R/L)

R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

L L

R R

V, VII – Corneal reflex (R/L)

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

Doll's eyes if appropriate Two step verbal command One step verbal command Unable to follow command *= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT Initials

L

IX – Gag reflex X, IX – Cough reflex

Follows commands

L

Signature

Title

Initials

FIGURE 62-6. Continued.

Signature

Title

L

CHAPTER 62

drainage from the brain through increased intrathoracic pressure (Hickey, 2013). Activities that increase ICP, as indicated by changes in waveforms, should be avoided if possible. Isometric muscle contractions such as pushing with feet or elbows against the mattress are also contraindicated because they raise the systemic blood pressure and hence the ICP. Spacing nursing interventions may prevent transient increases in ICP. During nursing interventions, the ICP should not rise above 25 mm Hg, and it 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 (AANN, 2011). Patients with the potential for a significant increase in ICP may need sedation and a paralytic agent before initiation of nursing activities. Emotional stress and frequent arousal from sleep are avoided. A calm atmosphere is maintained. Environmental stimuli (e.g., noise, conversation) should be minimal.

Maintaining Euvolemia (Appropriate Hydration) The administration of various osmotic and loop diuretics is part of the treatment protocol to reduce ICP. However the overall management goal of increased ICP, is adequate fluid management with saline to prevent hypotension and dehydration. Monitoring of skin turgor, mucous membranes, serum osmolarity, electrolytes, urine specific gravity, daily weights, and serum glucose is the standard to guide clinical decisions regarding fluid and electrolyte replacement. Concentration of saline and rate of administration of fluid is also determined by these values (Hickey, 2013). 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 (AANN, 2012). For patients undergoing dehydrating procedures, vital signs must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid output. During the acute phase, urine output is monitored hourly. An output greater than 200 mL/h for 2 consecutive hours may indicate the onset of DI (Baird & Bethel, 2011). These patients need careful oral hygiene, because mouth dryness occurs with dehydration. Frequently rinsing the mouth with nondrying solutions, lubricating the lips, and removing encrustations relieve dryness and promote comfort (Baird & Bethel, 2011).

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Management of Patients With Neurologic Dysfunction

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managing these systems and maintaining their sterility; strict adherence to the protocols and aseptic technique 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 for loose connections, because they can cause leakage and contamination of the CSF as well as inaccurate readings of ICP. The nurse observes the character of the CSF drainage and reports increasing cloudiness or blood. The patient is monitored for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persistent headache. (See Chapter 65 for a discussion of meningitis.)

Monitoring and Managing Potential Complications The primary complication of increased ICP is brain herniation resulting in death (Fig. 62-2). Nursing management focuses on detecting early signs of increasing ICP, because medical interventions are usually ineffective once later signs develop. Frequent neurologic assessments and documentation and analysis of trends will reveal the subtle changes that may indicate increasing ICP. DETECTING EARLY INDICATIONS OF INCREASING INTRACRANIAL PRESSURE. The nurse assesses for and

immediately reports any of the following early signs or symptoms of increasing ICP: • Anxiety, irritability, disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion; these are early clinical indications of increasing 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), which arise from the midbrain and brain stem (see Chapter 61) • Weakness in one extremity or on one side of the body; this occurs as increasing ICP compresses the corticospinal tracts • 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 INDICATIONS OF INCREASING INTRACRANIAL PRESSURE. As ICP increases, the

Preventing Infection

patient’s condition worsens, as manifested by the following later signs and symptoms:

The risk of infection is greatest when ICP is monitored with an intraventricular catheter and increases with the duration of the monitoring (AANN, 2011). Most health care facilities have written protocols for

• The LOC continues to deteriorate until the patient is comatose. • The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and

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temperature increase. 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 Cheyne–Stokes 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 centre 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 clinical sign of approaching death. MONITORING INTRACRANIAL PRESSURE.

Because clinical assessment is not always a reliable guide in recognizing increased ICP, especially in patients who are comatose, monitoring of ICP and cerebral oxygenation is an essential part of management (Hickey, 2013). 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 an 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 and lead to infection (AANN, 2011). When ICP is monitored with a fluid system, the transducer is calibrated at a particular reference point, usually at the level of the external auditory meatus, with the patient in the supine position; this point corresponds to the level of the foramen of Monro (Fig. 62-7) (Preuss, 2011). CSF pressure readings depend on the patient’s position. For subsequent

To transducer

Height scale in cm Fluid scale in mL (cc) 1 inch FIGURE 62-7. Location of the foramen of Monro for calibration of

intracranial pressure monitoring system.

pressure readings, the head should be in the same position relative to the transducer. Fibreoptic 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. When technology is associated with patient management, the nurse must be certain that the technologic equipment is functioning properly. The most important concern must be the patient to whom equipment is attached. 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. Astute 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 DI, CSW, and SIADH (see Chapters 15 and 43). Urine output should be monitored closely. DI requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Serum electrolyte levels are monitored for imbalances. SIADH requires fluid restriction and monitoring of serum electrolyte levels. CSW requires replacement of lost fluid and sodium.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 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 redness, swelling, or drainage at arterial, IV, and urinary catheter sites c. Has no redness, swelling, or purulent drainage from invasive intracranial monitoring device 6. Absence of complications a. Has ICP values that remain within normal limits b. Demonstrates urine output and serum electrolyte levels within acceptable limits

CHAPTER 62

TABLE 62-4

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2023

Comparison of Cranial Surgical Approaches

Supratentorial

Infratentorial

Trans-sphenoidal

Pituitary tumor Tip of forceps

Site of Surgery Above the tentorium

Below the tentorium, brain stem

Sella turcica and pituitary region

Incision Location Incision is made above the area to be operated on; usually located behind the hairline.

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.

Selected Nursing Interventions Maintain head of bed elevated 30–45 degrees, with neck in neutral alignment.

Position patient on either side or back. (Avoid positioning patient on operative side if a large tumour has been removed.)

Keep head of bed elevated to promote venous drainage and drainage from the surgical site.

INTRACRANIAL SURGERY A craniotomy involves opening the skull surgically to gain access to intracranial structures. This procedure is performed to remove a tumour, relieve elevated ICP, evacuate a blood clot, or control hemorrhage. The surgeon cuts the skull to create a bone 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 third approach, the trans-sphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland (Scholz, Parvin, Thissen, et al., 2010; Urden et al., 2013). Table 62-4 compares the three different surgical approaches: supratentorial, infratentorial, and trans-sphenoidal. Alternatively, intracranial structures may be approached through burr holes (Fig. 62-8), which are small circular openings made in the skull by either a hand drill or an automatic craniotome (which has a self-controlled system to stop the drill when the bone is penetrated). Burr holes

FIGURE 62-8. Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

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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 that allows 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).

Supratentorial and Infratentorial Approaches Preoperative Management Medical Management Preoperative diagnostic procedures may include a CT scan to establish placement of the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement of anatomical structures within the skull. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. The MRI is better suited for soft tissue evaluation such as brain tumours and can examine the lesion in many planes (Scholz et al., 2010). Cerebral angiography may be used to study a tumour’s blood supply or obtain information about vascular lesions. TCD flow studies are used to evaluate the blood flow within intracranial blood vessels. Most patients are prescribed an antiseizure medication such as phenytoin (Dilantin) or a phenytoin metabolite (Cerebyx) before surgery to reduce the risk of postoperative seizures (paroxysmal transient disturbances of the brain resulting from transient and abnormal electric discharge in the neurons of the cerebral cortex) (Diepenbrock, 2012; Hickey, 2013). Before surgery, corticosteroids such as dexamethasone (Decadron) may be administered to reduce cerebral edema if the patient has a brain tumour. Fluids may be restricted. A hyperosmotic agent (Mannitol) and a diuretic agent such as furosemide (Lasix) may be administered IV immediately before and sometimes during surgery if the patient tends to retain fluid, as do many who have intracranial dysfunction. Antibiotics may be administered if there is a chance of cerebral contamination. Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) may be prescribed prior to surgery to allay anxiety.

Nursing Management The preoperative assessment serves as a baseline against which postoperative status and recovery are compared. This assessment includes evaluating the LOC and responsiveness to stimuli and identifying any neurologic deficits, such as paralysis, visual dysfunction, alterations in personality or speech, and bladder and bowel disorders. Distal and proximal motor strength in both upper and lower extremities is recorded using the 5-point scale. Testing of motor function is discussed in Chapter 61. The patient’s and their family’s understanding of and reactions to the anticipated surgical procedure and its

possible sequelae are assessed, as is the availability of support systems for the patient and family. Adequate preparation for surgery, with attention to the patient’s physical and emotional status, can reduce the risk of anxiety, fear, and postoperative complications. The patient is assessed for neurologic deficits and their potential impact after surgery. For motor deficits or weakness or paralysis of the arms or legs, trochanter rolls are applied to the extremities, and the feet are positioned against a footboard or the ankles are supported in a neutral position with orthotic boots. A patient who can ambulate is encouraged to do so. If the patient is aphasic, writing materials or picture and word cards showing the bedpan, glass of 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. Hair is removed with the use of clippers and the surgical site prepared immediately before surgery (usually in the operating room), to decrease the chance of infection. 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 central and arterial lines placed for fluid administration and monitoring of pressures after surgery. The large head dressing applied after surgery may impair hearing temporarily. Vision may be limited if the eyes are swollen shut. If a tracheostomy or endotracheal tube is in place, the patient will be unable to speak until the tube is removed, so an alternative method of communication must be established. An altered cognitive state may make the patient unaware of the impending surgery (Chart 62-1). Even so, encouragement and attention to the patient’s needs are necessary. Whatever the state of awareness of the patient, the family needs reassurance and support, because they usually recognize the seriousness of brain surgery.

CHART 62-1

Ethics and Related Issues What Ethical Principles are Involved With Surrogate Consent? SITUATION A 35-year-old woman has had a brain injury, is in and out of a comatose state, and needs a craniotomy for removal of an epidural hematoma. The health care provider determines that the patient is unable to give informed consent for the procedure, so consent is obtained from the next of kin. DILEMMA The principle of autonomy for the patient conflicts with the principle of paternalism for the health care providers. DISCUSSION 1. What are the essential elements of informed consent pertinent to this situation? 2. What mechanisms can the nursing staff use to assist them in resolving any dilemma they have regarding the patient’s right to autonomy?

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Postoperative Management Postoperatively, an arterial line and a central venous pressure line may be in place to monitor and manage blood pressure and central venous pressure. The patient may be intubated and ventilated via a ventilator or may receive supplemental oxygen therapy via another respirator adjunct. Ongoing postoperative management is aimed at detecting and reducing cerebral edema, relieving pain and preventing seizures, monitoring ICP and neurologic status. REDUCING CEREBRAL EDEMA, PREVENTING SEIZURES, AND RELIEVING PAIN. Medications to reduce cerebral

edema in the postoperative patient are essentially the same as those which are used to reduce elevated ICP in the preoperative patient. Mannitol 20% IV is given rapidly to reduce cerebral edema within 10 to 20 minutes; however, more recently hypertonic saline (3% or 10% or 23.4% NaCL) is being used as an alternative to Mannitol. The hypertonic saline is given by continuous IV infusion and the patients’ serum sodium and osmolarity are monitored closely. For patients who have undergone supratentorial craniotomy, the risk of seizures after the procedure is high. Antiseizure medication such as phenytoin (dilantin) continues to be widely used as a prophylactic seizure medication, but more recently levetiracetam (Keppra) has been prescribed. Anticonvulsant medication is usually continued for 1 to 4 weeks postsurgery and steroid medications are usually tapered over several days. New research indicates that steroid medication is no longer recommended for patients with severe traumatic brain injury. In addition, sedation and paralysis are important means of controlling pain and agitation which is very important in reducing brain metabolism. Use of medication such as morphine, propofol, and lorazepam are used for analgesia and sedation, while muscular paralytics such as vecuronium can be used with patients who require ventilatory support postoperatively to reduce the stress of mechanical ventilation. MONITORING INTRACRANIAL PRESSURE. A patient undergoing intracranial surgery may have an ICP or cerebral oxygenation monitor inserted during surgery. Strict adherence to written protocols for managing these systems is essential, as discussed earlier, for preventing infection and managing ICP. The system is removed after the ICP or cerebral oxygenation is normal and stable. The neurosurgeon must be notified immediately if the system is not functioning.

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Nursing Process

The Patient Who Has Undergone Intracranial Surgery Assessment After surgery, the frequency of postoperative monitoring is based on the patient’s clinical status. Assessing respiratory function is essential, because even a small degree of hypoxia can increase cerebral

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ischemia. The respiratory rate and pattern are monitored, and arterial blood gas values are assessed frequently. Fluctuations in vital signs are carefully monitored and documented, because they may indicate increased ICP. The patient’s temperature is measured to assess for hyperthermia secondary to infection or damage to the hypothalamus. Neurologic checks are made frequently to detect increased ICP resulting from cerebral edema or bleeding. A slight change in LOC or response to stimuli may be the first sign of increasing ICP. The surgical dressing is inspected for evidence of bleeding and CSF drainage. The incision is monitored for redness, tenderness, bulging, separation, or foul odour. Sodium retention may occur in the immediate postoperative period. Serum and urine electrolytes, BUN, blood glucose, blood counts, arterial blood gases, weight, and clinical status are monitored. Intake and output are measured in view of losses associated with fever, respiration, and CSF drainage. The nurse must be alert to the development of complications; all assessments are carried out with these issues in mind. Seizures are a potential complication, and any seizure activity is carefully recorded and reported. Restlessness may occur as the patient becomes more responsive, or restlessness may be caused by pain, confusion, hypoxia, or other stimuli.

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses after intracranial surgery may include the following: • Risk for ineffective cerebral tissue perfusion related to cerebral edema • Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection • Potential for impaired gas exchange related to hypoventilation, aspiration, and immobility • Disturbed sensory perception related to periorbital edema, head dressing, endotracheal tube, and effects of ICP • Body image disturbance related to change in appearance or physical disabilities Other nursing diagnoses may include impaired communication (aphasia) related to insult to brain tissue, and high risk for impaired skin integrity related to immobility, pressure, and incontinence; impaired physical mobility related to a neurologic deficit secondary to the neurosurgical procedure or to the underlying disorder may also occur.

Collaborative Problems/ Potential Complications Potential complications include the following: • Increased ICP • Bleeding

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• Hypovolemic shock • Deep vein thrombosis (DVT) • Gastric ulcer hemorrhage Fluid and electrolyte disturbances • SIADH • CSW • DI Hyperglycemia Infection • Pneumocephalus • Hydrocephalus • CSF leakage Seizures

Planning and Goals The major goals for the patient include neurologic homeostasis to improve cerebral tissue perfusion, adequate thermoregulation, adequate ventilation and gas exchange, ability to cope with sensory deprivation, adaptation to changes in body image, and absence of complications.

Nursing Interventions Maintaining Cerebral Tissue Perfusion Attention to the patient’s respiratory status is essential, because even slight decreases in the oxygen level (hypoxia) or slight increases in the carbon dioxide level (hypercarbia) can affect cerebral perfusion, the clinical course, and the patient’s outcome. The endotracheal tube is left in place until the patient shows signs of awakening and has adequate spontaneous ventilation, as evaluated clinically and by arterial blood gas analysis. Secondary brain damage can result from impaired cerebral oxygenation. Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. The control of cerebral edema was discussed earlier. Nursing strategies used to control factors that may raise ICP were presented in the previous Nursing Process section discussing increased ICP. Intraventricular drainage is carefully monitored, using strict asepsis when any part of the system is handled. Vital signs and neurologic status (LOC and responsiveness, pupillary and motor responses) are assessed every 15 to 60 minutes. Extreme head rotation is avoided, because this raises ICP. After supratentorial surgery, the patient is placed on his or her back or side (on the unoperated side if a large lesion was removed) with one pillow under the head. The head of the bed may be elevated 30 degrees, depending on the level of the ICP and the neurosurgeon’s preference. After posterior fossa (infratentorial) surgery, the patient is kept flat on one side (off the back) with the head on a small, firm pillow (Hickey, 2013). The patient may be turned on either side, keeping the neck in a neutral position. When the patient is being turned, the body is turned as a unit to prevent placing strain on the incision and possibly tearing the

sutures. The head of the bed may be elevated slowly as tolerated by the patient. The patient’s position is changed every 2 hours, and skin care is given frequently. During position changes, care is taken to prevent disruption of the ICP monitoring system. A turning sheet placed under the patient’s head to midthigh makes it easier to move and turn the patient safely.

Regulating Temperature Moderate temperature elevation can be expected after intracranial surgery because of the reaction to blood at the operative site or in the subarachnoid space. Injury to the hypothalamic centres that regulate body temperature can occur during surgery. Fever is treated vigorously to combat the effect of an elevated temperature on brain metabolism and function. Nursing interventions include monitoring the patient’s temperature and using the following measures to reduce body temperature: removing blankets, applying ice bags to axilla and groin areas, using a hypothermia blanket as prescribed, and administering prescribed medications to reduce fever (Baird & Bethel, 2011). Conversely, hypothermia may be seen after lengthy neurosurgical procedures. Therefore, frequent measurements of rectal temperatures are necessary. Rewarming should occur slowly to prevent shivering, which increases cellular oxygen demands.

Improving Gas Exchange The patient undergoing neurosurgery is at risk for impaired gas exchange and pulmonary infections due to immobility, immunosuppression, decreased LOC, and fluid restriction. Immobility compromises the respiratory system by causing pooling and stasis of secretions in dependent areas and the development of atelectasis. The patient whose fluid intake is restricted may be more vulnerable to atelectasis as a result of inability to expectorate thickened secretions. Pneumonia can develop due to aspiration and restricted mobility. Repositioning the patient every 2 hours helps to mobilize pulmonary secretions and prevent stasis. After the patient regains consciousness, additional measures to expand collapsed alveoli can be instituted, such as yawning, sighing, deep breathing, incentive spirometry, and coughing (unless contraindicated). If necessary, the oropharynx and trachea are suctioned to remove secretions that cannot be raised by coughing; however, coughing and suctioning cause sharp, but transient increases in ICP. Therefore, suctioning should be used cautiously. Increasing the humidity in the oxygen delivery system may help to loosen secretions. The nurse and the respiratory therapist work together to monitor the effects of chest physical therapy.

Managing Sensory Deprivation Periorbital edema is a common consequence of intracranial surgery, because fluid drains into the

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dependent periorbital areas when the patient has been positioned in a prone position during surgery. A hematoma may form under the scalp and spread down to the orbit, producing an area of ecchymosis (black eye). Before surgery, the patient and family are informed that one or both eyes may be edematous temporarily after surgery. After surgery, elevating the head of the bed (if not contraindicated) and applying cold compresses over the eyes will help reduce the edema. If periorbital edema increases significantly, the surgeon is notified, because this may indicate that a postoperative clot is developing or that there is increasing ICP and poor venous drainage. Health care personnel should announce their presence when entering the room to avoid startling the patient whose vision is impaired due to periorbital edema or neurologic deficits. Additional factors that can affect sensation include a bulky head dressing, the presence of an endotracheal tube, and effects of increased ICP. The first postoperative dressing change is usually performed by the neurosurgeon. In the absence of bleeding or a CSF leak, every effort is made to minimize the size of the head dressing. If the patient requires an endotracheal tube for mechanical ventilation, every effort is made to extubate the patient as soon as clinical signs indicate it is possible. The patient is monitored closely for the effects of elevated ICP.

• An accumulation of blood under the bone flap (epidural, subdural, or intracerebral hematoma) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose condition deteriorates. An intracranial hematoma is suspected if the patient has any new postoperative neurologic deficits (especially a dilated pupil on the operative side). In these circumstances, the patient is returned to the operating room immediately for evacuation of the clot if indicated. • Cerebral edema, infarction, metabolic disturbances, and hydrocephalus are conditions that may mimic the clinical manifestations of a clot.

Enhancing Self-Image

MANAGING FLUID AND ELECTROLYTE DISTURBANCES. Fluid and electrolyte imbalances

The patient is encouraged to verbalize feelings and frustrations about any change in appearance. Nursing support is based on the patient’s reactions and feelings. Factual information may need to be provided if the patient has misconceptions about puffiness about the face, periorbital bruising, and hair loss. Attention to grooming, the use of the patient’s own clothing, and covering the head with a turban (and later a wig until hair growth occurs) are encouraged. Social interaction with close friends, family, and hospital personnel may increase the patient’s sense of self-worth. The family and social support system can be of assistance while the patient recovers from surgery.

Monitoring and Managing Potential Complications The nurse must be vigilant for complications that may develop within hours of surgery and require close collaboration with the neurosurgeon. These include increased ICP, bleeding and hypovolemic shock, altered fluid and electrolyte balance (e.g., water intoxication and DI), infection, and seizures. MONITORING FOR INCREASED INTRACRANIAL PRESSURE AND BLEEDING. Increased ICP and bleed-

ing are life-threatening to the patient who has undergone intracranial surgery. The following points must be kept in mind when caring for any patient who has undergone such surgery: • An increase in systolic blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

The patient is monitored closely for indicators of complications, and early signs and trends in clinical status are reported to the surgeon. Treatments are initiated promptly, and the nurse assists in evaluating the patient’s response to treatment. The nurse also provides support to the patient and family. If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), decreasing stimulation, administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents. may occur because of the patient’s underlying condition and its management or as complications of surgery. These disturbances can contribute to the development of cerebral edema. The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Oral fluids are usually resumed after the first 24 hours. The presence of gag and swallowing reflexes must be checked before initiation of oral fluids. Some patients with posterior fossa tumours have impaired swallowing, so fluids may need to be administered by alternative routes. The patient is observed for signs and symptoms of nausea and vomiting as the diet is progressed (Hickey, 2013). Patients undergoing surgery for brain tumours often receive large doses of corticosteroids and therefore tend to develop hyperglycemia. Serum glucose levels are measured every 4 to 6 hours. These patients are prone to stress ulcers, so histamine-2 receptor antagonists (H2 blockers) are prescribed to suppress the secretion of gastric acid. Patients also are monitored for bleeding and assessed for gastric pain. If the surgical site is near to (or causes edema to) the pituitary gland and hypothalamus, the patient may develop symptoms of DI, which is characterized by excessive urinary output, elevated serum

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osmolality, decreased urine osmolality, hypernatremia, and a low urine specific gravity. The urine specific gravity is measured hourly, and fluid intake and output are monitored. Fluid replacement must compensate for urine output, and serum potassium levels must be monitored. SIADH, which results in water retention with hyponatremia and serum hypo-osmolality, occurs in a wide variety of CNS disorders (e.g., brain tumour, head trauma) causing fluid disturbances. Nursing management includes careful intake and output measurements, specific gravity determinations of urine, and monitoring of serum and urine electrolyte levels while following directives for fluid restriction. SIADH is usually self-limited. PREVENTING INFECTION. The patient undergoing neurosurgery is at risk for infection related to the neurosurgical procedure (brain exposure, bone exposure, wound hematomas) and the presence of IV and arterial lines for fluid administration and monitoring. Risk for infection is increased in patients who undergo lengthy intracranial operations, in those who have external ventricular drains in place longer than 5 days, and with those who have ventricular catheters placed outside of the operating room (AANN, 2011). The dressing is often stained with blood in the immediate postoperative period. Because blood is an excellent culture medium for bacteria, the dressing is reinforced with sterile pads so that contamination and infection are avoided. A heavily stained or displaced dressing should be reported immediately. A drain is sometimes placed in the craniotomy incision to facilitate drainage. The incision site is monitored for redness, tenderness, bulging, separation, or foul odour. After suboccipital surgical procedures, CSF may leak through the incision. This complication is dangerous because of the possibility of meningitis. Any sudden discharge of fluid from a cranial incision is reported at once, because a massive leak requires surgical repair. Attention should be paid to the patient who reports a salty taste or “postnasal drip,” because this can be caused by CSF trickling down the throat. After a craniotomy, the patient is instructed to avoid coughing, sneezing, or nose blowing, which in addition to increasing ICP, can cause CSF leakage by creating pressure on the operative site. Aseptic technique is used when handling dressings, drainage systems, and IV and arterial lines. The patient is monitored carefully for signs and symptoms of infection, and cultures are obtained if infection is suspected. Appropriate antibiotics are administered as prescribed. Other causes of infection in the patient undergoing intracranial surgery, such as pneumonia and urinary tract infections, are similar to those in other postoperative patients. MONITORING FOR SEIZURE ACTIVITY. Seizures may occur as complications after any intracranial neurosurgical procedure. Preventing seizures is essential to avoid further cerebral edema. Administering the prescribed antiseizure medication before and after surgery may prevent the development of seizures in subsequent months and years. Status epilepticus

(prolonged seizures without recovery of consciousness in the intervals between seizures) may occur after craniotomy and also may be related to the development of complications (hematoma, ischemia). The management of status epilepticus is described later in this chapter. MONITORING AND MANAGING OTHER COMPLICATIONS. Other complications may occur

during the first 2 weeks or later and may compromise the patient’s recovery. The most important of these are thromboembolic complications (DVT, pulmonary embolism), pulmonary and urinary tract infection, and pressure ulcers. Most of these complications may be avoided with frequent changes of position, adequate suctioning of secretions, thrombosis prophylaxis, early ambulation, and skin care.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The recovery of a neurosurgical patient at home depends on the extent of the surgical procedure and its success. The patient’s strengths as well as limitations are assessed and explained to the family, along with the family’s part in promoting recovery. Because administration of antiseizure medication is a priority, the patient and family are taught to use a check-off system, pill boxes, and alarms to ensure that the medication is taken as prescribed. The patient and family are taught what to expect after surgery. Dietary restrictions usually are not required unless another health problem necessitates a special diet. Although showering or tub bathing is permitted, the scalp should be kept dry until all the sutures have been removed. A clean scarf or cap may be worn until a wig or hairpiece is purchased. If skull bone has been removed, the neurosurgeon may prescribe a protective helmet. After a craniotomy, the patient may require rehabilitation, depending on the postoperative level of function. The patient may require physical therapy for residual weakness and mobility issues. An occupational therapist is consulted to assist with self-care issues. If the patient is aphasic, speech therapy may be necessary. CONTINUING CARE. Barring complications, patients are discharged from the hospital as soon as possible. Patients with severe motor deficits require extensive physical therapy and rehabilitation. Those with postoperative cognitive and speech impairments require psychological evaluation, speech therapy, and rehabilitation. The nurse collaborates with the physician and other health care professionals during hospitalization and home care to achieve as complete a rehabilitation as possible and to assist the patient in living with residual disability. If tumour, injury, or disease makes the prognosis poor, care is directed toward making the patient as comfortable as possible. With return of the tumour or cerebral compression, the patient becomes less alert and aware. Other possible consequences include weakness or paralysis, blindness, and seizures. The home care nurse, hospice nurse, and social worker collaborate with the family to plan for additional

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home health care or hospice services or placement of the patient in an extended-care facility (see also the section on cerebral metastases in Chapter 66). The patient and family are encouraged to discuss end-oflife preferences for care; the patient’s end-of-life preferences must be respected (see Chapter 18). The nurse involved in home and continuing care of patients after cranial surgery also needs to remind patients and family members of the need for health promotion and recommended health screening.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Achieves optimal cerebral tissue perfusion a. Opens eyes on request; uses recognizable words, progressing to usual speech b. Obeys commands with appropriate motor responses 2. Maintains appropriate body temperature a. Registers normal body temperature 3. Has expected gas exchange a. Has arterial blood gas values within expected ranges b. Breathes easily; lung sounds are clear without adventitious sounds c. Takes deep breaths and changes position as directed 4. Copes with sensory deprivation 5. Demonstrates improving self-concept a. Pays attention to grooming b. Visits and interacts with others 6. Exhibits absence of complications a. Exhibits ICP within expected range b. Has minimal bleeding at surgical site; surgical incision is healing without evidence of infection c. Shows fluid balance and electrolyte levels within desired ranges d. Exhibits no evidence of seizures

Trans-Sphenoidal Approach Tumours within the sella turcica and small adenomas of the pituitary can be removed through a trans-sphenoidal approach: An incision is made beneath the upper lip, and entry is then gained successively into the nasal cavity, sphenoidal sinus, and sella turcica (Table 62-4). Although an otorhinolaryngologist may make the initial opening, the neurosurgeon completes the opening into the sphenoidal sinus and exposes the floor of the sella. Microsurgical techniques provide improved illumination, magnification, and visualization so that nearby vital structures can be avoided. The trans-sphenoidal approach offers direct access to the sella turcica with minimal risk of trauma and hemorrhage (Urden et al., 2013; Yuan, 2013). It avoids many of the risks of craniotomy, and the postoperative discomfort is similar to that of other transnasal surgical procedures. It

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may also be used for pituitary ablation (destruction) in patients with disseminated breast or prostatic cancer.

Complications Manipulation of the posterior pituitary gland during surgery may produce transient DI of several days’ duration (Hickey, 2013). It is treated with vasopressin but occasionally persists. Other complications include CSF leakage, visual disturbances, postoperative meningitis, pneumocephalus (air in the intracranial cavity), and SIADH (see Chapter 43).

Preoperative Management MEDICAL MANAGEMENT. The preoperative workup includes a series of endocrine tests, rhinologic evaluation (to assess the status of the sinuses and nasal cavity), and neuroradiologic studies. Funduscopic examination and visual field determinations are performed, because the most serious effect of pituitary tumour is localized pressure on the optic nerve or chiasm. In addition, the nasopharyngeal secretions are cultured, because a sinus infection is a contraindication to an intracranial procedure using this approach. Corticosteroids may be administered before and after surgery, because the surgery involves removal of the pituitary, the source of adrenocorticotropic hormone (ACTH). Antibiotics may or may not be administered prophylactically. NURSING MANAGEMENT. Deep breathing is taught before surgery. The patient is instructed that after the surgery he or she will need to avoid vigorous coughing, blowing the nose, sucking through a straw, or sneezing, because these actions may place increased pressure at the surgical site and cause a CSF leak (Hickey, 2013).

Postoperative Management MEDICAL MANAGEMENT. Because the procedure disrupts the oral and nasal mucous membranes, management focuses on preventing infection and promoting healing. Medications include antimicrobial agents (which are continued until the nasal packing inserted at the time of surgery is removed), corticosteroids, analgesic agents for discomfort, and agents for the control of DI if necessary (Hickey, 2013). NURSING MANAGEMENT. Vital signs are measured to monitor hemodynamic, cardiac, and ventilatory status. Because of the anatomic proximity of the pituitary gland to the optic chiasm, visual acuity and visual fields are assessed at regular intervals. One method is to ask the patient to count the number of fingers held up by the nurse. Evidence of decreasing visual acuity suggests an expanding hematoma (Eisenberg & Redick, 1998). The head of the bed is raised to decrease pressure on the sella turcica and to promote normal drainage. The patient is cautioned against blowing the nose or engaging in any activity that raises ICP, such as bending over or straining during urination or defecation. Intake and output are measured as a guide to fluid and electrolyte replacement and to assess for DI. The urine specific gravity is measured after each voiding. Daily weight is monitored. Fluids are usually given after nausea ceases, and the patient then progresses to a regular diet.

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The nasal packing inserted during surgery is checked frequently for blood or CSF drainage. The major discomfort is related to the nasal packing and to mouth dryness and thirst caused by mouth breathing. Oral care is provided every 4 hours or more frequently. Usually, the teeth are not brushed until the incision above the teeth has healed. Warm saline mouth rinses and the use of a cool mist vaporizer are helpful. Petrolatum is soothing when applied to the lips. A room humidifier assists in keeping the mucous membranes moist. The packing is removed in 3 to 4 days, and only then can the area around the nares be cleaned with the prescribed solution to remove crusted blood and moisten the mucous membranes (Hickey, 2013). Home care considerations include advising the patient to use a room humidifier to keep the mucous membranes moist and to soothe irritation. The head of the bed is elevated for at least 2 weeks after surgery.

Seizure Disorders Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) that result from sudden excessive discharge from cerebral neurons (Hickey, 2013). A part or all of the brain may be involved. The international classification of seizures differentiates between two main types: partial seizures that begin in one part of the brain, and generalized seizures that involve electrical discharges in the whole brain (Book & Pierazzo, 2010) (Chart 62-2). In a simple partial seizure, consciousness remains intact, whereas in a complex CHART 62-2

International Classification of Seizures Partial Seizures (seizures beginning locally) SIMPLE PARTIAL SEIZURES (with elementary symptoms, generally without impairment of consciousness) • With motor symptoms • With special sensory or somatosensory symptoms • With autonomic symptoms • Compound forms COMPLEX PARTIAL SEIZURES (with complex symptoms, generally with impairment of consciousness) • With impairment of consciousness only • With cognitive symptoms • With affective symptoms • With psychosensory symptoms • With psychomotor symptoms (automatisms) • Compound forms

Partial Seizures Secondarily Generalized GENERALIZED SEIZURES (convulsive or nonconvulsive, bilaterally symmetric, without local onset) Tonic–clonic seizures Tonic seizures Clonic seizures Absence (petit mal) seizures Atonic seizures Myoclonic seizures (bilaterally massive epileptic) Unclassified seizures

partial seizure, consciousness is impaired. Unclassified seizures are so termed because of incomplete data. The underlying cause is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. The characteristic seizure is a manifestation of this excessive neuronal discharge. Associated loss of consciousness, excess movement or loss of muscle tone or movement, and disturbances of behaviour, mood, sensation, and perception may also occur. The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include: • Cerebrovascular disease • Hypoxemia of any cause, including vascular insufficiency • Fever (childhood) • Head injury • Hypertension • CNS infections • Metabolic and toxic conditions (e.g., renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) • Brain tumour • Drug and alcohol withdrawal • Allergies

Nursing Management DURING A SEIZURE. Major responsibilities of the nurse are to protect the patient from injury (Book & Pierazzo, 2010) and to observe and record the sequence of signs. The nature of the seizure usually indicates the type of treatment that is required (Rho, Sankar & Cavazos, 2004). Before and during a seizure, the patient is assessed and the following items are documented:

• The circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) (Chart 62-3) • The occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or olfactory) • The first thing the patient does in the seizure—where the movements or the stiffness begins, conjugate gaze position, and the position of the head at the beginning of the seizure. This information gives clues to the location of the seizure origin in the brain. (In recording, it is important to state whether the beginning of the seizure was observed and the time.) • The type of movements in the part of the body involved • The areas of the body involved (turn back bedding to expose patient) • The size of both pupils and whether the eyes are open • Whether the eyes or head turned to one side • The presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing) • Incontinence of urine or stool • Duration of each phase of the seizure • Unconsciousness, if present, and its duration • Any obvious paralysis or weakness of arms or legs after the seizure

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NURSING RESEARCH PROFILE

Chart 62-3. Satisfaction of Staff in a Seizure Monitoring Unit Sauro, K., Krassman, C., Jette, N., et al. (2012). Experience and satisfaction of staff working in a seizure monitoring unit. Canadian Journal of Neuroscience Nursing, 34 (2), 33–38. Purpose Quality care has been linked to higher job satisfaction among nurses. Additionally, staff turnover is decreased when job satisfaction is higher, resulting in a more experienced and cohesive team. A seizure unit is much different than a general nursing unit, so job satisfaction data from general nursing units cannot be generalized to a seizure unit or other high acuity units. The purpose of the study was to examine satisfaction of staff in a regional tertiary care seizure monitoring unit in a large Canadian health region. Design This qualitative research was designed as a survey, and was completed either by paper or electronic format. The survey included 34 Likert scale questions and two open-ended questions. The surveys were distributed annually for a four year period.

• • • •

Inability to speak after the seizure Movements at the end of the seizure Whether or not the patient sleeps afterward Cognitive status (confused or not confused) after the seizure

In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient, not only physically but also psychologically (Book & Pierazzo, 2010). Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient. AFTER A SEIZURE. After a patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure and to prevent complications (e.g., aspiration, injury). The patient is at risk for hypoxia, vomiting, and pulmonary aspiration. To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration (Chart 62-4). Seizure precautions are maintained, including having available functioning suction equipment with a suction catheter and oral airway. The bed is placed in a low position with two to three side rails up and padded, if necessary, to prevent injury to the patient. The patient may be drowsy and may wish to sleep after the seizure; he or she may not remember events leading up to the seizure and for a short time thereafter.

Findings Descriptive statistics were obtained for the variables and four subcategories emerged; professional development, interdisciplinary teamwork, environment, and patientcentred care. Interdisciplinary teamwork was ranked highest – meaning the teamwork has improved over the four years, and this provides satisfaction to the staff. The physical environment was rated the lowest because of lack of space availability for working—and this had not changed significantly over the four years. In general, the staff rated this unit as an above-average place to work. Nursing Implications Nurses’ satisfaction with worklife and working conditions is known to correspond directly with positive patient outcomes. This research suggests that professional development, interdisciplinary teamwork, environment, and patient-centred care are areas that nursing teams might focus on as areas for improvement to lead to higher job satisfaction, and ultimately, an increase in positive outcomes for those they care for.

sies are differentiated by how the seizure activity manifests (Chart 62-3), the most common syndromes being those with generalized seizures and those with partialonset seizures (Hickey, 2013). Epilepsy can be primary (idiopathic) or secondary (when the cause is known and the epilepsy is a symptom of another underlying condition, such as a brain tumour). Epilepsy affects a small percentage (0.6%) of the Canadian population (Book & Pierazzo, 2010). However, the incidence of new-onset epilepsy is at its highest in older adults (Miller, Buello, & Bakas, 2014). The improved treatment of cerebrovascular disorders, head injuries, brain tumours, meningitis, and encephalitis has increased the number of patients at risk for seizures after recovery from these conditions. Also, advances in EEG have aided in the diagnosis of epilepsy. The general public has been educated about epilepsy, which has reduced the stigma associated with it; as a result, more people are willing to acknowledge that they have epilepsy. Although some evidence suggests that susceptibility to some types of epilepsy may be inherited, the cause of seizures in many people is idiopathic (unknown). Epilepsy can follow birth trauma, asphyxia neonatorum, head injuries, some infectious diseases (bacterial, viral, parasitic), toxicity (carbon monoxide and lead poisoning), circulatory issues, fever, metabolic and nutritional disorders, or drug or alcohol intoxication. It is also associated with brain tumours, abscesses, and congenital malformations.

The Epilepsies

Pathophysiology

Epilepsy is a group of syndromes characterized by unprovoked, recurring seizures. Epileptic syndromes are classified by specific patterns of clinical features, including age at onset, family history, and seizure type. Types of epilep-

Messages from the body are carried by the neurons (nerve cells) of the brain by means of discharges of electrochemical energy that sweep along them. These impulses occur in bursts whenever a nerve cell has a task

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CHART 62-4

Guidelines for Seizure Care Nursing Care During a Seizure

• No attempt should be made to restrain the patient during

• Provide privacy and protect the patient from curious

• • • • • • •

onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) Ease the patient to the floor, if possible. Protect the head with a pad to prevent injury (from striking a hard surface). Loosen constrictive clothing. Push aside any furniture that may injure the patient during the seizure. If the patient is in bed, remove pillows and raise side rails. If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patient’s biting the tongue or cheek. Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

the seizure, because muscular contractions are strong and restraint can produce injury. • If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions.

Nursing Care After the Seizure • Keep the patient on one side to prevent aspiration. Make sure the airway is patent.

• There is usually a period of confusion after a grand mal seizure. • A short apneic period may occur during or immediately after a generalized seizure.

• The patient, on awakening, should be reoriented to the environment.

• If the patient becomes agitated after a seizure (postictal),

use persuasion and gentle restraint to assist him or her to stay calm. Privacy provided as soon as possible

Oxygen and suction apparatus available

Oxygen tubing

Two to three side rails up and padded

Loosened clothing

Pillow under head

Bed in lowest position

Patient in side-lying position (immediate postseizure)

to perform. Sometimes, these cells or groups of cells continue firing after a task is finished. During the period of unwanted discharges, parts of the body controlled by the errant cells may perform erratically. Resultant dysfunction ranges from mild to incapacitating and often causes loss of consciousness (Hickey, 2013). If these uncontrolled, abnormal discharges occur repeatedly, a person is said to have an epileptic syndrome. Epilepsy is not associated with intellectual level. People who have epilepsy without other brain or nervous system disabilities fall within the same intelligence ranges as the overall popu-

lation. Epilepsy is not synonymous with mental retardation or illness. However, many people who have developmental disabilities because of serious neurologic damage also have epilepsy.

Clinical Manifestations Depending on the location of the discharging neurons, seizures may range from a simple staring episode (absence seizure) to prolonged convulsive movements with loss of consciousness.

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The initial pattern of the seizures indicates the region of the brain in which the seizure originates (Chart 62-3). In simple partial seizures, only a finger or hand may shake, or the mouth may jerk uncontrollably. The person may talk unintelligibly; may be dizzy; and may experience unusual or unpleasant sights, sounds, odours, or tastes, but without loss of consciousness (Hickey, 2013). In complex partial seizures, the person either remains motionless or moves automatically but inappropriately for time and place, or he or she may experience excessive emotions of fear, anger, elation, or irritability. Whatever the manifestations, the person does not remember the episode when it is over. Generalized seizures (previously referred to as grand mal seizures) involve both hemispheres of the brain, causing both sides of the body to react (Hickey, 2013). Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic– clonic contraction). The simultaneous contractions of the diaphragm and chest muscles may produce a characteristic epileptic cry. The tongue is often chewed, and the patient is incontinent of urine and feces. After 1 or 2 minutes, the convulsive movements begin to subside; the patient relaxes and lies in deep coma, breathing noisily. The respirations at this point are chiefly abdominal. In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. Many patients report headache, sore muscles, fatigue, and depression after a seizure.

Assessment and Diagnostic Findings The diagnostic assessment is aimed at determining the type of seizures, their frequency and severity, and the factors that precipitate them. A developmental history is taken, including events of pregnancy and childbirth, to seek evidence of preexisting injury. The patient is also questioned about illnesses or head injuries that may have affected the brain. In addition to physical and neurologic evaluations, diagnostic examinations include biochemical, hematologic, and serologic studies. MRI is used to detect structural lesions such as focal abnormalities, cerebrovascular abnormalities, and cerebral degenerative changes (Gulanick & Myers, 2013). The EEG furnishes diagnostic evidence for a substantial proportion of patients with epilepsy and assists in classifying the type of seizure. Abnormalities in the EEG usually continue between seizures or, if not apparent, may be elicited by hyperventilation or during sleep (Urden et al., 2013). Microelectrodes (depth electrodes) can be inserted deep in the brain to probe the action of single brain cells. Some people with clinical seizures have normal EEGs, whereas others who have never had seizures have abnormal EEGs. Telemetry and computerized equipment are used to monitor electrical brain activity while the patient pursues his or her usual activities and to store the readings on computer tapes for analysis. Video recording of seizures taken simultaneously with EEG telemetry is useful in determining the type of seizure as well as its duration and magnitude. SPECT is an additional tool of nuclear medicine that is sometimes used in the diagnostic workup. It is useful for calculating regional and global cerebral

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blood flow, by measuring cerebral metabolic use of oxygen and glucose. This helps to identify the epileptogenic zone so that the area in the brain giving rise to seizures can be removed surgically or appropriate treatment can be determined (Urden et al., 2013).

Epilepsy in Women Women who have epilepsy face particular needs associated with the syndrome. They often note an increase in seizure frequency during menses; this has been linked to the increase in sex hormones that alter the excitability of neurons in the cerebral cortex (Dworetzky, Townsend, Pennell, et al., 2012). The effectiveness of contraceptives is decreased by antiseizure medications. Therefore, patients are encouraged to discuss family planning with their primary health care provider and to obtain preconception counselling if they are considering childbearing (Rauchenzauner, Ehrensberger, Prieschl, et al., 2013). Women of childbearing age who have epilepsy require special care and guidance before, during, and after pregnancy. Many women note a change in the pattern of seizure activity during pregnancy. The risk of congenital fetal anomaly is two to three times higher in women with epilepsy. Maternal seizures, antiseizure medications, and genetic predisposition all contribute to possible malformations. Women who take certain antiseizure medications for epilepsy are at risk and need careful monitoring, including blood studies to detect the level of antiseizure medications taken throughout pregnancy (Ko, 2014). High-risk mothers (teenagers, women with histories of difficult deliveries, women who use illicit drugs [e.g., crack, cocaine], and women with diabetes or hypertension) should be identified and monitored closely during pregnancy, because damage to the fetus during pregnancy and delivery can increase the risk of epilepsy. All of these issues need further study (Thomas & Devi, 2012).

Gerontologic Considerations Cerebrovascular disease is the leading cause of seizures in older adults. The increased incidence is also associated with stroke, head injury, dementia, infection, alcoholism, and aging. Treatment depends on the underlying cause. Because many older people have chronic health problems, they may be taking other medications that can interact with medications prescribed for seizure control (Hickey, 2013). In addition, the absorption, distribution, metabolism, and excretion of medications are altered in the elderly as a result of age-related changes in renal and liver function. Therefore, elderly patients must be monitored closely for adverse and toxic effects of antiseizure medications and for osteoporosis. The cost of antiseizure medications can lead to poor adherence to the prescribed regimen in elderly patients on fixed incomes.

Prevention Society-wide efforts are the key to prevention of epilepsy. Head injury is one of the main causes of epilepsy that can be prevented. Through highway safety programs and occupational safety precautions, lives can be saved and epilepsy due to head injury prevented; these programs are discussed in Chapter 64.

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Medical Management The management of epilepsy is individualized to meet the needs of each patient and not just to manage and prevent seizures. Management differs from patient to patient, because some forms of epilepsy arise from brain damage and others result from altered brain chemistry. PHARMACOLOGIC THERAPY. Many medications are available to control seizures, although the exact mechanisms of action are unknown. The objective is to achieve seizure control with minimal side effects. Medication therapy controls rather than cures seizures. Medications are selected on the basis of the type of seizure being treated and the effectiveness and safety of the medications. If properly prescribed and taken, medications control seizures in 70% to 80% of patients with seizures. However, 20% of patients with generalized seizures and 30% of those with partial seizures do not demonstrate improvement with any prescribed medication or may be unable to tolerate the side effects of medications (Torbic, Forni, Anger, et al., 2013). Table 62-5 lists the medications in current use.

!

NURSING ALERT

Nurses must take care when administering lamotrigine (Lamictal), an antiseizure medication. The drug packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with terbinafine (Lamisil), labetalol hydrochloride (Trandate), lamivudine (Epivir), maprotiline (Ludiomil), and the combination of diphenoxylate and atropine (Lomotil). Patients with epilepsy are at risk for status epilepticus from having their medication regimen interrupted.

TABLE 62-5

Treatment usually starts with a single medication. The starting dose and the rate at which the dosage is increased depend on the occurrence of side effects. The medication levels in the blood are monitored, because the rate of drug absorption varies among patients. Changing to another medication may be necessary if seizure control is not achieved or if toxicity makes it impossible to increase the dosage. The medication may need to be adjusted because of concurrent illness, weight changes, or increases in stress. Side effects of antiseizure medications may be divided into three groups: (1) idiosyncratic or allergic disorders, which manifest primarily as skin reactions; (2) acute toxicity, which may occur when the medication is initially prescribed; and (3) chronic toxicity, which occurs late in the course of therapy. The manifestations of drug toxicity are variable, and any organ system may be involved. Gingival hyperplasia (swollen and tender gums) can be associated with longterm use of phenytoin (Dilantin), for example (Torbic et al., 2013). Periodic physical and dental examinations and laboratory tests are performed for patients receiving medications that are known to have hematopoietic, genitourinary, or hepatic effects. SURGICAL MANAGEMENT. Surgery is indicated for patients whose epilepsy results from intracranial tumours, abscesses, cysts, or vascular anomalies. Some patients have intractable seizure disorders that do not respond to medication. A focal atrophic process may occur secondary to trauma, inflammation, stroke, or anoxia. If the seizures originate in a reasonably well-circumscribed area of the brain that can be excised without producing significant neurologic deficits, the removal of the area generating the seizures may produce long-term control and improvement (Morton & Fontaine 2013). This type of neurosurgery has been aided by several advances, including microsurgical techniques, EEGs with

Major Antiseizure Medications

Medication

Dose-Related Side Effects

Toxic Effects

carbamazepine (Tegretol)

Dizziness, drowsiness, unsteadiness, nausea and vomiting, diplopia, mild leukopenia Drowsiness, behaviour changes, headache, hirsutism, alopecia, palpitations Nausea and vomiting, headache, gastric distress

Severe skin rash, blood dyscrasias, hepatitis

clonazepam (Rivotril) ethosuximide (Zarontin) gabapentin (Neurotonin) lamotrigine (Lamictal) levetiracetam (Keppra) oxacarbazepine (Trileptal) phenobarbital (Luminal) phenytoin (Dilantin) primidone (Mysoline) topiramate (Topamax) valproate (Depakote, Depakene) zonisamide (Zonegran, Excegran)

Dizziness, drowsiness, somnolence, fatigue, ataxia, weight gain, nausea Drowsiness, tremor, nausea, ataxia, dizziness, headache, weight gain Somnolence, dizziness, fatigue Dizziness, somnolence, double vision, fatigue, nausea, vomiting, loss of coordination, abnormal vision, abdominal pain, tremor, abnormal gait Sedation, irritability, diplopia, ataxia Visual problems, hirsutism, gingival hyperplasia, dysrhythmias, dysarthria, nystagmus Lethargy, irritability, diplopia, ataxia, impotence Fatigue, somnolence, confusion, ataxia, anorexia, depression, weight loss Nausea and vomiting, weight gain, hair loss, tremor, menstrual irregularities Somnolence, dizziness, anorexia, headache, nausea, agitation, rash

Hepatotoxicity, thrombocytopenia, bone marrow failure, ataxia Skin rash, blood dyscrasias, hepatitis, systemic lupus erythematosus Leukopenia, hepatotoxicity Severe rash (Stevens-Johnson syndrome) Unknown Hepatotoxicity

Skin rash, anemia Severe skin reaction, peripheral neuropathy, ataxia, drowsiness, blood dyscrasias Skin rash Nephrolithiasis Hepatotoxicity, skin rash, blood dyscrasias, nephritis Leukopenia, hepatotoxicity

CHAPTER 62

depth electrodes, improved illumination and hemostasis, and the introduction of neuroleptanalgesic agents (droperidol and fentanyl). These techniques, combined with use of local anesthetic agents, enable the neurosurgeon to perform surgery on an alert and cooperative patient. Using special testing devices, electrocortical mapping, and the patient’s responses to stimulation, the boundaries of the epileptogenic focus (i.e., abnormal area of the brain) are determined. Any abnormal epileptogenic focus is then excised (Morton & Fontaine 2013). Resection surgery significantly reduces the incidence of seizures in patients with refractory epilepsy. When seizures are refractory to medication in adolescents and adults with partial seizures, a generator may be implanted under the clavicle. The device is connected to the vagus nerve in the cervical area, where it delivers electrical signals to the brain to control and reduce seizure activity (Kinney, 2012). An external programming system is used by the physician to change stimulator settings. Patients can turn the stimulator on and off with a magnet More research is needed to determine the effects of the various surgical approaches on complication rates, quality of life, anxiety, and depression, all of which are issues for patients with epilepsy.

!!"##

Nursing Process

The Patient With Epilepsy Assessment The nurse elicits information about the patient’s seizure history. The patient is asked about the factors or events that may precipitate the seizures. Alcohol intake is documented. The nurse determines whether the patient has an aura before an epileptic seizure, which may indicate the origin of the seizure (e.g., seeing a flashing light may indicate that the seizure originated in the occipital lobe) (Urden et al., 2013). Observation and assessment during and after a seizure assist in identifying the type of seizure and its management. The effects of epilepsy on the patient’s lifestyle are assessed. What limitations are imposed by the seizure disorder? Does the patient participate in any recreational activities? Have any social contacts? Is the patient working, and is it a positive or stressful experience? What coping mechanisms are used?

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Risk for injury related to seizure activity • Fear related to the possibility of seizures • Ineffective individual coping related to stresses imposed by epilepsy

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• Deficient knowledge related to epilepsy and its control

Collaborative Problems/ Potential Complications The major potential complications for patients with epilepsy are status epilepticus and medication side effects (toxicity).

Planning and Goals The major goals for the patient may include prevention of injury, control of seizures, achievement of a satisfactory psychosocial adjustment, acquisition of knowledge and understanding about the condition, and absence of complications.

Nursing Interventions Preventing Injury Injury prevention for the patient with seizures is a priority. Patients for whom seizure precautions are instituted should have pads applied to the side rails while in bed. Steps to prevent or minimize injury are presented in Chart 62-4.

Reducing Fear of Seizures Fear that a seizure may occur unexpectedly can be reduced by the patient’s adherence to the prescribed treatment regimen. Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures. The nurse emphasizes that the prescribed antiseizure medication must be taken on a continuing basis and that drug dependence or addiction does not occur. Periodic monitoring is necessary to ensure the adequacy of the treatment regimen, to prevent side effects, and to monitor for drug resistance (Hickey, 2013). In an effort to control seizures, factors that may precipitate them are identified, such as emotional disturbances, new environmental stressors, onset of menstruation in female patients, or fever (Queally & Lailey, 2012). The patient is encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, and rest (sleep deprivation may lower the seizure threshold). Moderate activity is therapeutic, but excessive exercise should be avoided. Photic stimulation (e.g., bright flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering one eye may be preventive. Tension states (anxiety, frustration) induce seizures in some patients. Classes in stress management may be of value. Because seizures are known to occur with alcohol intake, alcoholic beverages should be avoided.

Improving Coping Mechanisms The social, psychological, and behavioural problems that frequently accompany epilepsy can be more of

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a disability than the actual seizures. Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, and uncertainty. The patient must cope with the constant fear of a seizure and the psychological consequences (Sung, Muller & Ditchman, et al., 2013). Children with epilepsy may be ostracized and excluded from school and peer activities. These problems are compounded during adolescence and add to the challenges of dating, not being able to drive, and feeling different from other people. Adults face these problems in addition to the burden of finding employment, concerns about relationships and childbearing, insurance problems, and legal barriers. Alcohol abuse may complicate matters. Family reactions may vary from outright rejection of the person with epilepsy to overprotection. Counselling assists the patient and family to understand the condition and the limitations it imposes. Social and recreational opportunities are necessary for good mental health. Nurses can improve the quality of life for patients with epilepsy by teaching them and their families about symptoms and their management (Sung et al., 2013) (Chart 62-3).

Providing Patient and Family Education Perhaps the most valuable facets of care contributed by the nurse to the person with epilepsy are education and efforts to modify the attitudes of the patient and family toward the disorder. The person who experiences seizures may consider every seizure a potential source of humiliation and shame. This may result in anxiety, depression, hostility, and secrecy on the part of the patient and family. Ongoing education and encouragement should be given to patients to enable them to overcome these reactions. The patient with epilepsy should carry an emergency medical identification card or wear a medical information bracelet. The patient and family need to be educated about medications as well as care during a seizure.

Monitoring and Managing Potential Complications Status epilepticus, the major complication, is described later in this chapter. Another complication is the toxicity of medications. The patient and family are instructed about side effects and are given specific guidelines to assess and report signs and symptoms that indicate medication overdose. Anticonvulsant medications require careful monitoring for therapeutic levels. The patient should plan to have serum drug levels assessed at regular intervals. Many known drug interactions occur with antiseizure medications. A complete pharmacologic profile should be reviewed with the patient to avoid interactions that either potentiate or inhibit the effectiveness of the medications.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Thorough oral hygiene after each meal, gum massage, daily

flossing, and regular dental care are essential to prevent or control gingival hyperplasia in patients receiving phenytoin (Dilantin). The patient is also instructed to inform all health care providers of the medication being taken, because of the possibility of drug interactions. An individualized comprehensive teaching plan is needed to assist the patient and family to adjust to this chronic disorder (Day, Love, Popowich, et al., 1992; Queally & Lailey, 2012). Written patient education materials must be appropriate for the patient’s reading level and must be provided in alternative formats if warranted. See Chart 62-5 for home care instruction points. CONTINUING CARE. For many people with epilepsy, overcoming employment problems is a challenge. Vocational rehabilitation agencies can provide information about job training. According to the Canadian Human Rights Act, it is illegal for an employer (within federal jurisdiction) to discriminate on the basis of physical or mental disability., but barriers to employment still exist. Epilepsy Canada (2014), a national organization, works to advocate and lobby for people with disabilities. People who have uncontrollable seizures accompanied by psychological and social difficulties can be referred to comprehensive epilepsy centres where continuous audio–video and EEG monitoring, specialized treatment, and rehabilitation services are available (Queally & Lailey, 2012). Patients and their families need to be reminded the importance of following the prescribed treatment regimen and of keeping follow-up appointments. In addition, they are reminded of the importance of participating in health promotion activities and recommended health screenings to promote a healthy lifestyle. Genetic and preconception counselling is advised.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Sustains no injury during seizure activity a. Complies with treatment regimen and identifies the hazards of stopping the medication b. Can identify appropriate care during seizure; caregivers can also do so 2. Indicates a decrease in fear 3. Displays effective individual coping 4. Exhibits knowledge and understanding of epilepsy a. Identifies the side effects of medications b. Avoids factors or situations that may precipitate seizures (e.g., flickering lights, hyperventilation, alcohol) c. Follows a healthy lifestyle by getting adequate sleep and eating meals at regular times to avoid hypoglycemia 5. Absence of complications

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CHART 62-5

HOME CARE CHECKLIST •

The Patient With Epilepsy

At the completion of the home instruction, the patient and caregiver will be able to:

Patient

Caregiver

• Take medications daily as prescribed to keep the drug level constant to prevent seizures.

✔

• Keep a medication and seizure chart, noting when medications are taken and any seizure

✔

✔

• Notify the patient’s physician if patient cannot take medications due to illness.

✔

✔

• Have antiseizure medication serum levels checked regularly. When testing is prescribed, the

✔

• Avoid activities that require alertness and coordination (driving, operating machinery) until

✔

• Report signs of toxicity so dosage can be adjusted. Common signs include drowsiness,

✔

• Avoid over-the-counter medications unless approved by the patient’s physician.

✔

• Carry a medical alert bracelet or identification card specifying the name of the patient’s

✔

• Avoid seizure triggers, such as alcoholic beverages, electrical shocks, stress, caffeine,

✔

• Take showers rather than tub baths to avoid drowning if seizure occurs; never swim alone.

✔

• Exercise in moderation in a temperature-controlled environment to avoid excessive heat.

✔

• Develop regular sleep patterns to minimize fatigue and insomnia.

✔

✔

• Use the Epilepsy Foundation of America’s special services, including help in obtaining

✔

✔

The patient should never discontinue medications, even if there is no seizure activity. activity.

patient should report to the laboratory for blood sampling before taking morning medication. after the effects of the medication have been evaluated.

✔

lethargy, dizziness, difficulty walking, hyperactivity, confusion, inappropriate sleep, and visual disturbances.

antiseizure medication and physician.

constipation, fever, hyperventilation, and hypoglycemia.

medications, vocational rehabilitation, and coping with epilepsy.

Status Epilepticus Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks (Diepenbrock, 2012). The term has been broadened to include continuous clinical or electrical seizures (on EEG) lasting at least 30 minutes, even without impairment of consciousness. It is considered a medical emergency. Status epilepticus produces cumulative effects. Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations. Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia of the brain. Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain damage. Factors that precipitate status epilepticus include withdrawal of antiseizure medication, fever, and concurrent infection.

Medical Management The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to maintain the patient in a seizure-free state. An airway and adequate oxygenation are established. If the patient remains unconscious and unresponsive, a cuffed endotracheal tube is inserted. IV diazepam (Valium), lorazepam

(Ativan), or fosphenytoin (Cerebyx) is administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state (Mirski & Valeras, 2008). An IV line is established, and blood samples are obtained to monitor serum electrolytes, glucose, and phenytoin levels. EEG monitoring may be useful in determining the nature of the seizure activity. Vital signs and neurologic signs are monitored on a continuing basis. An IV infusion of dextrose is administered if the seizure is caused by hypoglycemia. If initial treatment is unsuccessful, general anesthesia with a short-acting barbiturate may be used. The serum concentration of the antiseizure medication is measured, because a low level suggests that the patient was not taking the medication or that the dosage was too low. Cardiac involvement or respiratory depression may be life-threatening. The potential for postictal cerebral edema also exists.

Nursing Management The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function because of the risk for delayed depression of respiration and blood pressure secondary to administration of antiseizure medications and

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sedatives to halt the seizures. Nursing assessment also includes monitoring and documenting the seizure activity and the patient’s responsiveness. The patient is turned to a side-lying position, if possible, to assist in draining pharyngeal secretions. Suction equipment must be available because of the risk of aspiration. The IV line is closely monitored, because it may become dislodged or occluded during seizures. A person who has received long-term antiseizure therapy has a significant risk for fractures resulting from bone disease (osteoporosis, osteomalacia, and hyperparathyroidism), a side effect of therapy. Therefore, during seizures, the patient is protected from injury with the use of seizure precautions and is monitored closely. The patient having seizures can inadvertently injure nearby people, so nurses should protect themselves. Additional nursing interventions for the person having seizures are presented in Chart 62-4.

Headache Headache, or cephalgia, is one of the most common of all human physical complaints. Headache is a symptom rather than a disease entity; it may indicate organic disease (neurologic or other disease), a stress response, vasodilation (migraine), skeletal muscle tension (tension headache), or a combination of factors. A primary headache is one for which no organic cause can be identified. These types of headache include migraine, tension-type, and cluster headaches (Hickey, 2013). Cranial arteritis is another common cause of headache. A classification of headaches was issued first by the Headache Classification Committee of the International Headache Society in 1988. The International Headache Society revised the headache classification in 2004; an abbreviated list is shown in Chart 62-6. CHART 62-6

International Headache Society Classification of Headache 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal-autonomic cephalalgias 4. Other primary headaches 5. Headache attributed to head and/or neck trauma 6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to nonvascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection 10. Headache attributed to disorder of homeostasis 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 12. Headache attributed to psychiatric disorder 13. Cranial neuralgias and central causes of facial pain 14. Other headache From Headache Classification Subcommittee of the International Headache Society. (2004). International classification of headache disorders (2nd ed.). Cephalalgia, 24 (Suppl 1), 1–150.

Migraine is a complex of symptoms characterized by periodic and recurrent attacks of severe headache lasting from 4 to 72 hours in adults. It affects 3.5 million Canadians (Litwack, 2010) and is common worldwide. The cause of migraine has not been clearly demonstrated, but it is primarily a vascular disturbance that occurs more commonly in women and has a strong familial tendency. The typical time of onset is at puberty, and the global incidence is 15% to 18% in women and 5% to 7% in men (Buse, Manack, Fanning, et al., 2012). About 15% of people affected by migraines will experience an aura prior to the headache (Litwack, 2010). There are six subtypes of migraine headache, including migraine with and without aura. Mixed headache includes symptoms of tension headache, nasal symptoms, chronic daily headaches, and sinus headaches. Tension-type headaches tend to be chronic and less severe and are probably the most common type of headache (Steefel & Novak, 2012). Cluster headaches are a severe form of unilateral vascular headache. They are seen five times more frequently in men than in women. Types of headaches not subsumed under these categories fall into the Other Primary Headache group and include headaches triggered by cough, exertion, and sexual activity. Cranial arteritis is a cause of headache in the older population, reaching its greatest incidence in those older than 70 years of age. Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. The inflammation may be generalized (in which case cranial arteritis is part of a vascular disease) or focal (in which case only the cranial arteries are involved). A secondary headache is a symptom associated with an organic cause, such as a brain tumour or an aneurysm. Although most headaches do not indicate serious disease, persistent headaches require further investigation. Serious disorders related to headache include brain tumours, subarachnoid hemorrhage, stroke, severe hypertension, meningitis, and head injuries.

Pathophysiology The cerebral signs and symptoms of migraine may result from dysfunction of the brain stem pathways that normally modulate sensory input. Abnormal metabolism of serotonin, a vasoactive neurotransmitter found in platelets and cells of the brain, plays a major role. The headache is preceded by a rise in plasma serotonin, which dilates the cerebral vessels, but migraines are more than just vascular headaches. The exact mechanism of pain in migraine is poorly understood but is thought to be related to the cranial blood vessels, the innervation of the vessels, and the reflex connections in the brain stem (Hickey, 2013). Recent research based on newer imaging techniques suggests neurovascular mechanisms in the development of migraines, and they may be primarily neural-based, with secondary vascular changes (Aurora & Nagnesh, 2011). Migraines can be triggered by menstrual cycles, bright lights, stress, depression, sleep deprivation, fatigue, overuse of certain medications, and certain foods containing tyramine, monosodium glutamate, nitrites, or milk products. Food triggers also include aged cheese and many

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processed foods. Use of oral contraceptives may be associated with increased frequency and severity of attacks in some women (Hickey, 2013). Emotional or physical stress may cause contraction of the muscles in the neck and scalp, resulting in tension headache. The pathophysiology of cluster headache is not fully understood. One theory is that it is caused by dilation of orbital and nearby extracranial arteries. Cranial arteritis is thought to represent an immune vasculitis in which immune complexes are deposited within the walls of affected blood vessels, producing vascular injury and inflammation. A biopsy may be performed on the involved artery to make the diagnosis.

Clinical Manifestations MIGRAINE. The migraine with aura can be divided into four phases: prodrome, aura, the headache, and recovery (headache termination and postdrome).

Prodrome Phase. The prodrome phase is experienced by 60% of patients, with symptoms that occur hours to days before a migraine headache. Symptoms may include depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation. Patients usually experience the same prodrome with each migraine headache. Aura Phase. Aura occurs in a minority of patients who experience migraines (Buse et al., 2012, Lipton, Serrano, Holland, et al., 2013). The aura usually lasts less than 1 hour and may provide enough time for the patient to take the prescribed medication to avert an attack (see later discussion). This period is characterized by focal neurologic symptoms. Visual disturbances (i.e., light flashes and bright spots) are most common and may be hemianopic (affecting only half of the visual field). Other symptoms that may follow include numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness. This period of aura corresponds to the phenomenon of cortical spreading depression that is associated with reduced metabolic demand in abnormally functioning neurons. This is associated with decreased blood flow that is the initial physiologic change characteristic of classic migraine (Hickey, 2013). Cerebral blood flow studies performed during migraine headaches demonstrate that during all phases of migraine, cerebral blood flow is reduced throughout the brain, with subsequent loss of autoregulation and impaired carbon dioxide responsiveness. Headache Phase. As vasodilation and a decline in serotonin levels occur, a throbbing headache (unilateral in 60% of patients) intensifies over several hours. This headache is severe and incapacitating and is often associated with photophobia, nausea, and vomiting. Its duration varies, ranging from 4 to 72 hours (Hickey, 2013). Recovery Phase. In the recovery phase (termination and postdrome), the pain gradually subsides. Muscle contraction in the neck and scalp is common, with associated muscle ache and localized tenderness, exhaustion, and mood changes. Any physical exertion exacerbates the headache pain. During this postheadache phase, patients may sleep for extended periods.

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OTHER HEADACHE TYPES. The tension-type headache is characterized by a steady, constant feeling of pressure that usually begins in the forehead, temple, or back of the neck. The pain often feels band-like and may be described as dull, aching, and diffuse (Litwack, 2010). Cluster headaches are unilateral and come in clusters of one to eight daily, with excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. The pain is accompanied by watering of the eye and nasal congestion. Each attack lasts 15 minutes to 3 hours and may have a crescendo–decrescendo pattern (Hickey, 2013). The headache is often described as penetrating. Cranial arteritis often begins with general manifestations, such as fatigue, malaise, weight loss, and fever. Clinical manifestations associated with inflammation (heat, redness, swelling, tenderness, or pain over the involved artery) usually are present. Sometimes a tender, swollen, or nodular temporal artery is visible. Visual problems are caused by ischemia of the involved structures.

Assessment and Diagnostic Findings The diagnostic evaluation includes a detailed history, a physical assessment of the head and neck, and a complete neurologic examination. Headaches may manifest differently in the same person over the course of a lifetime, and the same type of headache may manifest differently from patient to patient. The health history focuses on assessing the headache itself, with emphasis on the factors that precipitate or provoke it. The patient is asked to describe the headache in his or her own words. Because headache is often the presenting symptom of various physiologic and psychological disturbances, a general health history is an essential component of the patient database. Headache may be a symptom of endocrine, hematologic, gastrointestinal, infectious, renal, cardiovascular, or psychiatric disease. Therefore, questions addressed in the health history should cover major medical and surgical illness as well as a body systems review. The medication history can provide insight into the patient’s overall health status and indicate medications that may be provoking headaches. Antihypertensive agents, diuretic medications, anti-inflammatory agents, and monoamine oxidase (MAO) inhibitors are a few of the categories of medications that can provoke headaches. Emotional factors can play a role in precipitating headaches. Stress is thought to be a major initiating factor in migraine headaches; therefore, sleep patterns, level of stress, recreational interests, appetite, diet, emotional or psychiatric problems, and family stressors are relevant. There is a strong familial tendency for headache disorders, and a positive family history may help in making a diagnosis (Latimer, 2013). A direct relationship may exist between exposure to toxic substances and headache. Careful questioning may uncover chemicals to which a worker has been exposed. The Workplace Hazardous Materials Information System (WHMIS) is a national system established in 1988 that provides employees information on hazardous material used in the workplace. Employees have access to material safety data sheets (commonly referred to as MSDS) for all substances with which they come in contact in the

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workplace. The occupational history also includes assessment of the workplace as a possible source of stress and for a possible ergonomic basis of muscle strain and headache. A complete description of the headache itself is crucial. The nurse reviews the age at onset of headache; the headache’s frequency, location, and duration; the type of pain; factors that relieve and precipitate the event; and associated symptoms. The data obtained should include the patient’s own words about the headache in response to the following questions: • What is the location? Is it unilateral or bilateral? Does it radiate? • What is the quality—dull, aching, steady, boring, burning, intermittent, continuous, paroxysmal? • How many headaches occur during a given period of time? • What are the precipitating factors, if any—environmental (e.g., sunlight, weather change), foods, exertion, other? • What makes the headache worse (e.g., coughing, straining)? • What time (day or night) does it occur? • How long does a typical headache last? • Are there any associated symptoms, such as facial pain, lacrimation (excessive tearing), or scotomas (blind spots in the field of vision)? • What usually relieves the headache (aspirin, nonsteroidal anti-inflammatory drugs, ergot preparation, food, heat, rest, neck massage)? • Does nausea, vomiting, weakness, or numbness in the extremities accompany the headache? • Does the headache interfere with daily activities? • Do you have any allergies? • Do you have insomnia, poor appetite, loss of energy? • Is there a family history of headache? • What is the relationship of the headache to your lifestyle or physical or emotional stress? • What medications are you taking? Diagnostic testing often is not helpful in the investigation of headache, because often there are few objective findings. In patients who demonstrate abnormalities on the neurologic examination, CT, cerebral angiography, or MRI may be used to detect underlying causes, such as tumour or aneurysm. Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial muscles. Laboratory tests may include complete blood count, erythrocyte sedimentation rate, electrolytes, glucose, creatinine, and thyroid hormone levels.

Prevention Prevention begins by having the patient avoid specific triggers that are known to initiate the headache syndrome. Preventive medical management of migraine involves the daily use of one or more agents that are thought to block the physiologic events leading to an attack. Treatment regimens vary greatly, as do patient responses; therefore, close monitoring is indicated. Several widely used medications for the prevention of migraine are available. Two beta-blocking agents, propranolol (Inderal) and metoprolol (Lopressor), inhibit the action of beta-receptors—cells in the heart and brain that control the dilation of blood vessels. This is thought to be

a major reason for their antimigraine action. Antidepressants are widely used in the treatment of migraines and amitriptyline is often used as a first-line option. The dose required to prevent migraines is much lower than the dose used to treat depression. Recent research has shown that the serotonin–norepinephrine reuptake inhibitor venlafaxine has been effective in preventing migraine attacks (Fenstermacher, Levin & Ward, 2011). Calcium channel blockers (e.g., flunarizine) are widely used but may require several weeks at a therapeutic dosage before improvement is noted. Calcium channel blockers are not as effective as beta-blockers for prevention but may be more appropriate for some patients, such as those with asthma (Fenstermacher et al., 2011). Anticonvulsant medications are also being utilized for migraine prevention. Topiramate (Topamax), an extensively studied preventive agent, has been shown to be effective. Started at a low dose, topiramate is titrated to 50 to 100 mg bid. Valproate is also widely used (Fenstermacher et al., 2011).

Medical Management Therapy for migraine headache is divided into abortive (symptomatic) and preventive approaches. The abortive approach, best used in those patients who have less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress. The preventive approach is used in patients who experience more frequent attacks at regular or predictable intervals and may have a medical condition that precludes the use of abortive therapies (Hickey, 2013). The triptans, serotonin receptor agonists, are the most specific antimigraine agents available. These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission. The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan (Zomig), and almotriptan (Axert). Numerous serotonin receptor agonists are under study. Many of the triptan medications are available in a variety of formulations, such as nasal sprays, inhalers, suppositories, or injections (Gilmore & Michael, 2011). The most widely used triptan is sumatriptan succinate (Imitrex) and is effective for the treatment of acute migraine and cluster headaches in adults (Gilmore & Michael, 2011). The subcutaneous form usually relieves symptoms within 1 hour and is available in an autoinjector for immediate patient use, although this form is expensive. Sumatriptan has been found to be effective in relieving moderate to severe migraine headaches in a large number of adult patients. Sumatriptan can cause chest pain and is contraindicated in patients with ischemic heart disease. Careful administration and dosing instructions to patients are important to prevent adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety. Ergotamine preparations (taken orally, sublingually, subcutaneously, intramuscularly, by rectum, or by inhalation) may be effective in aborting the headache if taken early in the migraine process. They are low in cost. Ergotamine tartrate acts on smooth muscle, causing prolonged constriction of the cranial blood vessels. Each patient’s dosage is based on individual needs.

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Side effects include aching muscles, paresthesias (numbness and tingling), nausea, and vomiting. Cafergot, a combination of ergotamine and caffeine, can arrest or reduce the severity of the headache if it is taken at the first sign of an attack. None of the triptan medications should be taken concurrently with medications containing ergotamine, because of the potential for a prolonged vasoactive reaction. The use of ergotamines has for the most part been supplanted by the triptan medications (Gilmore & Michael, 2011). The medical management of an acute attack of cluster headaches may include 100% oxygen by face mask for 15 minutes, ergotamine tartrate, sumatriptan, corticosteroids, or a percutaneous sphenopalatine ganglion blockade (Hickey, 2013). The medical management of cranial arteritis consists of early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery. The patient is instructed not to stop the medication abruptly, because this can lead to relapse. Analgesic agents are prescribed for comfort.

Nursing Management When migraine or the other types of headaches have been diagnosed, the goal of nursing management is to enhance pain relief. It is reasonable to try nonpharmacologic interventions first, but the use of medications should not be delayed. The goal is to treat the acute event of the headache and to prevent recurrent episodes. Prevention involves patient education regarding precipitating factors, possible lifestyle or habit changes that may be helpful, and pharmacologic measures. RELIEVING PAIN. Individualized treatment depends on the type of headache and differs for migraine, cluster headaches, cranial arteritis, and tension headache. Nurs-

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ing care is directed toward treatment of the acute episode. A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Some headaches can be prevented if the appropriate medications are taken before the onset of pain. Nursing care during an attack includes comfort measures such as a quiet, dark environment; elevation of the head of the bed to 30 degrees; and symptomatic treatment (i.e., administration of antiemetic medication) (Hickey, 2013). Symptomatic pain relief for tension headache may be obtained by application of local heat or massage. Additional strategies may include administration of analgesic agents, antidepressant medications, and muscle relaxants. PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care. Headaches, especially migraines, are more likely to occur when the patient is ill, overly tired, or stressed. Nonpharmacologic therapies are important and include patient education about the type of headache, its mechanism (if known), and appropriate changes in lifestyle to avoid triggers. Regular sleep, meals, exercise, relaxation, and avoidance of dietary triggers may be helpful in avoiding headaches (Hickey, 2013). The patient with tension headaches needs teaching and reassurance that the headache is not the result of a brain tumour; this is a common unspoken fear. Stress reduction techniques, such as biofeedback, exercise programs, and meditation, are examples of nonpharmacologic therapies that may prove helpful. The patient and family need to be reminded of the importance of following the prescribed treatment regimen for headache and keeping follow-up appointments. In addition, the patient is reminded of the importance of participating in health promotion activities and recommended health screenings to promote a healthy lifestyle. Chart 62-7 presents a home care checklist for the patient with migraine headaches.

CHART 62-7

HOME CARE CHECKLIST •

The Patient With Migraine Headaches Patient

Caregiver

• Define migraine headaches and describe characteristics and manifestations.

✔

✔

• Identify triggers of migraine headaches and how to avoid such triggers as: • Foods that contain tyramine, such as chocolate, cheese, coffee, dairy products • Dietary habits that result in long periods between meals • Menstruation and ovulation (caused by hormone fluctuation) • Alcohol (causes vasodilation of blood vessels) • Fatigue and fluctuations in sleep patterns

✔ ✔ ✔ ✔ ✔

✔ ✔ ✔ ✔ ✔

• State importance of developing and using a headache diary.

✔

✔

• State stress management and lifestyle changes to minimize the frequency of headaches.

✔

✔

• State pharmacologic management: acute therapy and prophylaxis, to include medication

✔

✔

• Identify comfort measures during headache attacks, such as resting in a quiet and dark

✔

✔

• Identify resources for education and support, such as the National Headache Foundation.

✔

✔

At the completion of the home instruction, the patient or caregiver will be able to:

regimen and side effects.

environment, applying cold compresses to the painful area, and elevating the head.

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Continuing Care. The National Headache Foundation (see Resources) provides a list of clinics in the United States and the names of physicians who specialize in headache and who are members of the American Association for the Study of Headache.

Critical Thinking Exercises 1

Your 25-year-old patient with a brain injury has signs of ICP. Describe the nursing measures that are indicated. How would you determine whether your interventions were effective in alleviating the increased ICP? What is the evidence base for practices to decrease ICP? Identify the criteria used to evaluate the strength of the evidence for these practices.

2 A patient is admitted to your unit after undergoing transsphenoidal surgery for a pituitary tumour. Describe the major complications to assess for, along with the signs and symptoms of each. Describe the pharmacologic treatment and nursing measures that are indicated postoperatively. What patient and family teaching is important for the patient and family? How would you modify your teaching and discharge planning if the patient understands little English? 3

You are caring for a 35-year-old patient who is admitted to the hospital for evaluation of her seizures. What resources would you use to identify the current guidelines for classification and treatment of seizures? What is the evidence base for treatment practices? Identify the criteria used to evaluate the strength of the evidence for these practices.

Dudek, S. G. (2013). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Gulanick, M., & Myers, J. (2013). Nursing care plans; nursing diagnosis and intervention. St Louis, MO. Elsevier/Mosby. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hickey, J. V. (2013). The clinical practice of neurological & neurosurgical nursing (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Litwack, K. (2010). Somatosensory function, pain, and headache. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1177–1209). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Makic, M., & Wiegand, D. (2011). Lumbar subarachnoid catheter insertion (assist) for cerebrospinal fluid drainage and pressure monitoring. In D. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., 826–835). St. Louis, MO; Elsevier/Saunders. Morton, P., & Fontaine, D. (2013). Critical care nursing; a holistic approach (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Preuss, D. (2011). Intraventricular catheter with external transducer for cerebrospinal fluid drainage and intracranial pressure monitoring. In D. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., 836–848). St. Louis, MO; Elsevier/Saunders. Queally, C., & Lailey, S. (2012). Care of the person with epilepsy in the hospital environment – getting it right. British Journal of Neuroscience Nursing, 8(1), 14–20. Slazinski, T. (2011). Combination intraventricular/fiberoptic catheter insertion (assist), monitoring, nursing care, troubleshooting, and removal. In D. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., 809–815). St. Louis, MO; Elsevier/Saunders. Stewart-Amidei, C., & Klein, D. G. (2013). Nervous System Alterations. In M. Sole, D. Klein, & M. Moseley (Eds.), Introduction to critical care nursing (6th ed.). St. Louis: Elsevier Saunders. Terry, C., & Weaver A. (2011). Critical care nursing demystified. New York, NY: McGraw Hill. Urden, L., Stacy, K., & Lough, M. (2013). Critical care nursing; diagnosis and management (7th ed.). St Louis, MO. Elsevier/Mosby.

JOURNALS AND ELECTRONIC DOCUMENTS REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS American Association of Neuroscience Nurses (AANN). (2011). Guide to the care of the patient with intracranial pressure monitoring/external ventricular drainage or lumbar drainage: AANN clinical practice guideline series. Glenview, IL: Author. American Association of Neuroscience Nurses (AANN). (2012). Nursing management of adults with severe traumatic brain injury. AANN clinical practice guidelines series. Glenview, IL: Author. Baird, M., & Bethel, S. (2011). Manual of critical care nursing; nursing interventions and collaborative management (6th ed.). St. Louis, MO. Elsevier/Mosby. Bhatia, A., & Gupta, A. (2013). Neuromonitoring in the Intensive Care unit. In M. Pinsky, L. Brochard, G. Hedenstiema, et al. (Eds.), Applied physiology in intensive care medicine (145–151). New York, NY; Springer. Book, D. S., & Pierazzo, J. (2010). Disorders of brain function. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1246–1280). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Brain Trauma Foundation. (2007). Guidelines for the management of severe traumatic brain injury. New York, NY: Author. Diepenbrock, N. (2012). Quick reference to critical care. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

General Iavagnilio, C. (2011). Traumatic brain injury: Improving the patient’s outcome demands timely and accurate diagnosis. Journal of Legal Nurse Consulting, 22(3), 3–10. Johannson, R., Malmvall, B., Andersson-Gare, B., et al. (2012). Guidelines for preventing urinary retention and bladder damage during hospital care. Journal of Clinical Nursing, 22(3–4), 347–355. *Keenan, A., & Joseph, A. (2010). The needs of family members of severe traumatic brain injured patients during critical and acute care: A qualitative study. Canadian Journal of Neuroscience Nursing, 32(3), 25–35. *Robertson, T., & Carter, D. (2013). Oral intensity: Reducing nonventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients. Canadian Journal of Neuroscience Nursing, 35(2), 10–17. Headache Aurora, S., & Nagesh, V. (2011). Pathophysiology of migraine. Handbook of Clinical Neurology, 97(3), 267–273. Buse, D., Manack, A., Fanning, K., et al. (2012). Chronic migraine prevalence, disability and sociodemographic factors: Results from the American migraine prevalence and prevention study. Headache: The Journal of Head and Face Pain, 52(10), 1456–1470. Fenstermacher, N., Levin, M., & Ward, T. (2011). Pharmacological prevention of migraine. British Medical Journal, 342, 540–543. Gilmore, B., & Michael, M. (2011). Treatment of acute migraine headache. American Family Physician, 83(3), 271–280. **Headache Classification Subcommittee of the International Headache Society. (2004). International classification of headache disorders (2nd ed.). Cephalalgia, 24(Suppl. 1), 1–150. Lipton, R., Serrano, D., Holland, S., et al. (2013). Barriers to the diagnosis and treatment of migraine: Effects of sex, income, and

CHAPTER 62 headache features. Headache: The Journal of Head and Face Pain, 53(1), 81–92. Steefel, L., & Novak, D. (2012). When tension headaches become chronic. The Nurse Practitioner, 37(11), 24–29. Increased Intracranial Pressure Vergouwen, M. D., Ross, Y. B., & Kamphuisen, P. W. (2008). Venous thrombosis prophilaxis and treatment with patients with acute stroke and traumatic brain injury. Current Opinion in Critical Care, 14, 149– 155. *Mattar, I. (2011). Using the Roper, Logan and Tierny model in the management of traumatic brain injury in a critical care setting. Singapore Nursing Journal, 38(3), 14–19. Meierhans, R., Béchir, M., Ludwig, S., et al. (2010). Brain metabolism is significantly impaired at blood glucose below 6 mM and brain glucose below 1 mM in patients with severe traumatic brain injury. Critical care, 14(1), R13. Momi, J., Tang, C. M., Abcar, A. C., et al. (2010). Hyponatremia- what is cerebral salt wasting? The Permanente Journal, 2(12), 62–65. *Olson, D., McNett, M., Lewis, L., et al. (2013). Effects of nursing interventions on intracranial pressure. American Journal of Critical Care, 22(5), 431–438. Raboel, P. H., Bartek, Jr. J., Andresen, M., et al. (2012). Intracranial pressure monitoring: Invasive versus non-invasive methods-a review. Critical Care research and practice, 1–14. doi:10.1155/2012/950393 Timofeev, I., Czosnyka, M., Carpenter, K., et al. (2011). Interaction between brain chemistry and physiology after traumatic brain injury: Impact of autoregulation and microdialysis catheter location. Journal of Neurotrauma, 28(6), 849–860. Wilensky, E. M., & Bloom, S. (2014). Critical care: Monitoring brain tissue oxygenation after severe brain injury. Nursing 2014. (35)2, 32cc1-32cc4. Retrieved from http://www.nursingcenter.com/inc/ journalarticleprint?Article_ID=571503 Neurosurgical Care **Eisenberg, A., & Redick, E. (1998). Transsphenoidal resection of pituitary adenoma: Using a critical pathway. Dimensions of Critical Care Nursing, 17(6), 306–312. Scholz, M., Parvin, R., Thissen, J., et al. (2010). Skull base approaches in neurosurgery. Head and Neck Oncology, 16(2), 109. Yuan, W., (2013). Managing the patient with transsphenoidal pituitary tumor resection. Journal of Neuroscience Nursing 2(45), 101–107. doi: 101097/JNN.0b013e3182828e28 Seizures and Epilepsy **Day, R. A., Love, S., Popowich, J., et al. (1992). Client education in a rehabilitation anticonvulsant outpatient clinic. Canadian Journal of Rehabilitation, 61(1), 23–32. Dworetzky, B. A., Townsend, M. K., Pennell, P. G., et al. (2012). Female reproductive factors and risk of seizure or epilepsy: Data from the nurses’ health study II. Epilepsia 53(1), e1–e4. doi: 10.1111/j.1528-1167.2011.03308.x Epilepsy Canada. (2014). Epilespy facts, Retrieved from http://www.epilepsy.ca/en-CA/Facts/Epilepsy-Facts.html Kinney, S. (2012). Vagus nerve stimulation therapy for seizure control. Journal of Nurse Life Care Planning, 12(2), 613–617. Ko, D. Y., (2014). Epilepsy and seizures treatment & management. Medscape Reference: Drugs, Diseases and Procedures. Retrieved from http:// emedicine.medscape.come/article/1184846- treatment

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Latimer, K. M., (2013). Chronic headache: Stop the pain before it starts. The Journal of Family Practice, 3(62), 126–133. *Miller, W., Buelow, L., & Bakas, T. (2014). Older adults and new-onset epilepsy: Experiences with diagnosis. The Journal of Neuroscience Nursing, 46(1), 2–10. **Mirski, M. A., & Varelas, P. N. (2008). Seizures and status epilepticus in the critically ill. Critical Care Clinics, 1(24), 115–147. Rauchenzauner, M., Ehrensberger, M., Prieschl, M., et al. (2013). Generalized tonic-clonic seizures and antiepileptic drugs during pregnancy – a matter of importance for the baby? Journal of Neurology, 260(2), 484–488. **Rho, J. M., Sankar, R., & Cavazos, J. E. (2004). Epilepsy: Scientific foundations of clinical practice. NewYork, NY: Marcel-Dekker. *Sauro, K., Krassman, C., Jette, N., et al. (2012). Experience and satisfaction of staff working in a seizure monitoring unit. Canadian Journal of Neuroscience Nursing, 34(2), 33–38. Sung, C., Muller, V. R., Ditchman, N., et al. (2013). Positive coping, selfefficacy, and self-esteem as mediators between seizure severity and life satisfaction in epilepsy. Rehabilitation Research, Policy, and Education, 27(3), 154–170. Thomas, S., & Devi, J. (2012). Predictors of seizures during pregnancy in women with epilepsy. Epilepsia, 53, 85–88. Torbic, H., Forni, A., Anger, K., et al. (2013). Use of antiepileptics for seizure prophylaxis after traumatic brain surgery. American Journal of Health-System Pharmacy, 70, 759–766. Unconsciousness and Coma Arbour, R. (2013). Brain death: Assessment, controversy, and confounding factors. American Journal of Critical Care Nurses, 33(6), 27–48. Lee, M., Savage, J., McKee, H., et al. (2013). How do you know when your patient is “waking up”? Coma recovery assessment in a complex continuing care setting. Canadian Journal of Neuroscience Nursing, 35(2), 27–33. Schirmer, C. M., Kornbluth, J., Heilman, C. B., et al. (2011). Gastrointestinal prophylaxis in neurocritical care. Neurocritical Care. July. Retrieved from Springer Science+Business Media http://springer.com/ article/10.1007/s12028-011-9580-1fulltext.html#Sec22

RESOURCES Brain Injury Association of Canada; http://biac-aclc.ca/en/ Brain Tumour Foundation of Canada; http://www.braintumour.ca Canadian Association of Neuroscience Nurses; http://www.cann.ca Canadian Epilepsy Alliance; http://www.epilepsymatters.com Canadian League against Epilepsy; http://www.clae.org/ Canadian Neurological Sciences Federation; http:// http://www.cnsfederation.org/ Council of Canadians with Disabilities; http://www.ccdonline.ca Epilepsy Canada; http://www.epilepsy.ca Epilepsy Foundation; http://www.epilepsyfoundation.org Help for Headaches; http://www.headache-help.org International Bureau for Epilepsy; http://www.ibe-epilepsy.org International Headache Society; http://www.i-h-s.org/ International League against Epilepsy; http:// http://www.ilae.org/ National Headache Foundation; http://www.headaches.org Neuro-Patient Resource Centre; http://infoneuro.mcgill.ca Spina Bifida and Hydrocephalus Association of Canada; http://www. sbhac.ca Think First Foundation of Canada; http://www.thinkfirst.ca

CHAPTER

63 Management of Patients With Cerebrovascular Disorders Adapted by Sandra Carless and David Reid

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the incidence and social impact of cerebrovascular disorders. 2. Identify the risk factors for cerebrovascular disorders and related measures for prevention. 3. Compare the various types of cerebrovascular disorders: their causes, clinical manifestations, and medical management. 4. Apply the principles of nursing management to the care of a patient in the acute stage of an ischemic stroke. 5. Use the nursing process as a framework for care of a patient recovering from an ischemic stroke. 6. Use the nursing process as a framework for care of a patient with a hemorrhagic stroke. 7. Identify essential elements for family teaching and preparation for home care of the patient who has had a stroke.

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Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the usual blood supply to the brain is disrupted. Stroke/brain attack is caused by a blockage of blood vessels or by rupture of a blood vessel and bleeding into brain tissue. The term brain attack is being used to “alert people to the need for immediate treatment at the first sign of a stroke” (Book, 2010, p. 1263). Stroke is the third leading cause of death in Canada. It ranks third among women and fourth among men (Statistics Canada, 2013). The Canadian Heart and Stroke Foundation estimates that there is a death related to stroke or heart disease every 7 minutes (Statistics Canada, 2011). Health care costs associated with heart disease and stroke are more than $20.9 billion annually. The nature of these costs are associated with physician/medical services, the cost of hospitalization, and lost income and work productivity (Conference Board of Canada, 2010). A study conducted by Grant, Goldsmith and Anton (2014), revealed that the average length of stay for Canadians post stroke is 35 days in inpatient rehabilitative units. The costs associated with length of stay compound the annual expenditure. Strokes, defined as an interruption of brain function due to vascular origin, are classed as ischemic in 80% of cases and hemorrhagic in the remaining 20% of cases (Catangui, 2013). Although there are some similarities between the two broad types of stroke, differences exist in etiology, pathophysiology, medical management, surgical management, and nursing care. Table 63-1 compares ischemic and hemorrhagic strokes.

ISCHEMIC STROKE An ischemic stroke, cerebrovascular accident (CVA), or “brain attack” is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. The term brain attack is being used to suggest to health care practitioners and the public that a stroke is an urgent health care issue similar to a heart attack. With the approval of thrombolytic therapy for the treatment of acute ischemic

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Management of Patients With Cerebrovascular Disorders

TABLE 63-1

Comparison of Major Types of Stroke

Item

Ischemic

Hemorrhagic

Causes

Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolic Cryptogenic (no known cause) Other

Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral aneurysm Arteriovenous malformation

Main presenting symptoms

Numbness or weakness of the face, arm, or leg, especially on one side of the body

“Exploding headache” Decreased level of consciousness

Functional recovery

Usually plateaus at 6 months

Slower, usually plateaus at about 18 months

stroke in 1996 came a revolution in the care of patients after a stroke. Early treatment with thrombolytic therapy for ischemic stroke results in fewer stroke symptoms and less loss of function. Approved thrombolytic therapy initially had a treatment window of only 3 hours after the onset of a stroke. The time has now been extended to 4.5 hours. Rapid intervention in 4.5 hours or less is key to successful reprofusion of the ischemic penumbra region (Manning, Campbell, Oxley, et al., 2014; Rosso & Samson, 2014). Urgency is needed on the part of the public and health care practitioners for rapid transport of the patient to a hospital for assessment and administration of the medication. Ischemic strokes are subdivided into five different types based on the cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%) (see Table 63-1). Thrombotic (large vessel) strokes are caused by sites of plaque formation along the vessel wall which leads to occlusion and resultant ischemia of the area being fed by the vessel (Book, 2010).

Glossary agnosia: failure to recognize familiar objects perceived by the senses aneurysm: a weakening or bulge in an arterial wall aphasia: inability to express oneself or to understand language apraxia: inability to perform previously learned purposeful motor acts on a voluntary basis atrial fibrillation: rapid irregular electrical activity in the atria of the heart, leading to irregular apical pulse rate cryptogenic stroke: a stroke of unknown origin dysarthria: defects of articulation due to neurologic causes expressive aphasia: inability to express oneself; often associated with damage to the left frontal lobe area hemianopsia: blindness of half of the field of vision in one or both eyes

hemiplegia/hemiparesis: weakness/paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain infarction: a zone of tissue deprived of blood supply Korsakoff’s syndrome: disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations lacunar type stroke: lack of blood flow through a small artery in the brain which results in decreased blood flow. A group of lacuna strokes can lead to dementia. penumbra region: area of low cerebral blood flow receptive aphasia: inability to understand what someone else is saying; often associated with damage to the temporal lobe area

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Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created once the infarcted brain tissue disintegrates (American Association of Neuroscience Nurses [AANN], 2008). Recent knowledge has identified six underlying causes for the formation of lacunar type strokes: embolism, high blood pressure, blood dyscrasias, vasospasm, small brain vessel bleeds, and the occlusion of small vessels (Book, 2010). Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery (MCA), resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation. The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

Pathophysiology In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade (Fig. 63-1). The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine

Clinical Manifestations An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow (see Chapter 61 for discussion of anatomy and brain blood supply). The patient may present with any of the following signs or symptoms:

Ischemia

Energy failure

Acidosis

triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The ischemic cascade threatens cells in the penumbra because membrane depolarization of the cell wall leads to an increase in intracellular calcium and the release of glutamate. The influx of calcium and the release of glutamate, if continued, activate a number of damaging pathways that result in the destruction of the cell membrane, the release of more calcium and glutamate, vasoconstriction, and the generation of free radicals. These processes enlarge the area of infarction into the penumbra, extending the stroke. A person experiencing a stroke typically loses 1.9 million neurons each minute that a stroke is not treated, and the ischemic brain ages 3.6 years each hour without treatment (Saver, 2006). Rapid intervention, 4.5 hours or less, is key to successful reperfusion of the ischemic penumbra region (Rosso & Samson, 2014; Manning et al., 2014). Each step in the ischemic cascade represents an opportunity for intervention to limit the extent of secondary brain damage caused by a stroke. The penumbra area may be revitalized by administration of tissue plasminogen activator (t-PA). Medications that protect the brain from secondary injury are called neuroprotectants. Neuroprotection involves pharmacotherapeutics and physical treatment strategies to improve the cellular environment following ischemic events. By improving environmental conditions, programmed apoptosis is inhibited. This allows for better health outcomes for stroke survivors (Mandel, Fonoff, Bor-Seng-Shu, et al., 2012). Ongoing research is investigating the role selective brain cooling can play in preventing stroke damage (Heart and Stroke Foundation, 2013).

Ion imbalance

Depolarization Intracellular calcium increased Glutamate Cell membranes and proteins break down Formation of free radicals Protein production decreased

Cell injury and death

FIGURE 63-1. Processes contributing to ischemic brain cell injury.

Courtesy of National Stroke Association, Englewood, Colorado.

• Numbness or weakness of the face, arm, or leg, especially on one side of the body • Confusion or change in mental status • Trouble speaking or understanding speech • Visual disturbances • Difficulty walking, dizziness, or loss of balance or coordination • Sudden severe headache Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted. Table 63-2 reviews the neurologic deficits frequently seen in patients with strokes. Table 63-3 compares the symptoms and behaviours seen in right hemispheric stroke with those seen in left hemispheric stroke.

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TABLE 63-2

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Management of Patients With Cerebrovascular Disorders

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Neurologic Deficits of Stroke: Manifestations and Nursing Implications

Neurologic Deficit Visual Field Deficits Homonymous hemianopsia (loss of half of the visual field)

Loss of peripheral vision

Manifestation

Nursing Implications/Patient Teaching Applications

• Unaware of persons or objects on

Place objects within intact field of vision. Approach the patient from side of intact field of vision. Instruct/remind the patient to turn head in the direction of visual loss to compensate for loss of visual field. Encourage the use of eyeglasses if available. When teaching the patient, do so within patient’s intact visual field. Place objects in centre of patient’s intact visual field. Encourage the use of a cane or other object to identify objects in the periphery of the visual field. Driving ability will need to be evaluated. Explain to the patient the location of an object when placing it near the patient. Consistently place patient care items in the same location.

side of visual loss • Neglect of one side of the body • Difficulty judging distances

• Difficulty seeing at night • Unaware of objects or the borders

of objects Diplopia

• Double vision

Motor Deficits Hemiparesis

• Weakness of the face, arm, and leg

Hemiplegia

on the same side (due to a lesion in the opposite hemisphere) • Paralysis of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere)

Place objects within the patient’s reach on the nonaffected side. Instruct the patient to exercise and increase the strength on the unaffected side. Encourage the patient to provide range-of-motion exercises to the affected side. Provide immobilization as needed to the affected side. Maintain body alignment in functional position. Exercise unaffected limb to increase mobility, strength, and use. Support patient during the initial ambulation phase. Provide supportive device for ambulation (walker, cane). Instruct the patient not to walk without assistance or supportive device. Provide the patient with alternative methods of communicating. Allow the patient sufficient time to respond to verbal communication. Support patient and family to alleviate frustration related to difficulty in communicating. Test the patient’s pharyngeal reflexes before offering food or fluids. Assist the patient with meals. Place food on the unaffected side of the mouth. Allow ample time to eat.

Ataxia

• Staggering, unsteady gait • Unable to keep feet together; needs

Dysarthria

• Difficulty in forming words

Dysphagia

• Difficulty in swallowing

Sensory Deficits Paresthesia (occurs on the side opposite the lesion)

• Numbness and tingling of extremity • Difficulty with proprioception

Instruct patient that sensation may be altered. Provide range of motion to affected areas and apply corrective devices as needed.

• Unable to form words that are

Encourage patient to repeat sounds of the alphabet. Explore the patient’s ability to write as an alternative means of communication. Speak slowly and clearly to assist the patient in forming the sounds. Explore the patient’s ability to read as an alternative means of communication. Speak clearly and in simple sentences; use gestures or pictures when able. Establish alternative means of communication. Reorient patient to time, place, and situation frequently. Use verbal and auditory cues to orient patient. Provide familiar objects (family photographs, favorite objects). Use noncomplicated language. Match visual tasks with a verbal cue; holding a toothbrush, simulate brushing of teeth while saying, “I would like you to brush your teeth now.” Minimize distracting noises and views when teaching the patient. Repeat and reinforce instructions frequently. Support patient during uncontrollable outbursts. Discuss with the patient and family that the outbursts are due to the disease process. Encourage patient to participate in group activity. Provide stimulation for the patient. Control stressful situations, if possible. Provide a safe environment. Encourage patient to express feelings and frustrations related to disease process.

a broad base to stand

Verbal Deficits Expressive aphasia

understandable; may be able to speak in single-word responses Unable to comprehend the spoken word; can speak but may not make sense Combination of both receptive and expressive aphasia Short- and long-term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment

Receptive aphasia

•

Global (mixed) aphasia

•

Cognitive Deficits

• • • • •

Emotional Deficits

• Loss of self-control • Emotional lability • Decreased tolerance to stressful • • • •

situations Depression Withdrawal Fear, hostility, and anger Feelings of isolation

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TABLE 63-3

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Comparison of Left and Right Hemispheric Strokes

two or more objects in spatial areas) are frequently seen in patients with right hemispheric damage.

Left Hemispheric Stroke

Right Hemispheric Stroke

Sensory Loss

Paralysis or weakness on right side of body Right visual field deficit Aphasia (expressive, receptive, or global) Altered intellectual ability

Paralysis or weakness on left side of body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behaviour and poor judgment Lack of awareness of deficits

The sensory losses from stroke may take the form of slight impairment of touch, or it may be more severe, with loss of proprioception (ability to perceive the position and motion of body parts) as well as difficulty in interpreting visual, tactile, and auditory stimuli. Agnosias are deficits in the ability to recognize previously familiar objects perceived by one or more of the senses.

Slow, cautious behaviour

Adapted from Hickey, J. V. (2013). The clinical practice of neurological and neurosurgical nursing (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Motor Loss A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis of one side of the body) caused by a lesion of the opposite side of the brain. Hemiparesis, or weakness of one side of the body, is another sign. The concept of upper and lower motor neuron lesions is described in more detail in Chapter 61. In the early stage of stroke, the initial clinical features may be flaccid paralysis and loss of or decrease in the deep tendon reflexes. When these deep reflexes reappear (usually by 48 hours), increased tone is observed along with spasticity (abnormal increase in muscle tone) of the extremities on the affected side.

Communication Loss Other brain functions affected by stroke are language and communication. In fact, stroke is the most common cause of aphasia. The following are dysfunctions of language and communication: • Dysarthria (difficulty in speaking), caused by paralysis of the muscles responsible for producing speech • Dysphasia (impaired speech) or aphasia (loss of speech), which can be expressive aphasia, receptive aphasia, or global (mixed) aphasia • Apraxia (inability to perform a previously learned action), as may be seen when a patient makes verbal substitutions for desired syllables or words

Perceptual Disturbances Perception is the ability to interpret sensation. Stroke can result in visual-perceptual dysfunctions, disturbances in visual-spatial relations, and sensory loss. Visual-perceptual dysfunctions are caused by disturbances of the primary sensory pathways between the eye and visual cortex. Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. The affected side of vision corresponds to the paralyzed side of the body. Disturbances in visual-spatial relations (perceiving the relationship of

Cognitive Impairment and Psychological Effects If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. These changes can cause the patient to become easily frustrated during rehabilitation. Depression is common and may be exaggerated by the patient’s natural response to this catastrophic event. Emotional lability, hostility, frustration, resentment, lack of cooperation, and other psychological problems may occur.

Assessment and Diagnostic Findings Any patient with neurologic deficits needs a careful history and a complete physical and neurologic examination. Initial assessment focuses on airway patency, which may be compromised by loss of gag or cough reflexes and altered respiratory pattern; cardiovascular status (including blood pressure, cardiac rhythm and rate, carotid bruit); and gross neurologic deficits. Patients may present to the acute care facility with temporary neurologic symptoms. A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain but when brain imaging is performed there is no evidence of ischemia. A TIA may serve as a warning of impending stroke. Quick response and timely intervention by skilled health care professionals can significantly reduce the potential of a stroke event and the negative sequelae that follow (Sander, 2013). All patients presenting to an emergency department with suspected stroke or TIA must have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke and TIA, or determine eligibility for thrombolytic therapy, and develop a plan for further management (Casaubon & Suddes, 2013). Lack of evaluation and treatment of a patient who has experienced previous TIAs may result in a stroke and irreversible deficits (Poisson & Johnston, 2011). Quick response and timely intervention by skilled health care providers can significantly reduce the potential of a stroke event and the negative sequelae to follow (Sander, 2013). The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan performed emergently to determine if the event is ischemic or hemorrhagic

CHAPTER 63

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(the category of stroke determines treatment). Further diagnostic workup for ischemic stroke involves attempting to identify the source of the thrombi or emboli. A 12-lead electrocardiogram (ECG) and a carotid ultrasound are standard tests. Other studies may include CT angiography or magnetic resonance imaging and angiography (MRI and MRA) of the brain and neck vessels; transcranial Doppler flow studies; transthoracic or transesophageal echocardiography; xenon-enhanced CT scan; and single photon emission CT (SPECT) scan (Adams, Zoppo, Alberts, et al., 2007). CT scanning continues to be the most reliable and effective means of delineating between hemorrhagic and ischemic strokes. It is an integral component in stroke management (Catangui, 2013). The emergence of Telestroke Networks in Canada has been instrumental in overcoming geographical barriers in the management of acute stroke care. Telestroke Networks are enhancing the model of care in rural and remote hospitals. Through this approach to care, patients receive an early diagnosis and early intervention which leads to much better health outcomes (Switzer, Demaerschalk, Xie, et al., 2012).

Prevention Primary prevention of ischemic stroke remains the best approach. Preventive strategies including a healthy lifestyle reduces the risk of an initial stroke, and the risk of a subsequent stroke for patients with prior strokes. Hypertension is the single most important modifiable risk factor for stroke (Coutts & Kelloway, 2013). Leading a healthy lifestyle, which includes not smoking, maintaining a healthy weight, following a healthy diet (including low sodium [Appel, 2014] and modest alcohol consumption), and daily exercise, can reduce the risk of having a stroke by about one half (Coutts & Kelloway, 2012). Referral to a Stroke Prevention Clinic after an initial hospital visit for a TIA is associatied with significantly lower mortality and with increased use of evidence-based therapies for secondary stroke prevention (Webster, Saposnik, Kapral, et al., 2011). Prevention includes diet/nutrition, fitness, monitoring of blood pressure, adherence to appropriate medication regimens, smoking cessation, and healthy sleep hygiene practices. Prevention also includes access to medical care in the form of diagnostics, interventions, and education (Heart and Stroke Foundation, 2013). The risk of coronary heart disease and stroke has decreased in women on the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH-style diet highlights the following consumption guidelines: increase the number of fruit and vegetable servings, reduce salt intake, and lower saturated fat intake. In addition to dietary modifications, physical exercise is a vital component in stroke prevention (Appel, 2014; Kokubo, 2012; Lahr, van der Zee, Luijckx, et al., 2013). Stroke risk screenings are an ideal opportunity to lower stroke risk by identifying people or groups of people who are at high risk for stroke and by educating patients and the community about recognition and prevention of stroke. Recent research indicates that a dose of Aspirin 100 mg every other day has the potential to reduce the risk of ischemic events, especially TIAs (Rist, Buring, Kase, et al., 2013).

Management of Patients With Cerebrovascular Disorders

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Advanced age, gender, and race are well-known nonmodifiable risk factors for stroke (Heart and Stroke Foundation, 2014). High-risk groups include people older than 55 years of age, as the incidence of stroke more than doubles in each successive decade. Men have a higher rate of stroke than women. Additional research reveals that there should be a more focused look at stroke and its challenges when considering cultural differences. It is imperative that stroke risk factors, age of onset of stroke events, the degree of deficits at the onset of a stroke, and access to comprehensive stroke care centres be closely reviewed to provide for better clinical outcomes. For example, Hispanics have a higher incidence of metabolic syndrome and diabetes mellitus, and thus they are at greater risk for experiencing a stroke event (Qian, Fonarow, Smith, et al., 2013). First Nations, Inuit, and Métis, and people of African and South Asian descent are more likely to have high blood pressure and diabetes and therefore are at greater risk of stroke than the general Canadian population (Heart and Stroke Foundation, 2014). The incidence of stroke in African Canadians is almost twice as high as in Caucasians. African Canadians also suffer more extensive physical impairments and are twice as likely to die from stroke than are Caucasians. Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, obesity, smoking, and diabetes (Chart 63-1). For people who are at high risk, interventions that alter modifiable factors, such as treating hypertension and hyperglycemia and stopping smoking, reduce stroke risk. Other treatable conditions that increase risk of stroke are asymptomatic carotid stenosis and valvular heart disease (e.g., endocarditis, prosthetic heart valves). Periodontal disease has also been linked to stroke risk. The association between periodontal disease and stroke may result from the host inflammatory response and the chronic bacterial infection, but the exact mechanism is not fully understood. Periodontal disease is a treatable and preventable condition. Several methods of preventing recurrent stroke have been identified for patients with TIAs or ischemic stroke. New research involves investigating the effectiveness of carotid artery stenting over the alternative method of endarterectomy (Coutts & Kelloway, 2013; Poisson & Johntson, 2011). In patients with atrial fibrillation, which increases the risk of emboli, administration of warfarin

CHART 63-1

Modifiable Risk Factors for Ischemic Stroke • Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke)

• Atrial fibrillation • Hyperlipidemia • Diabetes mellitus (associated with accelerated atherogen• • • •

esis) Smoking Asymptomatic carotid stenosis Obesity Excessive alcohol consumption

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(Coumadin), or newer anticoagulants, inhibit clot formation, and may prevent both thrombotic and embolic strokes.

Medical Management Patients who have experienced a TIA or stroke should have medical management for secondary prevention. Those with atrial fibrillation (or cardioembolic strokes) are treated with dose-adjusted warfarin (Coumadin) unless contraindicated. The international normalized ratio (INR) target is 2 to 3. Anticoagulant therapy approaches are well documented and well established in the medical community for patients with atrial fibrillation; however care and consideration must be given to the associated risk of bleeding events (García-Rodríguez, Gaist, Morton, et al. 2013). Platelet-inhibiting medications, including aspirin, extended-release dipyridamole (Persantine) plus aspirin, clopidogrel (Plavix), and ticlopidine (Ticlid), decrease the incidence of cerebral infarction in patients who have experienced TIAs and stroke from suspected embolic or thrombotic causes. The specific medication that is used is based on the patient’s health history. Research has found that medications classified as 3-hydroxy-2-methyl-glutaryl-coenzyme A reductase inhibitors (also known as statins) reduce coronary events and strokes. Benefits were independent of cholesterol levels, and these medications are now widely used for stroke prevention. Very recent research indicates that the ongoing use of statin drugs in secondary stroke prevention reduces the risk of negative health outcomes and mortality (Bautista, 2012; Scheitz, Seiffge, Tütüncü, et al. 2014). After the acute stroke period, antihypertensive medications are also used, if indicated, for secondary stroke prevention. The use of antihypertensive medications continues to allow for positive health outcomes for stroke survivors. It is crucial to monitor the individual response to the various choices in antihypertensive medications: calcium channel blockers, beta blockers, alpha blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). Additionally, diuretics in collaboration with antihypertensive agents have allowed for better management of blood pressure (Dawes, 2013). Ongoing research is focusing on several aspects of the medical management of acute ischemic stroke. Recanalization devices are receiving significant attention as a means of restoring blood flow following an ischemic stroke. The sooner the blood flow is restored, the better the health outcome will be for the stroke patient. Devices that aid in the retrieval and removal of a thrombus (thrombectomy) are collectively referred to as retrievable stents. Research investigating the efficacy of the Solitaire Flow Restoration Device, Penumbra System, Merci and TREVO devices compare the rate of recanalization and improved outcomes following the procedure. Recanalization refers to clearing the vessel passageway thereby restoring blood flow. In two studies the Solitaire Flow Restoration Device had the best rate of recanalization over the other thrombectomy devices (Hann, Calouhi, Starke, et al., 2013; Almekhlafi, Menon, Freiheit, et al., 2013; Hussain, Zaidat, & Fitzsimmons, 2012). Transcra-

nial ultrasound is proven to be useful in monitoring the hemmorhagic changes seen post-recanalization. Transcrial ultrasound can be performed at the bedside (Demchuk & Bal, 2012).

Thrombolytic Therapy Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain (Catangui, 2013). Recombinant t-PA is a genetically engineered form of t-PA, a thrombolytic substance made naturally by the body. It works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the atherosclerotic lesion. Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3.0 to 4.5 hours) in patients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months (Adams et al., 2007). The combination of fibrinolytics with antithrombotics works as a means of improving recanalization times (Bautista, 2012; Demchuk & Bal, 2012). Other research studies are currently reviewing the pharmacokinetics and pharmacodynamics associated with the direct factor Xa inhibitor, Apixaban. This anticoagulant agent shows promise as a means of reducing the risk of stroke associated with atrial fibrillation (Keating, 2013). Canada’s dispersed population presents numerous challenges, especially to the implementation of best practices for stoke care (Registered Nurses Association of Ontario [RNAO], 2005). To realize the full potential of thrombolytic therapy, community education directed at recognizing the symptoms of stroke and obtaining appropriate emergency care is necessary to ensure rapid transport to a hospital and initiation of therapy within the 3.0- to 4.5hour period. Delays make the patient ineligible for thrombolytic therapy, because revascularization of necrotic tissue (which develops after 3 to 4.5 hours) increases the risk of cerebral edema and hemorrhage. ENHANCING PROMPT DIAGNOSIS. After being notified by emergency medical service personnel, the emergency department contacts the appropriate staff (neurologist, neuroradiologist, radiology department, nursing staff, ECG, and laboratory technicians) and informs them of the patient’s imminent arrival at the hospital. A multidisciplinary approach to stroke management is vital in achieving positive rehabilitative outcome goals. Nurses, physiotherapists, occupational therapists, and speech therapists are instrumental in maximizing independence in stroke survivors (Shah, Tartaro, Chew, et al., 2013; Eissa, Krass, & Bajorek, 2012). Initial management requires the definitive diagnosis of an ischemic stroke by brain imaging and a careful history to determine whether the patient meets the criteria for t-PA therapy (Chart 63-2). Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 4.5 hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma). Once it is determined that the patient is a candidate for t-PA therapy, no anticoagulants are administered for the next 24 hours. Before receiving t-PA, the patient is assessed using the National Institutes of Health Stroke Scale (NIHSS), a

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CHART 63-2

Eligibility Criteria for t-PA Administration • • • • • • • • • • • • • •

Age 18 years or older Clinical diagnosis of ischemic stroke Time of onset of stroke known and is 3–4.5 h or less Systolic blood pressure ≤185 mm Hg; diastolic ≤110 mm Hg Not a minor stroke or rapidly resolving stroke No seizure at onset of stroke Not taking warfarin (Coumadin) Prothrombin time ≤15 sec or INR ≤1.7 Not receiving heparin during the past 48 h with elevated partial thromboplastin time Platelet count ≥100,000/mm3 No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm No major surgical procedures within 14 d No stroke, serious head injury, or intracranial surgery within 3 mo No gastrointestinal or urinary bleeding within 21 d

standardized assessment tool that helps evaluate stroke severity (Table 63-4). NIHSS scores range from 0 (no stroke) to 42 (severe stroke) (Catangui, 2013). Certification in the administration of the scale is recommended and is available for nurses and other health care professionals. The NIH Stroke Scale continues to be the most reliable indicator in identifying functional outcome in post stroke survivors (Siegler, Boehme, Kumar, et al., 2013; Saposnik, Guzik, Reeves, et al., 2012; Specogna, Patten, Turin, et al., 2013). DOSAGE AND ADMINISTRATION. The patient is weighed to determine the dose of t-PA. The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. Ten percent of the calculated dose is administered as an intravenous (IV) bolus over 1 minute. The remaining dose (90%) is administered via an infusion pump over 1 hour. The patient is admitted to the intensive care unit or an acute stroke unit, where continuous cardiac monitoring and frequent neurologic assessments are conducted. Vital signs are obtained frequently, with particular attention to blood pressure (with the goal of lowering the risk of intracranial hemorrhage). An example of a standard protocol would be to obtain vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, then every hour until 24 hours after treatment. Research suggests that the burden associated with hypertension and the increased risk associated with stroke warrants an aggressive approach to blood pressure control. Clinical trials reveal that control of systolic hypertension significantly reduces stroke mortality (Lackland, 2013; Weiss, Beloosesky, Kenett, et al., 2013). (See Chapter 33 on Hypertension). Airway management is instituted based on the patient’s clinical condition and arterial blood gas values. SIDE EFFECTS. Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding (IV insertion sites, urinary catheter site, endotracheal tube, nasogastric tube, urine, stool, emesis, other secretions). A 24-hour delay in placement of nasogastric tubes, urinary catheters, and intra-arterial

Management of Patients With Cerebrovascular Disorders

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pressure catheters is recommended. Intracranial bleeding is a major complication that occurred in approximately 6.4% of patients in the initial t-PA study (NINDS, 1995). A number of factors are associated with the occurrence of symptomatic intracranial bleeding: age greater than 70 years, baseline NIHSS score greater than 20, serum glucose concentration 16.6 mmol/L or higher, and edema or mass effect observed on the patient’s initial CT scan.

Therapy for Patients With Ischemic Stroke Not Receiving t-PA Not all patients are candidates for t-PA therapy. Other treatments may include anticoagulant administration (IV heparin or low-molecular-weight heparin). New research is looking at the use of dabigatran etexilate (a direct thrombin inhibitor). The pharmacological safety associated with the administration of dabigatran shows great promise and more research is underway (Clemens, Ryn, Sennewald, et al., 2012). Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. Increased intracranial pressure (ICP) from brain edema, and associated complications, may occur after a large ischemic stroke. Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Other treatment measures include the following: • Elevation of the head of the bed to promote venous drainage and to lower increased ICP • Possible hemicraniectomy for increased ICP from brain edema in a very large stroke • Intubation with an endotracheal tube to establish a patent airway, if necessary • Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a patient who has not received thrombolytic therapy; antihypertensive treatment may be withheld unless the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg) • Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing; such complications may include seizures, bleeding from anticoagulation, or medication-induced bradycardia, which can result in hypotension and subsequent decreases in cardiac output and cerebral perfusion pressure Visit pathway.

to see an acute ischemic stroke clinical

Managing Potential Complications Adequate cerebral blood flow is essential for cerebral oxygenation. If cerebral blood flow is inadequate, the amount of oxygen supplied to the brain will decrease, and tissue ischemia will result. Adequate oxygenation begins with pulmonary care, maintenance of a patent airway, and administration of supplemental oxygen as needed. The importance of adequate gas exchange in these patients cannot be overemphasized as many are at risk for aspiration pneumonia. Other potential complications after a

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TABLE 63-4

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Summary of National Institutes of Health Stroke Scale (NIHSS)

Category

Description

Score

1a. Level of consciousness (LOC)

Alert Arousable by minor stimulation Obtunded, strong stimulation to attend Unresponsive, or reflexic responses only Answers both correctly Answers one correctly Both incorrect Obeys both correctly Obeys one correctly Both incorrect Normal Partial gaze palsy Forced deviation No visual loss Partial hemianopsia Complete hemianopsia Bilateral hemianopsia Normal Minor Partial Complete No drift Drift but maintains in air Unable to maintain in air No effort against gravity No movement Amputation, joint fusion (explain) No drift Drift but maintains in air Unable to maintain in air No effort against gravity No movement Amputation, joint fusion (explain) No drift Drift but maintains in air Unable to maintain in air No effort against gravity No movement Amputation, joint fusion (explain) No drift Drift but maintains in air Unable to maintain in air No effort against gravity No movement Amputation, joint fusion (explain) Absent Present in one limb Present in two limbs Normal Mild to moderate loss Severe to total loss No aphasia Mild to moderate aphasia Severe aphasia Mute Normal Mild to moderate dysarthria Severe dysarthria, mostly unintelligible or worse Intubated or other physical barrier No abnormality Visual, tactile, auditory, or other extinction to bilateral simultaneous stimulation Profound hemiattention or extinction to more than one modality

0 1 2 3 0 1 2 0 1 2 0 1 2 0 1 2 3 0 1 2 3 0 1 2 3 4 N/A 0 1 2 3 4 N/A 0 1 2 3 4 N/A 0 1 2 3 4 N/A 0 1 2 0 1 2 0 1 2 3 0 1 2 N/A 0 1

1b. LOC questions (month, age) 1c. LOC commands (open, close eyes; make fist, let go) 2. Best gaze (eyes open—patient follows examiner’s finger or face) 3. Visual (introduce visual stimulus/threat to patient’s visual field quadrants) 4. Facial palsy (show teeth, raise eyebrows and squeeze eyes shut)

5a. Motor; arm—left (elevate extremity to 90° and score drift/ movement)

5b. Motor; arm—right (elevate extremity to 90° and score drift/ movement)

6a. Motor; leg—left (elevate extremity to 30° and score drift/ movement)

6b. Motor; leg—right (elevate extremity to 30° and score drift/ movement)

7. Limb ataxia (finger-to-nose and heel-to-shin testing) 8. Sensory (pinprick to face, arm, trunk, and leg—compare side to side) 9. Best language (name items, describe a picture and read sentences) 10. Dysarthria (evaluate speech clarity by having patient repeat words) 11. Extinction and inattention (use information from prior testing to score)

Total score Adapted from the version available at the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. It is recommended that the full scale with all instructions be used.

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CHAPTER 63

Internal carotid artery

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External carotid artery

Plaque FIGURE 63-2. Plaque, a potential source of emboli in transient ischemic attack and stroke, is surgically removed from the carotid artery.

stroke include urinary tract infections, cardiac dysrhythmias, and complications of immobility.

Surgical Prevention of Ischemic Stroke The main surgical procedure for selected patients with TIAs and mild stroke is carotid endarterectomy, which is currently the most frequently performed noncardiac vascular procedure. A carotid endarterectomy is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries (Fig. 63-2). This surgery is indicated for patients with symptoms of TIA or mild stroke found to be caused by severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors (Gensicke, Zumbrunn, Jongen, et al., 2013). Carotid stenting, with or without angioplasty, is a less invasive procedure that is used, at times, for severe stenosis. It is used for selected patients who are at high risk for surgery, and its efficacy continues to be investigated. In a recent study, 334 patients with severe carotid artery stenosis and at high risk for surgery underwent stenting with the use of an emboli protection device or carotid endarterectomy. This study demonstrated that this procedure is not inferior to carotid endarterectomy as it resulted in similar long-term outcomes (Gensicke et al., 2013). NURSING MANAGEMENT. The primary complications of carotid endarterectomy are stroke, cranial nerve injuries, infection or hematoma at the incision, and carotid artery disruption. It is important to maintain adequate blood pressure levels in the immediate postoperative period. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction. Medications are used to reduce the blood pressure to previous levels. Close cardiac monitoring is necessary, because these patients have a high incidence of coronary artery disease.

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After carotid endarterectomy, a neurologic flow sheet is used to monitor and document assessment parameters for all body systems, with particular attention to neurologic status. The surgeon is notified immediately if a neurologic deficit develops. Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden increase in neurologic deficits, such as weakness on one side of the body. The patient should be prepared for repeat endarterectomy. Difficulty in swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available at the bedside. Table 63-5 provides more information about potential complications of carotid surgery.

!!"##

Nursing Process

The Patient Recovering From an Ischemic Stroke The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care. The patient who has had a stroke is at risk for multiple complications, including deconditioning and other musculoskeletal problems, swallowing difficulties, bowel and bladder dysfunction, inability to perform self-care, and skin breakdown. After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

Assessment During the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient’s clinical status: • Change in level of consciousness or responsiveness as evidenced by movement, resistance to changes of position, and response to stimulation; orientation to time, place, and person • Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body posture; and position of the head • Stiffness or flaccidity of the neck • Eye opening, comparative size and shape of pupils, and pupillary reactions to light, accommodation, and ocular position. At risk for dry eyes due to lack of spontaneous blink reflex • Colour of the face and extremities; temperature and moisture of the skin • Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure • Ability to speak

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TABLE 63-5

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Selected Complications of Carotid Endarterectomy and Nursing Interventions

Complication

Characteristics

Nursing Interventions

Incision hematoma

Occurs in 5.5% of patients. Large or rapidly expanding hematomas require emergency treatment. If the airway is obstructed by the hematoma, the incision may be opened at the bedside. Poorly controlled hypertension increases the risk of postoperative complications, including hematoma and hyperperfusion syndrome. There is an increased incidence of neurologic impairment and death due to intracerebral hemorrhage. May be related to surgically induced abnormalities of carotid baroreceptor sensitivity. Occurs in approximately 5% of patients. Treated with fluids and low-dose phenylephrine infusion. Usually resolves in 24–48 h. Patients with hypotension should have serial ECGs to rule out myocardial infarction. Occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated; increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. Occurs infrequently, but is often fatal (60%) or results in serious neurologic impairment. Can occur secondary to hyperperfusion syndrome. Increased risk with advanced age, hypertension, presence of high-grade stenosis, poor collateral flow, and slow flow in the region of the middle cerebral artery.

Monitor neck discomfort and wound expansion. Report swelling, subjective feelings of pressure in the neck, difficulty breathing.

Hypertension

Postoperative hypotension

Hyperperfusion syndrome

Intracerebral hemorrhage

• Volume of fluids ingested or administered; volume of urine excreted each 24 hours • Presence of bleeding • Maintenance of blood pressure within the desired parameters After the acute phase, the nurse assesses mental status (memory, attention span, perception, orientation, affect, speech/language), sensation/perception (usually the patient has decreased awareness of pain and temperature), motor control (upper and lower extremity movement), swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function. Ongoing nursing assessment continues to focus on any impairment of function in the patient’s daily activities, because the quality of life after stroke is closely related to the patient’s functional status.

Diagnosis Nursing Diagnoses Based on the assessment data, the major nursing diagnoses for a patient with a stroke may include the following: • Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury • Unilateral neglect as evidenced by inattention to one side of the body and overattention to the opposite side

Risk is highest in the first 48 h after surgery. Check blood pressure frequently and report deviations from baseline. Observe for and report new onset of neurologic deficits.

Monitor blood pressure and observe for signs and symptoms of hypotension.

Observe for severe unilateral headache improved by sitting upright or standing.

Monitor neurologic status and report any changes in mental status or neurologic functioning immediately.

• Acute pain (painful shoulder) related to hemiplegia and disuse • Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae • Disturbed sensory perception (kinesthetic, tactile, or visual) related to altered sensory reception, transmission, and/or integration • Impaired swallowing • Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating • Disturbed thought processes related to brain damage • Impaired verbal communication related to brain damage • Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility • Interrupted family processes related to catastrophic illness and caregiving burdens • Sexual dysfunction related to neurologic deficits or fear of failure

Collaborative Problems/ Potential Complications Potential complications include: • Decreased cerebral blood flow due to increased ICP • Inadequate oxygen delivery to the brain • Pneumonia

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Management of Patients With Cerebrovascular Disorders

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Planning and Goals Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort. It is helpful for the team to know what the patient was like before the stroke: his or her illnesses, abilities, mental and emotional state, behavioural characteristics, and activities of daily living (ADLs). The goal of rehabilitation is to reduce the level of dependency on others and to enable the stroke survivor to achieve a richer and more meaningful rehabilitative process. It is of utmost importance that the quality of life be restored (Shah et al., 2013). The major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of self-care, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications.

Nursing Interventions Nursing care has a significant impact on the patient’s recovery. Often, many body systems are impaired as a result of the stroke, and conscientious care and timely interventions can prevent debilitating complications. During and after the acute phase, nursing interventions focus on the whole person. In addition to providing physical care, the nurse encourages and fosters recovery by listening to the patient and asking questions to elicit the meaning of the stroke experience.

Improving Mobility and Preventing Joint Deformities A patient with hemiplegia has unilateral paralysis (paralysis on one side). When control of the voluntary muscles is lost, the strong flexor muscles exert control over the extensors. The arm tends to adduct (adductor muscles are stronger than abductors) and to rotate internally. The elbow and the wrist tend to flex, the affected leg tends to rotate externally at the hip joint and flex at the knee, and the foot at the ankle joint supinates and tends toward plantar flexion. Correct positioning is important to prevent contractures; measures are used to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies, especially of the ulnar and peroneal nerves. Because flexor muscles are stronger than extensor muscles, a splint applied at night to the affected extremity may prevent flexion and maintain correct positioning during sleep. (See Chapter 12 for additional information.) PREVENTING SHOULDER ADDUCTION. To prevent adduction of the affected shoulder while the patient is in bed, a pillow is placed in the axilla when there is limited external rotation; this keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than the

FIGURE 63-3. Correct positioning to prevent shoulder adduction.

more proximal joints (i.e., the elbow is positioned higher than the shoulder and the wrist higher than the elbow). This helps to prevent edema and the resultant joint fibrosis that will limit range of motion if the patient regains control of the arm (Fig. 63-3). POSITIONING THE HAND AND FINGERS. The fingers are positioned so that they are slightly flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position. If the upper extremity is flaccid, a splint can be used to support the wrist and hand in a functional position. If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. In this instance a dorsal wrist splint is useful in allowing the palm to be free of pressure. Every effort is made to prevent hand edema. Spasticity, particularly in the hand, can be a disabling complication after stroke. Research suggests that injections of botulinum toxin type A in addition to rehabilitive therapy is a cost-effective approach as compared to physical therapy alone (Shackley, Shaw, Price, et al., 2012). Other treatments for spasticity may include stretching and splinting. CHANGING POSITIONS. The patient’s position must be changed every 2 hours. To place a patient in a lateral (side-lying) position, a pillow is placed between the legs before the patient is turned. To promote venous return and prevent edema, the upper thigh should not be acutely flexed. The patient may be turned from side to side, but if sensation is impaired, the amount of time spent on the affected side should be limited. If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh (Fig. 63-4). This position helps promote hyperextension of the hip joints,

FIGURE 63-4. Prone position with pillow support helps prevent hip

flexion.

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which is essential for usual gait and helps prevent knee and hip flexion contractures. The prone position also helps drain bronchial secretions and prevents contractural deformities of the shoulders and knees. During positioning, it is important to reduce pressure and change position frequently to prevent pressure ulcers. ESTABLISHING AN EXERCISE PROGRAM. The affected extremities are exercised passively and put through a full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus. Repetition of an activity forms new pathways in the CNS and therefore encourages new patterns of motion. At first, the extremities are usually flaccid. If tightness occurs in any area, the range-of-motion exercises should be performed more frequently (see Chapter 12). The patient is observed for signs and symptoms that may indicate pulmonary embolus or excessive cardiac workload during exercise; these include shortness of breath, chest pain, cyanosis, and increasing pulse rate with exercise. Frequent short periods of exercise always are preferable to longer periods at infrequent intervals. Regularity in exercise is most important. Improvement in muscle strength and maintenance of range of motion can be achieved only through daily exercise. The patient is encouraged and reminded to exercise the unaffected side at intervals throughout the day. It is helpful to develop a written schedule to remind the patient of the exercise activities. The nurse supervises and supports the patient during these activities. The patient can be taught to put the unaffected leg under the affected one to assist in moving it when turning and exercising. Flexibility, strengthening, coordination, endurance, and balancing exercises prepare the patient for ambulation. Quadriceps muscle setting and gluteal setting exercises are started early to improve the muscle strength needed for walking; these are performed at least five times daily for 10 minutes at a time. PREPARING FOR AMBULATION. As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started. The patient is first taught to maintain balance while sitting and then to learn to balance while standing. If the patient has difficulty in achieving standing balance, a tilt table, which slowly brings the patient to an upright position, can be used. Tilt tables are especially helpful for patients who have been on bed rest for prolonged periods and have orthostatic blood pressure changes. If the patient needs a wheelchair, the folding type with hand brakes is the most practical because it allows the patient to manipulate the chair. The chair should be low enough to allow the patient to propel it with the uninvolved foot and narrow enough to permit it to be used in the home. Before

the patient is transferred from the wheelchair, the brakes must be applied and locked on both sides of the chair. The patient is usually ready to walk as soon as standing balance is achieved. Parallel bars are useful in these first efforts. A chair or wheelchair is readily available in case the patient suddenly becomes fatigued or feels dizzy. The training periods for ambulation should be short and frequent. As the patient gains strength and confidence, an adjustable cane can be used for support. Generally, a three- or four-pronged cane provides a stable support in the early phases of rehabilitation.

Preventing Shoulder Pain A case-control study revealed that out of 107 participants, 49% reported shoulder pain on admission to a treatment facility, upon discharge and at the 1-month follow up appointment. The pain was reported as more severe with spasticity. This study highlighted the importance for proper care and management of the affected limb. In addition to the care recommendations, the study gave credence to the importance of a multidisciplinary approach with the sharing of knowledge and expertise among all members of the care team. The benefits of a collaborative approach to care is to improve the quality of life of stroke survivors while enabling their recovery (Smith, 2012; Burr, Shephard, & Zehr, 2012). Shoulder function is essential in achieving balance and performing transfers and self-care activities. Three situations can occur: painful shoulder, subluxation of the shoulder, and shoulder–hand syndrome. A flaccid shoulder joint may be overstretched by the use of excessive force in turning the patient or from overstrenuous arm and shoulder movement. To prevent shoulder pain, the nurse should never lift the patient by the flaccid shoulder, or pull on the affected arm or shoulder. Overhead pulleys should also be avoided. If the arm is paralyzed, subluxation (incomplete dislocation) at the shoulder can occur as a result of overstretching of the joint capsule and musculature by the force of gravity when the patient sits or stands in the early stages after a stroke. This results in severe pain. Shoulder–hand syndrome (painful shoulder and generalized swelling of the hand) can cause a frozen shoulder and ultimately atrophy of subcutaneous tissues. When a shoulder becomes stiff, it is usually painful. Many shoulder issues can be prevented by proper patient movement and positioning. Muscle activation in the shoulder and arm is a priority focus of rehabilitation. Targeted motor training exercises are an essential part of rehabilitive protocols (Roh, Rymer, Perreault, et al., 2012). The flaccid arm is positioned on a table or with pillows while the patient is seated. Some clinicians advocate the use of a properly worn sling when the patient first becomes ambulatory, to prevent the paralyzed upper extremity from dangling without support. Range-of-motion exercises are important in preventing painful shoulder.

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Overstrenuous arm movements are avoided. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The patient is instructed to flex the affected wrist at intervals and move all the joints of the affected fingers. The patient is encouraged to touch, stroke, rub, and look at both hands. Pushing the heel of the hand firmly down on a surface is useful. Elevation of the arm and hand is also important in preventing dependent edema of the hand. Patients with continuing pain after attempted movement and positioning may require the addition of analgesia to their treatment program. In addition to limb mobilization, other treatment modalities must be considered, such as pain analgesia, positioning of the limb at rest and during the day, high intensity transcutaneous electrical nerve stimulation, and shoulder strapping (Smith, 2012). Other treatments to reduce shoulder pain may include massage, and aromatherapy combined with acupressure (Mehta, Teasell, & Foley, 2013). Medications are helpful in the management of poststroke pain. Amitriptyline hydrochloride (Elavil) has been used, but it can cause cognitive problems, has a sedating effect, and is not effective in all patients. Antiepileptic drugs used for post stroke seizures is still under investigation by the research community. New generation antiepileptic drugs are gaining more attention and more research efforts. The pharmacokinetic and pharmacodynamic properties associated with gabapentin, lamotrigine, topiramate, oxcarbazepine, and levetiracetam show great promise in the management of post stroke seizure activity. This is due to the fact that these medications have not shown to interfere or interact with anticoagulants or antiplatelet agents that are onboard (Gilad, 2012).

Enhancing Self-Care As soon as the patient can sit up, personal hygiene activities are encouraged. The patient is helped to set realistic goals; if feasible, a new task is added daily. The first step is to carry out all self-care activities on the unaffected side. Such activities as combing the hair, brushing the teeth, shaving with an electric razor, bathing, and eating can be carried out with one hand and should be encouraged. Although the patient may feel awkward at first, these motor skills can be learned by repetition, and the unaffected side will become stronger with use. The nurse makes sure that the patient does not neglect the affected side. Assistive devices will help make up for some of the patient’s deficits (Chart 63-3). A small towel is easier to control while drying after bathing, and boxed paper tissues are easier to use than a roll of toilet tissue. Return of functional ability is important to the patient recovering after a stroke. An early baseline assessment of functional ability with an instrument such as the Functional Independence Measure (FIM)

Management of Patients With Cerebrovascular Disorders

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CHART 63-3

Assistive Devices to Enhance Self-Care After Stroke Eating Devices • Nonskid mats to stabilize plates • Plate guards to prevent food from being pushed off plate • Wide-grip utensils to accommodate a weak grasp

Bathing and Grooming Devices • • • •

Long-handled bath sponge Grab bars, nonskid mats, handheld shower heads Electric razors with head at 90 degrees to handle Shower and tub seats, stationary or on wheels

Toileting Aids • Raised toilet seat • Grab bars next to toilet

Dressing Aids • Velcro closures • Elastic shoelaces • Long-handled shoe horn

Mobility Aids • Canes, walkers, wheelchairs • Transfer devices such as transfer boards and belts

is important in team planning and goal setting for the patient. The FIM is an 18-item ordinal scale used to measure the functional ability within rehabilitative populations. Functional skills that are assessed include activities of daily living: dressing one’s upper and lower body, toileting, bathing, grooming, transferring, walking, and negotiating stairs (Ward, Pivko, Brooks, et al., 2011). Perceptual problems may make it difficult for the patient to dress without assistance because of an inability to match the clothing to the body parts. To assist the patient, the nurse can take steps to keep the environment organized and uncluttered, because the patient with a perceptual problem is easily distracted. The clothing is placed on the affected side in the order in which the garments are to be put on. Using a large mirror while dressing promotes the patient’s awareness of what he or she is putting on the affected side. The patient has to make many compensatory movements when dressing; these can produce fatigue and painful twisting of the intercostal muscles. Support and encouragement are provided to prevent the patient from becoming overly fatigued and discouraged. Even with intensive training, not all patients can achieve independence in dressing. The Stroke Rehabilitation Assessment of Movement (STREAM), a 30-item scale, is another tool that can be used to examine voluntary movement and basic mobility in post stroke survivors (Ward et al., 2011). The Stroke Impact Scale-16 is a questionnaire used to help the practitioner gain a better understanding about the patient’s perception of his or her own recovery (Ward et al., 2011).

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Managing Sensory-Perceptual Difficulties Patients with a decreased field of vision are always approached on the side where visual perception is intact. All visual stimuli (e.g., clock, calendar, television) should be placed on this side. The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should make eye contact with the patient and draw his or her attention to the affected side by encouraging the patient to move the head. The nurse may also want to stand at a position that encourages the patient to move or turn to visualize who is in the room. Increasing the natural or artificial lighting in the room and providing eyeglasses if needed are important aids to increasing vision. The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to constantly remind the patient of the other side of the body, to maintain alignment of the extremities, and, if possible, to place the extremities where the patient can see them.

Assisting With Nutrition Stroke can result in swallowing issues (dysphagia) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition. A speech therapist will evaluate the patient’s swallowing ability. If swallowing function is partially impaired, it may return over time, or the patient may be taught alternative swallowing techniques, advised to take smaller boluses of food, and taught about types of foods that are easier to swallow. The patient may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. Having the patient sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest as he or she swallows will help prevent aspiration. The diet may be advanced as the patient becomes more proficient at swallowing. If the patient cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. Enteral tubes can be either nasogastric (placed in the stomach) or nasoenteral (placed in the duodenum) to reduce the risk of aspiration. Nursing responsibilities in feeding include elevating the head of the bed at least 30 degrees to prevent aspiration, checking the position of the tube before feeding, ensuring that the cuff of the tracheostomy tube (if in place) is inflated, and giving the tube feeding slowly.

The feeding tube is aspirated periodically to ensure that the feedings are passing through the gastrointestinal tract. Retained or residual feedings increase the risk of aspiration. Patients with retained feedings may benefit from the placement of a gastrostomy tube or a percutaneous endoscopic gastrostomy tube. In a patient with a nasogastric tube, the feeding tube should be placed in the duodenum to reduce the risk of aspiration. For long-term feedings, a gastrostomy tube is preferred. Management of patients with tube feedings is discussed in Chapter 37.

Attaining Bowel and Bladder Control After a stroke, the patient may have transient urinary incontinence due to confusion, inability to communicate needs, and inability to use the urinal or bedpan because of impaired motor and postural control. Occasionally after a stroke, the bladder becomes atonic, with impaired sensation in response to bladder filling. Sometimes control of the external urinary sphincter is lost or diminished. During this period, intermittent catheterization with sterile technique is carried out. After muscle tone increases and deep tendon reflexes return, bladder tone increases and spasticity of the bladder may develop. Because the patient’s sense of awareness is clouded, persistent urinary incontinence or urinary retention may be symptomatic of bilateral brain damage. The voiding pattern is analyzed, and the urinal or bedpan is offered on this pattern or schedule. The upright posture and standing position are helpful for male patients during this aspect of rehabilitation. Patients may have problems with bowel control, particularly constipation. Unless contraindicated, a high-fibre diet and adequate fluid intake (2 to 3 L/d) should be provided and a regular time (usually after breakfast) should be established for toileting. See Chapter 12 for additional information about bowel and bladder control.

Improving Thought Processes After a stroke, the patient may have challenges with cognitive, behavioural, and emotional deficits related to brain damage. However, in many instances, a considerable degree of function can be recovered, because not all areas of the brain are equally damaged; some remain more intact and functional than others. After assessment that delineates the patient’s deficits, the neuropsychologist, in collaboration with the primary care physician, psychiatrist, nurse, and other professionals, structures a training program using cognitive-perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses. The role of the nurse is supportive. The nurse reviews the results of neuropsychological testing, observes the patient’s performance and progress, gives positive feedback, and, most importantly, conveys an attitude of confidence and hope. Interventions capitalize on the patient’s strengths and remaining abilities while attempting to improve

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performance of affected functions. Other interventions are similar to those for improving cognitive functioning after a head injury (see Chapter 64).

Improving Communication Aphasia, which impairs the patient’s ability to express himself or herself and to understand what is being said, may become apparent in various ways. The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Broca’s area. It is located in a convolution adjoining the MCA. This area is responsible for control of the combinations of muscular movements needed to speak each word. Broca’s area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients who are paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances. The speech therapist assesses the communication needs of the patient with a stroke, describes the precise deficit, and suggests the best overall method of communication. Most language intervention strategies can be tailored for the individual patient. The patient is expected to take an active part in establishing goals. A person with aphasia may become depressed. The inability to talk on the telephone, answer a question, or participate in conversation often causes anger, frustration, fear of the future, and hopelessness. Nursing interventions include strategies to make the atmosphere conducive to communication. This includes being sensitive to the patient’s reactions and needs and responding to them in an appropriate manner, while always treating the patient as an adult. The nurse provides strong emotional support and understanding to allay anxiety and frustration. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This is to be avoided, because it causes the patient to become more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing sentences. A consistent schedule, routines, and repetition help the patient to function despite significant deficits. A written copy of the daily schedule, a folder of personal information (birth date, address, names of relatives), checklists, and an audiotaped list help improve the patient’s memory and concentration. The patient may also benefit from a communication board, which has pictures of common needs and phrases. The board may be translated into any language. When talking with the patient, it is important for the nurse to gain the patient’s attention, speak slowly, and keep the language of instruction consistent. One instruction is given at a time, and time is allowed for the patient to process what has been said. The use of gestures may enhance comprehension. Speaking is thinking out loud, and the emphasis is on thinking. Listening and sorting out incoming messages

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CHART 63-4

Communicating With the Patient With Aphasia • Face the patient and establish eye contact. • Speak in a normal manner and tone. • Use short phrases, and pause between phrases to allow the patient time to understand what is being said.

• Limit conversation to practical and concrete matters. • Use gestures, pictures, objects, and writing. • As the patient uses and handles an object, say what the

object is. It helps to match the words with the object or action. • Be consistent in using the same words and gestures each time you give instructions or ask a question. • Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

requires mental effort; the patient must struggle against mental inertia and needs time to organize a response. In working with the patient with aphasia, the nurse must remember to talk to the patient during care activities. This provides social contact for the patient. Chart 63-4 describes points to keep in mind when communicating with the patient with aphasia.

Maintaining Skin Integrity The patient who has had a stroke may be at risk for skin and tissue breakdown because of altered sensation and inability to respond to pressure and discomfort by turning and moving. Preventing skin and tissue breakdown requires frequent assessment of the skin, with emphasis on bony areas and dependent parts of the body. During the acute phase, a specialty bed (e.g., low-air-loss bed) may be used until the patient can move independently or assist in moving. A regular turning schedule (e.g., every 2 hours) is adhered to even if pressure-relieving devices are used to prevent tissue and skin breakdown. When the patient is positioned or turned, care must be used to minimize shear and friction forces, which cause damage to tissues and predispose the skin to breakdown. The patient’s skin must be kept clean and dry; gentle massage of healthy (nonreddened) skin and adequate nutrition are other factors that help to maintain skin and tissue integrity (see Chapter 12).

Improving Family Coping Family members play an important role in the patient’s recovery. Family members are encouraged to participate in counselling and to use support systems that will help with the emotional and physical stress of caring for the patient. Involving others in the patient’s care and teaching stress management techniques and methods for maintaining personal health also facilitate family coping. The family may have difficulty accepting the patient’s disability and may be unrealistic in their

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expectations. They are given information about the expected outcomes and are counselled to avoid doing activities for the patient that he or she can do. They are assured that their love and interest are part of the patient’s therapy. The family is informed that the rehabilitation of the patient with hemiplegia requires many months and that progress may be slow. The gains made by the patient in the hospital or rehabilitation unit must be maintained. All caregivers should approach the patient with a supportive and optimistic attitude, focusing on the patient’s remaining abilities. The rehabilitation team, the medical and nursing team, the patient, and the family are all involved in developing attainable goals for the patient at home. Most relatives of patients with stroke handle the physical changes better than the emotional aspects of care. The family is prepared to expect occasional episodes of emotional lability. The patient may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the patient’s laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time.

Helping the Patient Cope With Sexual Dysfunction Sexual functioning can be profoundly altered by stroke. Although research in this area of stroke management is limited, it appears that patients who have had a stroke consider sexual function important, and many have sexual dysfunction. Impaired sexual activity in poststroke survivors not only includes sexual dysfunction but also impaired sexual satisfaction. Although there are assessment tools to evaluate the level of independence associated with activities of daily living; those to evaluate the presence and/or degree of depression and anxiety, methods to adequately assess sexual function post stroke are not available (Bugincourt, Hamy, Canaple, et al., 2014). Post stroke survivors can be faced with a number of barriers to sexual activity. These barriers may include physical limitations; discomfort and/or pain which may limit sexual positions; and decreased libido/arousal depending on the location of the stroke event within the brain cortices (Rosenbaum, Vadas, & Kalichman, 2014). Nurses in the rehabilitation setting play a crucial role in beginning a dialogue between the patient and his or her partner about sexuality after a stroke. Indepth assessments to determine sexual history before and after the stroke are followed by appropriate interventions. Interventions related to impaired sexual activity should not be solely focused on the physical barriers, rather on exploring other alternatives that promote/enhance intimacy, pleasure, and ultimately self-confidence (Rosenbaum et al., 2014). An all-encompassing approach includes dialogue about impaired sexual activity by all members of the rehabilitative team—nurses, occupational therapists, physiotherapists, and speech pathologists (Rosenbaum et al., 2014).

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patient and family education is a fundamental component of rehabilitation. The nurse provides teaching about stroke, its causes and prevention, and the rehabilitation process. In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much self-care as possible. This may entail using assistive devices or modifying the home environment to help the patient live with a disability. An occupational therapist is helpful in assessing the home environment and recommending modifications to help the patient become more independent. For example, a shower is more convenient than a tub for the patient with hemiplegia because most patients do not gain sufficient strength to get up and down from a tub. Sitting on a stool of medium height with rubber suction tips allows the patient to wash with greater ease. A long-handled bath brush with a soap container is helpful to the patient who has only one functional hand. If a shower is not available, a stool may be placed in the tub and a portable shower hose attached to the faucet. Handrails may be attached alongside the bathtub and the toilet. Other assistive devices include special utensils for eating, grooming, dressing, and writing (see Chart 63-3). A program of physical therapy can be beneficial, whether it takes places in the home or in an outpatient program. Campbell and Matthews (2010) completed an integrative review of research literature from 1990 to 2009 related to risk factors for falls during inhospital stroke rehabilitation. They identified impaired balance, visual spacial hemineglect, and impaired performance of activities of daily living as the key risk factors for falls. Some association between falls and incontinence, cognitive function, defects in visual fields, and decreased vision and hearing were identified by Czernuszenko and Czlonkowska (2009). Recent research has focused on techniques using robotics and constraint-induced movement therapy. Constraint-induced movement therapy is widely used as a rehabilitative approach. It involves providing intensive exercises for the affected limb while restraining the unaffected extremity. This type of approach is used to re-establish lost function of the affected limb (El-Kafy, Elshemy, & Alghamdi, 2014). Robot-assisted therapy uses sensorimotor training of the upper limb. This method allows patients to train without the presence of a therapist. CONTINUING CARE. The recovery and rehabilitation process after stroke may be prolonged and requires patience and perseverance on the part of both the patient and the family. Depending on the specific neurologic deficits resulting from the stroke, the patient at home may require the services of a number of health care professionals. The nurse often coordinates the care of the patient at home and considers the many educational needs of caregivers and patients. The family (often the spouse) requires education as well as assistance in planning and providing care. The family is advised that the patient may tire easily, may become irritable and upset by small events,

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and may be less interested in events than expected. Emotional concerns associated with stroke are often related to speech dysfunction and the frustrations of being unable to communicate. A speech therapist allows the family to be involved and gives the family practical instructions to help the patient between therapy sessions. Depression is a common and serious concern in the patient who has had a stroke, and can affect the ability of the patient to participate in rehabilitation. Post stroke depression accounts for 30% to 40% of stroke patients having lengths of hospital stay longer than 4 weeks (Turner, 2012). A number of risk factors for depression have been identified in poststroke patients. These include the loss of body/limb function, the sense of losing control, the inability to clearly communicate their needs; depressive tendencies/illness prior to the stroke, cognitive impairment, and female gender (Kouwenhoven, Kirkevold, Engedal, et al., 2011). Nurses in all practice settings screen all patients to identify those who may be at risk while they are in the hospital. In the home or in the rehabilitation setting, nurses may be involved in coordinating care and referring patients and family to appropriate resources. The family can help by continuing to support the patient and by giving positive reinforcement for the progress that is being made. Antidepressant therapy may help if depression dominates the patient’s life. A qualitative study conducted by Kouwenhoven et al. (2011) revealed that participants described themselves as failures in that they could not perform different tasks,although they could mentally anticipate success. In other words, there was a mismatch

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between what they felt they could accomplish and what was indeed accomplished. Overwhelmingly, participants described their lives as “shades of grey” where there were no layers of colour, only tunnels from light grey to dark grey. This was essentially a new world for these participants and consequentially, there was great difficulty coping in such a world. This study sheds light on the ever important focus by health care practitioners to evaluate and reevaluate psychological and emotional health in addition to the physical health of post-stroke survivors. Communitybased stroke support groups may allow the patient and family to learn from others with similar concerns and to share their experiences. Support groups take the form of in-person meetings as well as Internetbased support programs. The patient is encouraged to continue hobbies and recreational and leisure interests and to maintain contact with friends to prevent social isolation. All nurses coming in contact with the patient encourage the patient to keep active, adhere to the exercise program, and remain as self-sufficient as possible. The nurse recognizes the potential effects of caregiving on the family. Not all families have the adaptive coping skills and adequate psychological functioning necessary for the long-term care of another person. The patient’s spouse may be older, with his or her own health concerns; in some instances, the patient may have been the provider of care to the spouse. A spouse may have to take on new roles and responsibilities in the relationship and around the home. He or she may also feel a sense of loss (of freedom and leisure time as well as of the marital relationship) (Chart 63-5).

NURSING RESEARCH PROFILE

Chart 63-5. Carers of Community-dwelling Stroke Survivors Cecil, R., Parahoo, K., Thompson, k., et al. (2011). ‘The hard work starts now’: A glimpse into the lives of carers of community-dwelling stroke survivors. Journal of Clinical Nursing, 20, 1723–1730. Purpose The unpredictability of a stroke often leaves the caregiver overwhelmed and unsure what to do and how to approach the situation. Some caregivers feel stressed with the prospects of caring for the stroke survivor. This study explores the lived experiences of caregivers of stroke survivors. It examines the nature of the stressors and other factors that impact the caregiver role. Design The study was framed around semi structured interviews followed by a focus group. The overarching purpose for the semi structured interviews was to explore, through informal dialogue, the issues that caregivers face on a day-to-day basis. Data was collated and used to generate topics in the second phase of this study—the focus group. 10 carers participated in the study with 4 carers involved in the semi structured interview phase and 6 carers making up the focus group.

Findings A total of seven main issues were identified from the semi structured interviews: the need for information; the availability and communication with health professionals; accessibility to various therapies and programs; courses aimed at reducing caregiver stress; the need for networking with family and friends; consideration of their own health (mental and physical); and uncertainty with facing the future and the unexpected. Nursing Implications This study reveals the importance of communication and ongoing dialogue between members of the health care community and caregivers of post stroke survivors. With timely and meaningful information, caregivers are able to provide appropriate care to both themselves and the stroke survivor. With ongoing communication and an uninterrupted flow of information, caregivers feel empowered with knowledge and information and enabled by the supportive health care team. The study also sheds light on the importance of care for the caregiver on an emotional and psychological level.

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Informal caregiver is the term applied to a person providing care without monetary compensation. Informal caregivers of post stroke survivors provide care in the form of assistance with dressing, walking, toileting, hygiene, and eating. In addition to these daily tasks, the caregiver also provides emotional support. The caregiver is the stroke survivor’s social support system. Often times, the informal caregiver is the spouse of the stroke survivor. With the overload associated with caring for a loved one, caregiver burden is closely linked to increased rates of depression and anxiety. It is imperative that nurses assess closely for signs of depression not only in the stroke survivor but in the caregiver. However, it is as important for the homecare nurses to begin dialogue with the caregiver about self-identification of signs of anxiety and depression and formulate strategies by which to reduce these negative feelings. This approach provides the caregiver with a much needed support system. When the caregiver is healthy, proper care can be provided to the loved one (Denno, Gillard, Graham, et al., 2013). Caregivers may require reminders to attend to their own health concerns and well-being. Even healthy caregivers may find it difficult to maintain a schedule that includes being available around the clock. The nurse encourages the family to arrange for respite care services (planned short-term care to relieve the family from having to provide continuous 24-hour care), which may be available from an adult day care centre. Some hospitals also offer weekend respite care that can provide caregivers with needed time for themselves. The nurse involved in home and continuing care also needs to remind the patient and family of the need for respite care as well as continuing health promotion and screening practices.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Achieves improved mobility a. Avoids deformities (contractures and footdrop) b. Participates in prescribed exercise program c. Achieves sitting balance d. Uses unaffected side to compensate for loss of function of hemiplegic side 2. Reports absence of shoulder pain a. Demonstrates shoulder mobility; exercises shoulder b. Elevates arm and hand at intervals 3. Achieves self-care; performs hygiene care; uses adaptive equipment 4. Demonstrates techniques to compensate for altered sensory reception, such as turning the head to see people or objects 5. Demonstrates safe swallowing 6. Achieves regular bowel and bladder elimination 7. Participates in cognitive improvement program

8. Demonstrates improved communication 9. Maintains intact skin without breakdown a. Demonstrates appropriate skin turgor b. Participates in turning and positioning activities 10. Family members demonstrate a positive attitude and coping mechanisms a. Encourage patient in exercise program b. Take an active part in rehabilitation process c. Contact respite care programs or arrange for other family members to assume some responsibilities for care 11. Develops alternative approaches to sexual expression

HEMORRHAGIC STROKE Hemorrhagic strokes account for 15% to 20% of cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage. Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension. Subarachnoid hemorrhage is caused by a tear in a cerebral artery. Bleeding from this site enters into the subarachnoid space. In 50% of the cases, bleeding is the result of a burst aneurysm (Book, 2010). Another common cause of intracerebral hemorrhage in older people is cerebral amyloid angiopathy, which involves damage caused by the deposit of beta-amyloid protein in the small- and medium-sized blood vessels of the brain. Secondary intracerebral hemorrhage is associated with arteriovenous malformations (AVMs), intracranial aneurysms, intracranial neoplasms, or certain medications (e.g., anticoagulants, amphetamines). Twenty percent of all strokes worldwide are of the intracerebral hemorrhage type. Of this group, there is a 32% to 50% mortality rate within 30 days post stroke (Martini, Flaherty, Brown, et al., 2012). Patients who survive the acute phase of care usually have more severe deficits and a longer recovery phase compared to those with ischemic stroke.

Pathophysiology The pathophysiology of hemorrhagic stroke depends on the cause and type of cerebrovascular disorder. Symptoms are produced when a primary hemorrhage, aneurysm, or AVM presses on nearby cranial nerves or brain tissue or, more dramatically, when an aneurysm or AVM ruptures, causing subarachnoid hemorrhage (hemorrhage into the cranial subarachnoid space). Usual brain metabolism is disrupted by the brain’s exposure to blood; by an increase in ICP resulting from the sudden entry of blood into the subarachnoid space, which compresses and injures brain tissue; or by secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm that frequently accompany subarachnoid hemorrhage.

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Intracerebral Hemorrhage

Arteriovenous Malformations (AVMs)

An intracerebral hemorrhage, or bleeding into the brain tissue, is most common in patients with hypertension and cerebral atherosclerosis, because degenerative changes from these diseases cause rupture of the blood vessel. An intracerebral hemorrhage may also result from certain types of arterial pathology, brain tumours, and the use of medications (e.g., oral anticoagulants, amphetamines, and illicit drug use). There seems to be a correlation between hematoma location and the rate of mortality associated with an intracerebral hemorrhage. More research is needed; however this sheds new light on the importance of diagnostic imaging to determine the extent and location of the bleed. Increased mortality is seen with hemorrhage isolated to regions such as the parietal lobe, basal ganglia, posterior insula, and posterolateral thalamus (Lee, King, Stradling, et al., 2014).

Most AVMs are caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed (see Fig. 63-5). The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture. AVM is a common cause of hemorrhagic stroke in young people.

Intracranial (Cerebral) Aneurysm An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. The cause of aneurysms is unknown, although research is ongoing. An aneurysm may be due to atherosclerosis, which results in a defect in the vessel wall with subsequent weakness of the wall; a congenital defect of the vessel wall; hypertensive vascular disease; head trauma; or advancing age. Any artery within the brain can be the site of a cerebral aneurysm, but these lesions usually occur at the bifurcations of the large arteries at the circle of Willis (Fig. 63-5). The cerebral arteries most commonly affected by an aneurysm are the internal carotid artery (ICA), anterior cerebral artery (ACA), anterior communicating artery (ACoA), posterior communicating artery (PCoA), posterior cerebral artery (PCA), and MCA. Multiple cerebral aneurysms are not uncommon.

Intracranial aneurysm

Anterior cerebral artery Intracranial aneurysm Anterior communicating artery Internal carotid artery Middle cerebral artery

Arteriovenous malformation FIGURE 63-5. Common sites of intracranial aneurysms and an arteriovenous malformation.

Subarachnoid Hemorrhage A subarachnoid hemorrhage (hemorrhage into the subarachnoid space) may occur as a result of an AVM, intracranial aneurysm, trauma, or hypertension. The most common causes are a leaking aneurysm in the area of the circle of Willis and a congenital AVM of the brain.

Clinical Manifestations The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache. A comprehensive assessment reveals the extent of the neurologic deficits. Many of the same motor, sensory, cranial nerve, cognitive, and other functions that are disrupted after ischemic stroke are also altered after a hemorrhagic stroke. Table 63-2 reviews the neurologic deficits frequently seen in patients with strokes. Table 63-3 compares the symptoms seen in right hemispheric stroke with those seen in left hemispheric stroke. Symptoms associated with subarachnoid hemorrhage include an atypical headache of sudden onset; vomiting; neck stiffness; photophobia; hypertension; and cardiac arrhythmias (Book, 2010). In addition to the neurologic deficits (similar to those of ischemic stroke), the patient with an intracranial aneurysm or AVM may have some unique clinical manifestations. Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and often loss of consciousness for a variable period of time. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur if the aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur. At times, an aneurysm or AVM leaks blood, leading to the formation of a clot that seals the site of rupture. In this instance, the patient may show little neurologic deficit. In other cases, severe bleeding occurs, resulting in cerebral damage, followed rapidly by coma and death. Prognosis depends on the neurologic condition of the patient, the patient’s age, associated diseases, and the extent and location of the hemorrhage or intracranial aneurysm. Subarachnoid hemorrhage from an aneurysm is a catastrophic event with significant morbidity and mortality. Chart 63-6 presents ethical issues related to the patient with a severe hemorrhagic stroke.

Assessment and Diagnostic Findings Any patient with suspected stroke should undergo a CT scan or MRI to determine the type of stroke, the size and

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CHART 63-6

Ethics and Related Issues What Are the Ethical Issues Related to DNR Orders After Severe Stroke? SITUATION An 85-year-old patient is admitted with a large intracerebral hemorrhage, severe neurologic deficits, and a past medical history of coronary artery bypass graft surgery, hypertension, atrial fibrillation, and gout. The patient does not have an advanced directive. The attending physician suggests a donot-resuscitate (DNR) order to the family.

DILEMMA The principle of autonomy for the patient (including death with dignity) conflicts with the principle of beneficence for the health care providers.

DISCUSSION 1. What arguments would you pose in favour of the DNR order? 2. What arguments would you pose against the DNR order? 3. Does the family have the right to refuse? 4. Is a DNR order an example of “patient abandonment” by health care workers, or an attempt to limit treatment and avoid CPR in a patient with an anticipated poor outcome?

location of the hematoma, and the presence or absence of ventricular blood and hydrocephalus (Catangui, 2013). Cerebral angiography confirms the diagnosis of an intracranial aneurysm or AVM. These tests show the location and size of the lesion and provide information about the affected arteries, veins, adjoining vessels, and vascular branches. Lumbar puncture is performed if there is no evidence of increased ICP, the CT scan results are negative, and subarachnoid hemorrhage must be confirmed. Lumbar puncture in the presence of increased ICP could result in brain stem herniation or rebleeding. When diagnosing a hemorrhagic stroke in a patient younger than 40 years of age, some clinicians obtain a toxicology screen for illicit drug use.

Prevention Primary prevention of hemorrhagic stroke is the best approach and includes managing hypertension and ameliorating other significant risk factors. Blood pressure management of a daytime value of less than 139/80 mm Hg and a nighttime value of greater than 115/65 mm Hg along with healthy lifestyle choices significantly reduces the risk associated with intracerebral hemorrhage (Aronow, 2013; Canadian Hypertension Education Program [CHEP] recommendations for blood pressure management, 2014). Additional risk factors are increased age, male gender, and excessive alcohol intake. Stroke risk screenings provide an ideal opportunity to lower hemorrhagic stroke risk by identifying high-risk individuals or groups and educating patients and the community about recognition and prevention.

Complications Potential complications of hemorrhagic stroke include rebleeding or hematoma expansion; cerebral vasospasm resulting in cerebral ischemia; acute hydrocephalus, which results when free blood obstructs the reabsorption of cerebrospinal fluid (CSF) by the arachnoid villi; and seizures.

Cerebral Hypoxia and Decreased Blood Flow Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. Cerebral blood flow is dependent on the blood pressure, cardiac output, and integrity of cerebral blood vessels. Adequate hydration (IV fluids) must be ensured to reduce blood viscosity and improve cerebral blood flow. Extremes of hypertension or hypotension need to be avoided to prevent changes in cerebral blood flow and the potential for extending the area of injury. A seizure can also compromise cerebral blood flow, resulting in further injury to the brain. Observing for seizure activity and initiating appropriate treatment are important components of care after a hemorrhagic stroke.

Vasospasm A common complication associated with a burst aneurysm is arterial vasospasm. Vasospasm occurs in approximately 70% of patients who have suffered an aneurysmal rupture. Vasospasm associated with cerebral ischemia leads to increased mortality rates. Efforts to restore cardiac output and cerebral perfusion are essential for improving the prognosis in post hemorrhagic stroke survivors (Zada, Terterov, Russin, et al., 2010; Bautista, 2012). The mechanism responsible for vasospasm is not clear, but it is associated with increasing amounts of blood in the subarachnoid cisterns and cerebral fissures, as visualized by CT scan. Monitoring for vasospasm may be performed through the use of bedside transcranial Doppler ultrasonography (TCD) or followup cerebral angiography. Vasospasm, in most cases, develops within 3 to 10 days with a peak at 7 days. A narrowing of the arterial vessel can be visualized with Doppler scans or arteriography (Malhotra, Conners, Lee, et al., 2014; Book, 2010). It leads to increased vascular resistance, which impedes cerebral blood flow and causes brain ischemia and infarction. The signs and symptoms reflect the areas of the brain involved. Vasospasm is often heralded by a worsening headache, a decrease in level of consciousness (confusion, lethargy, and disorientation), or a new focal neurologic deficit (aphasia, hemiparesis). Management of vasospasm remains difficult and controversial. It is believed that early surgery to clip the

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aneurysm prevents rebleeding and that removal of blood from the basal cisterns around the major cerebral arteries may prevent vasospasm. Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected patients to occlude the artery supplying the aneurysm with a balloon, coils, or other techniques to occlude the aneurysm itself. As more studies on these techniques are completed, their use will increase. Nimodipine, a vasodilator, is used to block calcium channels within cerebral blood vessels. By preventing the movement of calcium, vessels remain in a relaxed state of vasodilation for longer periods of time. This is thought to be effective in reversing the negative effects of the vasospasm (Book, 2010; Lord, Fernandez, Schmidt, et al., 2012; Bautista, 2012). Although current literature supports the underpinnings of Triple-H therapy, debate still ensues over the use of hypertonic versus isotonic solutions for fluid resuscitation. Similarly there is ongoing research surrounding the use of colloid versus crystalloid preparations as volume expanders (Gupta, Pandia, & Dash, 2013).

Increased Intracranial Pressure An increase in ICP can occur after either an ischemic or a hemorrhagic stroke but almost always follows a subarachnoid hemorrhage, usually because of disturbed circulation of CSF caused by blood in the basal cisterns. Neurologic assessments are performed frequently, and if there is evidence of deterioration from increased ICP (due to cerebral edema, herniation, hydrocephalus, or vasospasm), CSF drainage may be instituted by ventricular catheter drainage. Mannitol may be administered to reduce ICP. When mannitol is used as a long-term measure to control ICP, dehydration and disturbances in electrolyte balance (hyponatremia or hypernatremia; hypokalemia or hyperkalemia) may occur. Mannitol pulls water out of the brain tissue by osmosis and reduces total-body water through diuresis. The patient is monitored for signs of dehydration and for rebound elevation of ICP. Hypertonic saline infusions significantly decrease water content in cerebral tissue by inducing a hypernatremic state. However, a recent study demonstrates that there is a rebound hypernatremic effect seen following the use of hyperosmolar therapies. This study reflects the importance of continued blood analysis of sodium levels throughout the hypertonic saline infusion (Ryu, Walcott, Kahle, et al., 2013).

Hypertension Hypertension is the most common cause of intracerebral hemorrhage, and its treatment is critical. Specific goals for blood pressure management, which are individualized for each patient, remain controversial. New guidelines from the Canadian Hypertension Education Program (CHEP) (2014) recommend maintaining blood pressure at or below at 130/80 mm Hg. Elevated blood pressure during the initial phase of an acute intracerebral hemorrhage has a poorer health outcome for the stroke survivor (Rodriguez-Luna, Piñeiro, Rubiera, et al., 2013; Bautista, 2012).

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Systolic blood pressure may be lowered to prevent hematoma enlargement. If blood pressure is elevated, antihypertensive therapy (labetalol [Trandate], nicardipine [Cardene], nitroprusside [Nitropress], hydralazine [Apresoline]) may be prescribed. During the administration of antihypertensives, arterial hemodynamic monitoring is important to detect and avoid a precipitous drop in blood pressure, which can produce brain ischemia. Stool softeners are used to prevent straining, which can elevate the blood pressure.

Medical Management The goals of medical treatment for hemorrhagic stroke are to allow the brain to recover from the initial insult (bleeding), to prevent or minimize the risk of rebleeding, and to prevent or treat complications. Management may consist of bed rest with sedation to prevent agitation and stress, management of vasospasm, and surgical or medical treatment to prevent rebleeding. If the bleeding is caused by anticoagulation with warfarin (Coumadin), the INR may be corrected with fresh-frozen plasma and vitamin K. Because seizures can occur after intracerebral hemorrhage, antiseizure agents are often administered prophylactically for a brief period of time. Analgesic agents may be prescribed for head and neck pain. The patient is fitted with sequential compression devices or anti embolism stockings to prevent deep vein thrombosis (DVT). Fever should be treated. Hyperglycemia in the initial phase of a stroke is seen in nearly 48% of stroke patients. The concern associated with hyperglycemia during this phase is the inducement of a physiological stress or inflammatory response. A study investigating the health outcomes of post stroke survivors who developed hyperglycemia in the early stages of their stroke revealed that non diabetic persons experienced more negative health outcomes than their diabetic counterparts. This study concludes that efforts should be made to include hyperglycemia monitoring in the stroke protocol guidelines (Mitchell, Coates, Ryan, et al., 2012; Bautista, 2012). After discharge most patients will require antihypertensive medications to decrease their risk of another intracerebral hemorrhage.

Surgical Management Surgical options for a ruptured aneurysm include surgical clipping or coil embolization (coiling). In a recent study of 2,143 patients with a definitive subarachnoid hemorrhage, half of the patients underwent coiling while the remaining half had the surgical clipping procedure done. Better success rates were evidenced in the clinical group who underwent the coiling procedure; however this group also exhibited increased rates of post procedure rebleeding within the first year. This study highlights the existing controversy and the need for further research and randomized studies (Shivashankar, Miller, Jindal, et al., 2013; Bautista, 2012). Surgical evacuation is most frequently accomplished via a craniotomy (see Chapter 62). The patient with an intracranial aneurysm is prepared for surgical intervention as soon as his or her condition is considered stable. Surgical treatment of the patient with

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an unruptured aneurysm is an option. The goal of surgery is to prevent bleeding in an unruptured aneurysm or further bleeding in an already ruptured aneurysm. This objective is accomplished by isolating the aneurysm from its circulation or by strengthening the arterial wall. An aneurysm may be excluded from the cerebral circulation by means of a ligature or a clip across its neck. If this is not anatomically possible, the aneurysm can be reinforced by wrapping it with some substance to provide support and induce scarring. Less invasive endovascular treatments are now being used for aneurysms. These procedures are performed by neurosurgeons in neurointerventional radiology facilities. Two procedures include endovascular treatment (occlusion of the parent artery) and aneurysm coiling (obstruction of the aneurysm site with a coil). Although these techniques are associated with lower risks than intracranial surgery in general, secondary stroke and rupture of the aneurysm are still potential complications. Postoperative complications include psychological symptoms (disorientation, amnesia, Korsakoff’s syndrome, personality changes), intraoperative embolization, postoperative internal artery occlusion, fluid and electrolyte disturbances (from dysfunction of the neurohypophyseal system), and gastrointestinal bleeding.

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm • Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions) • Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions)

Collaborative Problems/ Potential Complications Based on the assessment data, potential complications that may develop include the following: • • • • •

Vasospasm Seizures Hydrocephalus Rebleeding Hyponatremia

Planning and Goals !!"##

Nursing Process

The Patient With a Hemorrhagic Stroke Assessment A complete neurologic assessment is performed initially and includes evaluation for the following: • • • •

Altered level of consciousness Sluggish pupillary reaction Motor and sensory dysfunction Cranial nerve deficits (extraocular eye movements, facial droop, presence of ptosis) • Speech difficulties and visual disturbance • Headache and nuchal rigidity or other neurologic deficits All patients should be monitored in the intensive care unit after an intracerebral or subarachnoid hemorrhage. Neurologic assessment findings are documented and reported as indicated. The frequency of these assessments varies depending on the patient’s condition. Any changes in the patient’s condition require reassessment and thorough documentation; changes should be reported immediately. Alteration in level of consciousness often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Because nurses have the most frequent contact with patients, they are in the best position to detect subtle changes. Mild drowsiness and slight slurring of speech may be early signs that the level of consciousness is deteriorating.

The goals for the patient may include improved cerebral tissue perfusion, relief of sensory and perceptual deprivation, relief of anxiety, and the absence of complications.

Nursing Interventions Optimizing Cerebral Tissue Perfusion The patient is closely monitored for neurologic deterioration resulting from recurrent bleeding, increasing ICP, or vasospasm. A neurologic flow record is maintained. The blood pressure, pulse, level of consciousness (an indicator of cerebral perfusion), pupillary responses, and motor function are checked hourly. Respiratory status is monitored, because a reduction in oxygen in areas of the brain with impaired autoregulation increases the chances of a cerebral infarction. Any changes are reported immediately. IMPLEMENTING ANEURYSM PRECAUTIONS.

Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate the blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remain flat to increase cerebral perfusion. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva manoeuvre, straining, forceful sneezing, pushing oneself up in bed, acute flexion or

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rotation of the head and neck (which compromises the jugular veins), and cigarette smoking. Any activity requiring exertion is contraindicated. The patient is instructed to exhale through the mouth during voiding or defecation to decrease strain. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas. Dim lighting is helpful, because photophobia (visual intolerance of light) is common. Coffee and tea, unless decaffeinated, are usually eliminated. Anti embolism stockings or sequential compression devices may be prescribed to decrease the incidence of DVT resulting from immobility. The legs are observed for signs and symptoms of DVT (tenderness, redness, swelling, warmth, and edema), and abnormal findings are reported. The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might increase the blood pressure. External stimuli are kept to a minimum, including no television, no radio, and no reading. Visitors are restricted in an effort to keep the patient as quiet as possible. This precaution must be individualized based on the patient’s condition and response to visitors. A sign indicating this restriction is placed on the door of the room, and the restrictions should be discussed with both patient and family. The purpose of aneurysm precautions are thoroughly explained to both the patient (if possible) and family.

Relieving Sensory Deprivation and Anxiety Sensory stimulation is kept to a minimum for patients on aneurysm precautions. For patients who are awake, alert, and oriented, an explanation of the restrictions helps reduce the patient’s sense of isolation. Reality orientation is provided to help maintain orientation. Keeping the patient well informed of the plan of care provides reassurance and helps minimize anxiety. Appropriate reassurance also helps relieve the patient’s fears and anxiety. The family also requires information and support.

Monitoring and Managing Potential Complications VASOSPASM. The patient is assessed for signs of possible vasospasm: intensified headaches, a decrease in level of responsiveness (confusion, disorientation, lethargy), or evidence of aphasia or partial paralysis. These signs may develop several days after surgery or on the initiation of treatment and must be reported immediately. If vasospasm is diagnosed, calcium channel blockers or fluid volume expanders may be prescribed. SEIZURES. Seizure precautions are maintained for every patient who may be at risk for seizure activity. Should a seizure occur, maintaining the airway and preventing injury are the primary goals. Medication therapy is initiated at this time, if not already prescribed. The medication of choice for many years has been phenytoin (Dilantin). Recent studies demonstrate that phenytoin is perhaps not the best choice for seizure prophylaxis in patients with subarachnoid

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hemorrhage (intracerebral hemorrhage). Fever and diminishing scores on the NIHSS at 2 weeks poststroke is commonly seen in patients who are on phenytoin. Newer antiepileptic agents such as levetiracetam and lacosamide demonstrate reduced adverse effects and better health outcomes. More study is indicated in the area of seizure management (Rowe, Goodwin, Brophy, et al., 2013; Bautista, 2012). HYDROCEPHALUS. Blood in the subarachnoid space or ventricles impedes the circulation of CSF, resulting in hydrocephalus. A CT scan that indicates dilated ventricles confirms the diagnosis. Hydrocephalus can occur within the first 24 hours (acute) after subarachnoid hemorrhage or several days (subacute) to several weeks (delayed) later. Symptoms vary according to the time of onset and may be nonspecific. Acute hydrocephalus is characterized by sudden onset of stupor or coma and is managed with a ventriculostomy drain to decrease ICP. Symptoms of subacute and delayed hydrocephalus include gradual onset of drowsiness, behavioural changes, and ataxic gait. A ventriculoperitoneal shunt is surgically placed to treat chronic hydrocephalus. Changes in patient responsiveness are reported immediately. REBLEEDING. The rate of recurrent hemorrhage is approximately 2% after a primary intracerebral hemorrhage. Hypertension is the most serious risk factor, suggesting the importance of appropriate antihypertensive treatment. Aneurysm rebleeding occurs most frequently during the first 2 weeks after the initial hemorrhage and is considered a major complication. Symptoms of rebleeding include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neurologic deficit. Rebleeding is confirmed by CT scan. Blood pressure is carefully maintained with medications. The most effective preventive treatment is to secure the aneurysm if the patient is a candidate for surgery or endovascular treatment. HYPONATREMIA. The most common electrolyte imbalance in patients with subarachnoid hemorrhage is hyponatremia (Bautista, 2012). Hyponatremia occurs in upwards of 50% of patients having suffered an aneurysmal subarachnoid hemorrhage (Bautista, 2012). Laboratory data must be checked frequently, and hyponatremia (defined as a serum sodium concentration of less than 135 mmol/L) must be identified as early as possible. The patient’s primary health care professional needs to be notified of a low serum sodium level that has persisted for 24 hours or longer. The patient is then evaluated for syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome (CSW). (SIADH is described in Chapter 15.) CSW occurs when the kidneys are unable to conserve sodium and volume depletion results. The treatment most often is the use of hypertonic 3% saline.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke

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and to prepare them to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. In addition, the patient and family are informed about the medical treatments that are implemented, including surgical intervention if warranted, and the importance of interventions taken to prevent and detect complications (i.e., aneurysm precautions, close monitoring of the patient). Depending on the presence and severity of neurologic impairment and other complications resulting from the stroke, the patient may be transferred to a rehabilitation unit or centre for additional patient and family teaching about strategies to regain self-care ability. Teaching addresses the use of assistive devices or modification of the home environment to help the patient live with the disability. Modifications of the home may be required to provide a safe environment. CONTINUING CARE. The acute and rehabilitation phase of care focuses on obvious needs, issues, and deficits for the patient with a hemorrhagic stroke. The patient and family are reminded of the importance of following recommendations to prevent further hemorrhagic stroke and keeping follow-up appointments with health care providers for monitoring of risk factors. Referral for home care may be warranted to assess the home environment and the ability of the patient and to ensure that the patient and family are able to manage at home. Home visits provide opportunities to monitor the physical and psychological status of the patient and the ability of the family to cope with any alterations in the patient’s status. In addition, the home care nurse reminds the patient and family of the importance of continuing health promotion and

screening practices. Chart 63-7 lists teaching points for the patient recovering from a stroke.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Demonstrates intact neurologic status and appropriate vital signs and respiratory patterns a. Is alert and oriented to time, place, and person b. Demonstrates usual speech patterns and intact cognitive processes c. Demonstrates equal strength, movement, and sensation of all four extremities d. Exhibits expected deep tendon reflexes and pupillary responses 2. Demonstrates appropriate sensory perceptions a. States rationale for aneurysm precautions b. Exhibits clear thought processes 3. Exhibits reduced anxiety level a. Is less restless b. Exhibits absence of physiologic indicators of anxiety (e.g., has appropriate vital signs including respiratory rate; absence of excessive, fast speech) 4. Is free of complications a. Exhibits absence of vasospasm b. Exhibits expected vital signs and neuromuscular activity without seizures c. Verbalizes understanding of seizure precautions d. Exhibits appropriate mental status and expected motor and sensory status e. Reports no visual changes

CHART 63-7

HOME CARE CHECKLIST •

The Patient Recovering From a Stroke Patient

Caregiver

• Discuss measures to prevent subsequent strokes.

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• Identify signs and symptoms of specific complications.

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• Identify potential complications and discuss measures to prevent them (blood clots, aspiration,

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• Identify psychosocial consequences of stroke and appropriate interventions.

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• Identify safety measures to prevent falls.

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• State names, doses, indications, and side effects of medications.

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• Demonstrate adaptive techniques for accomplishing ADLs.

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• Demonstrate swallowing techniques (for patients with dysphagia).

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• Demonstrate care of enteric feeding tube, if applicable.

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• Demonstrate home exercises, use of splints or orthotics, proper positioning, and frequent repo-

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• Describe procedures for maintaining skin integrity.

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• Demonstrate indwelling catheter care, if applicable. Describe a bowel and bladder elimination

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• Identify appropriate recreational or diversional activities, support groups, and community resources.

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At the completion of the home care instruction, the patient or caregiver will be able to:

pneumonia, urinary tract infection, fecal impaction, skin breakdown, contracture).

sitioning.

program as appropriate.

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Critical Thinking Exercises 1 A patient had symptoms of an ischemic stroke approximately 1 hour ago and is undergoing a CT scan. What are the time frames, criteria, and dosage for t-PA administration? What nursing assessments and actions would you take? What is your rationale for these assessments and actions? 2 A 58-year-old man was admitted with an ischemic stroke and has left-sided hemiplegia. Before discharge he is concerned about how to resume sexual relations with his wife and the possibility of not being able to resume sexual intimacy. Identify possible causes of sexual dysfunction after a stroke. What interventions can the nurse implement to address his concerns? 3 A 50-year-old patient with a history of hypertension is expected to be discharged to home today after a 7-day stay for a stroke. She has residual right-sided weakness and a visual field deficit. What teaching would be indicated to prevent another stroke? What resources may be needed to enable her to go home as scheduled? 4

A patient is admitted to the hospital following a hemorrhagic stroke and is at high risk for vasospasm. What medical and nursing measures should be implemented to prevent vasospasm? Identify the evidence for and the criteria used to evaluate the strength of the evidence for the specific measures identified for prevention of vasospasm.

REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS American Association of Neuroscience Nurses. (2008). Guide to the care of the hospitalized patient with ischemic stroke: AANN reference series for clinical practice. Glenview, IL: Author. Book, D. (2010). Disorders of brain function. In R. Hannon, C. Pooler, & C. M. Porth, (Eds.), Porth Pathophysiology: Concepts of altered health states. (1st Canadian ed., pp. 1246–1280). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Conference Board of Canada. (2010). The Canadian heart health strategy: Risk factors and future cost implications report. Ottawa: Author. Retrieved from http://www.conferenceboard.ca/e-library/abstract. aspx?did=3447 Canadian Hypertension Education Program. (2014). The 2014 Canadian Hypertension Education Program Recommendations. Markham, ON: Author. Retrieved from https://www.hypertension.ca/images/ CHEP_2014/2014_CHEPRecsFullVersion_EN_HCP1000.pdf Hickey, J. V. (2013). The clinical practice of neurological & neurosurgical nursing (7th ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS Adams, H. P., Zoppo, G., Alberts, M. J., et al. (2007). Guidelines for the early management of patients with ischemic stroke. A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke, 38(5), 1655–1711. Almekhlafi, M., Menon, B., Freiheit, E., et al. (2013). A meta-analysis of observational intra-arterial stroke therapy studies using the Merci

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Device, Penumbra System, and Retrievable Stents. American Journal of Neuroradiology, 34, 140–145. Appel, L. (2014). Reducing sodium intake to prevent stroke. Stroke, 45, 909–911. Aronow, W. (2013). Hypertension-related stroke prevention in the elderly. Current Hypertension Reports, 15, 582–589. Bautista, C. (2012). Unresolved issues in the management of aneurysmal subarachnoid hemorrhage. AACN Advanced Critical Care, 23(2), 175–185. Bugincourt, J., Hamy, O., Canaple, S., et al. (2014). Impaired sexual activity in young ischaemic stroke patients: An observational study. European Journal of Neurology, 21, 140–146. Burr, J., Shephard, R., & Zehr, E. (2012). Physical activity after stroke and spinal cord injury. Canadian Family Physician, 58, 1236–1239. *Campbell, G. B., & Matthews, J. T. (2010). An integrative review of factors associated with falls during post-stroke rehabilitation. Journal of Nursing Scholarship, 42(4), 395–404. Casaubon, L. K., Suddes, M. (2013). Hyperacute Stroke Care. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care. Ottawa: Canadian Stroke Network and Heart and Stroke Foundation of Canada. Retrieved from http:// www.strokebestpractices.ca/wp-content/uploads/2010/10/Ch3_SBP2013_ Hyper-Acute-_23MAY13_EN_-FINAL5.pdf Catangui, E. (2013). Knowledge and understanding of CT imaging in stroke: A case study approach. British Journal of Neuroscience Nursing, 9(5), 240–246. Cecil, R., Parahoo, K., Thompson, K., et al. (2010). ‘The hard work starts now’: A glimpse into the lives of carers of community-dwelling stroke survivors. Journal of Clinical Nursing, 20, 1723–1730. Clemens, A., Ryn, J., Sennewald, R., et al. (2012). Switching from enoxaparin to dabigatran etexilte: Pharmacokinetics, pharmacodynamics, and safety profile. European Journal of Clinical Pharmacology, 68, 607–616. Conference Board of Canada. (2014). Health, health care and wellness. Retrieved from http://www.conferenceboard.ca/topics/health/default.aspx Coutts, S. & Kelloway, L. (2013). Stroke prevention. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care. Ottawa: Canadian Stroke Network and Heart and Stroke Foundation of Canada. Retrieved from http://www.strokebestpractices.ca/wp-content/uploads/2013/10/ Ch2_SBP2013_Prevention-of-Stroke_Sept2012_FINAL_EN.pdf Czernuszenko, A., & Czlonkowska, A. (2009). Risk factors for falls in stroke patients during inpatient rehabilitation. Clinical Rehabilitation, 23, 176–188. Dawes, M. (2013). Why is controlling blood pressure after stroke so difficult? Canadian Medical Association Journal, 185(1), 11–12. Demchuk, A., & Bal, S. (2012). Thrombolytic therapy for acute ischaemic stroke: What can we do to improve outcomes? Current Opinion in Neurology, 72(14), 1833–1845. Denno, M., Gillard, P., Graham, G., et al. (2013). Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity. Archives of Physical Medicine and Rehabilitation, 94, 1731–1736. Eissa, A., Krass, I., & Bajorek, B. (2012). Barriers to the utilization of thrombolysis for acute ischemic stroke. Clinical Pharmacology and Therapeutics, 37, 399–409. El-Kafy, E., Elshemy, S., & Alghamdi, M. (2014). Effect of constraintinduced therapy on upper limb functions: A randomized control trial. Scandinavian Journal of Occupational Therapy, 21, 11–23. García-Rodríguez, L., Gaist, D., Morton, J., et al. (2013). Antithrombotic drugs and risk of hemorrhagic stroke in the general population. American Academy of Neurology, 81, 566–574. Gensicke, H., Zumbrunn, T., Jongen, L., et al. (2013). Characteristics of ischemic brain lesions after stenting or endarterectomy for symptomatic carotid artery stenosis: Results from the international carotid stenting study-magnetic resonance imaging substudy. Stroke, 44, 80–86. Gilad, R. (2012). Management of seizures following a stroke: What are the options? Drugs and Aging, 29(7), 533–538. Grant, C., Goldsmith, C., & Anton, H. (2014). Inpatient stroke rehabilitation lengths of stay in Canada derived from the national rehabilitation reporting system, 2008 and 2009. Archives of Physical Medicine and Rehabilitation, 95, 74–78. Gupta, N., Pandia, M., & Dash, H. (2013). Research studies that have influenced practice of neuroanesthesiology in recent years: A literature review. Indian Journal of Anaesthesia, 57(2), 117–126. Hann, S., Chalouhi, N., Starke, R., et al. (2013). Comparison of neurologic and radiographic outcomes for Solitaire versus Merci/Penumbra systems for acute stroke intervention. BioMed Research International, 1–9.

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Heart and Stroke Foundation. (2013). Stroke prevention. Retrieved from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483939/ k.16FB/Stroke__Stroke_prevention_and_risk_factors.htm Heart and Stroke Foundation. (2014). Stroke prevention. Retrieved from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483939/k.16FB/ Stroke__Stroke_prevention_and_risk_factors.htm Hussain, S., Zaoidat, O., & Fitzsimmons, B. (2012). The Penumbra System for mechanical thrombectomy in endovascular acute ischemic stroke therapy. American Academy of Neurology, 79(Supp 1), 135–140. Keating, G. (2013). Apixaban: A review of its use for reducing the risk of stroke and system embolism in patients with nonvalvular atrial fibrillation. Drugs: 73, 825–843. Kokubo, Y. (2012). Traditional risk factor management for stroke: A never-ending challenge for health behaviors of diet and physical activity. Current Opinion in Neurology, 25(1), 11–17. Kouwenhoven, S., Kirkevold, M., Engedal, K., et al. (2011). ‘Living a life in shades of grey’: Experiencing depressive symptoms in the acute phase after stroke. Journal of Advanced Nursing, 68(8), 1726–1737. Lackland, D. (2013). Hypertension: Joint national committee on detection, evaluation, and treatment of high blood pressure guidelines. Current Opinion in Neurology, 26(1), 8–12. Lahr, M., van der Zee, D., Luijckx, G., et al. (2013). A simulation-based approach for improving utilization of thrombolysis in acute brain infarction. Medical Care, 51(12), 1101–1105. Lee, J., King, C., Stradling, D., et al. (2014). Influence of hematoma location on acute mortality after intracerebral hemorrhage. Journal of Neuroimaging, 24, 131–136. Lord, A., Fernandez, L., Schmidt, J., et al. (2012). Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. Neurology, 78, 31–37. Malhotra, K., Conners, J., Lee, V. et al. (2014). Relative changes in transcranial Doppler velocities are inferior to absolute thresholds in prediction of symptomatic vasospasm after subarachnoid hemorrhage. Journal of Stroke and Cerebrovascular Diseases, 23(1), 31–36. Mandel, M., Fonoff, E., Bor-Seng-Shu, E., et al. (2012). Neurogenic neuroprotection: Clinical perspectives. Functional Neurology, 27(4), 207–216. Manning, N., Campbell, B., Oxley, T., et al. (2014). Acute ischemic stroke: Time, penumbra, and reperfusion. Stroke, 45, 640–644. Martini, S., Flaherty, M., Brown, W., et al. (2012). Risk factors for intracerebral hemorrhage differ according to hemorrhage location. Neurology, 79, 2275–2282. Mehta, S., Teasell, R., & Foley, N. (2013). Painful hemiplegic Shoulder. In R. Teaselll (Ed.) Evidence Based Review of Stroke Rehabilitation. http://www.ebrsr.com/sites/default/files/Chapter11_HemiplegicShoulder_FINAL__16ed.pdf Mitchell, E., Coates, V., Ryan, A., et al. (2012). Hyperglycaemia monitoring and management in stroke care: Policy versus practice. Diabetic Medicine, 29, 1108–1114. National Institute of Neurologic Disorders and Strokes (NINDS). (1995). Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 333(24), 1581–1587. Poisson, S. & Johnston, S. C. (2011). Prevention of stroke following transient ischemic attack. Current Atherosclerosis Reports, 13(4), 330–337 Qian, F., Fonarow, G., Smith, E., et al. (2013). Racial and ethnic differences in outcomes in older patients with acute ischemic stroke. Circulation: Cardiovascular Quality and Outcomes, 6, 284–292. Registered Nurses Association of Ontario [RNAO], (2005). Stroke Assessment Across the Continuum of Care. Retrieved from http://rnao.ca/bpg/ guidelines/stroke-assessment-across-continuum-care. Rist, P., Buring, J., Kase, C., et al. (2013). Effect of low-dose aspirin on functional outcome from cerebral vascular events in women. Stroke, 44, 432–436. Rodriguez-Luna, D., Pineiro, S., Rubiera, M., et al. (2013). Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage. European Journal of Neurology, 20, 1277–1283. Roh, J., Rymer, W., Perreault, E., et al. (2012). Alterations in upper limb muscle synergy structure in chronic stroke survivors. Journal of Neurophysiology, 109, 768–781. Rosenbaum, T., Vadas, D., & Kalichman, L. (2014). Sexual function in post-stroke patients: Considerations for rehabilitation. The Journal of Sexual Medicine, 11, 15–21. Rosso, C., & Samson, Y. (2014). The ischemic penumbra: The location rather than the volume of recovery determines outcome. Current Opinion in Neurology, 27(1), 35–41. Rowe, A., Goodwin, H., Brophy, G., et al. (2013). Seizure prophylaxis in neurocritical care: A review of evidence-based support. Pharmacotherapy, 1–13.

Ryu, J., Walcott, B., Kahle, K., et al. (2013). Induced and sustained hypernatremia for the prevention and treatment of cerebral edema following brain injury. Neurocritical Care Journal, 19, 222–231. Sander, R. (2013). Prevention and treatment of acute ischemic stroke. Nursing Older People, 25(8), 34–38. Saposnik, G., Guzik, A., Reeves, M., et al. (2012). Stroke prognostication using age and NIH stroke scale. Americal Academy of Neurology, 80, 21–28. Saver, J. L. (2006). Time is brain quantified. Stroke, 37(1), 263–266. Scheitz, J., Seiffge, D., Tütüncü, S., et al. (2014). Dose-related effects of statins on symptomatic intracerebral hemorrhage and outcome after thrombolysis for ischemic stroke. Stroke, 45, 509–514. Shackley, P., Shaw, L., Price, C., et al. (2012). Cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A: Results from the botulinum toxin for the upper limb after stroke (BoTULS) trial. Toxins, 4, 1415–1426. Shah, S., Tartaro, C., Chew, F., et al. (2013). Skilled nursing facility functional rehabilitation outcome: Analyses of stroke admissions. International Journal of Therapy and Rehabilitation, 20(7), 352–360. Shivashankar, R., Miller, R., Jindal, G., et al. (2013). Treatment of cerebral aneurysms—surgical clipping or endovascular coiling: The guiding principles. Seminars in Neurology, 33(05), 476–487. Siegler, J., Boehme, A., Kumar, A., et al. (2013). What change in the National Institute of Health Stroke Scale should define neurologic deterioration in acute ischemic stroke? Journal of Stroke and Cerebravascular Diseases, 22(5), 675–682. Smith, M. (2012). Management of hemiplegic shoulder pain following stroke. Nursing Standard, 26(44), 35–44. Specogna, A., Patten, S., Turin, T., et al. (2013). The reliability and sensitivity of the National Institute of Health Stroke Scale for spontaneous intracerebral hemorrhage in an uncontrolled setting. PLOS ONE, 8(12), 1–4. Statistics Canada. (2011). Life expectancy and death. Retrieved from http://www5.statcan.gc.ca/subject-sujet/result-resultat.action?pid=29 66&id=2979&lang=eng&type=DAILYART&pageNum=1&more=0 Statistics Canada. (2013). Leading causes of death in Canada. Retrieved from http://www.statcan.gc.ca/pub/84-215-x/2012001/hl-fs-eng.htm Switzer, J., Demaerschalk, B., Xie, J., et al. (2012). Cost-effectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke from the hospitals’ perspectives. Circulation: Cardiovascular Quality and Outcome, 6, 18–26. Turner, J. (2012). Environmental factors of hospitalisation which contribute to post-stroke depression during rehabilitation for over 65 year olds. Journal of the Australasian Rehabilitation Nurses Association, 15 (1), 11–15. Ward, I., Pivko, S., Brooks, G. et al. (2011). Validity of the stroke rehabilitation assessment of movement scale in acute rehabilitation: A comparison with the Functional Independence Measure and Stroke Impact Scale-16. American Academy of Physical Medicine and Rehabilitation, 3(11), 1013–1021. Webster, F. Saposnik, G., Kapral, M.K., et al. (2011) Organized outpatient care: Stroke prevention clinic referrals are associated with reduced mortality after transient ischemic attack and ischemic stroke. Stroke, 42, 3176–3182. Weiss, A., Beloosesky, Y., Kenett, R. et al. (2013). Systolic blood pressure during acute stroke is associated with functional status and long-term mortality in the elderly. Stroke, 44, 2434–2440. Zada, G., Terterov, S., Russin, J., et al. (2010). Cerebral vasospasm and concurrent left ventricular outflow tract obstruction: Requirement for modification of hyperdynamic therapy regimen. Neurocritical Care Journal, 12, 265–268.

RESOURCES American Association of Neuroscience Nurses, www.aann.org American Stroke Association, a Division of the American Heart Association, www.strokeassociation.org Canadian Association of Neuroscience Nurses, http://www.cann.ca/ Canadian Council of Cardiovascular Nurses, http://www.cccn.ca Canadian Hypertension Education Program (CHEP) Recommendations @www.hypertension.ca Canadian Stroke Network, http://www.Canadian stroke network.ca Heart and Stroke Foundation of Canada, www.heartandstroke.ca National Institute of Neurological Disorders and Stroke, www.ninds.nih. gov National Stroke Association, www.stroke.org

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64 Management of Patients With Neurologic Trauma Adapted by Jim Hunter

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the mechanisms of injury, clinical signs and symptoms, diagnostic testing, and treatment options for patients with traumatic brain and spinal cord injuries. 2. Describe the nursing management of patients with brain injury. 3. Use the nursing process as a framework for care of patients with traumatic brain injury. 4. Identify the population at risk for spinal cord injury. 5. Describe the clinical features and management of the patient with neurogenic shock. 6. Discuss the pathophysiology of autonomic dysreflexia and describe the appropriate nursing interventions. 7. Use the nursing process as a framework for care of patients with spinal cord injury.

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Trauma involving the central nervous system can be lifethreatening. Even if it is not life-threatening, brain and spinal cord injury (SCI) may result in major physical and psychological dysfunction and can alter the patient’s life completely. Neurologic trauma affects the patient, the family, the health care system, and society as a whole because of its major sequelae and the costs of acute, rehabilitation and long-term care of patients with trauma to the brain and spinal cord.

HEAD INJURIES Head injury is a broad classification that includes injury to the scalp, skull, or brain. Catastrophic head injuries account for one half of all trauma deaths and one half of trauma cases resulting in major disability. Head injuries in Canada are a significant portion of the burden of neurological conditions. The annual incidence of head injuries remains problematic (Tator, 2010). A head injury may lead to conditions ranging from scalp lacerations or mild concussion to coma and death; the most serious form is known as a traumatic brain injury (TBI). The most common causes of TBIs for people under 75 years of age are motor vehicle crashes (50%), while violence, sports, and other causes make up the remainder. People at highest risk for TBI are those in the 15- to 19-year age group. Males are twice as likely as females to sustain a TBI. Falls are the leading cause of TBI in adults 75 years of age or older and this age group has the highest TBIrelated hospitalization and death rates (Iavagnilio, 2011). The best approach to head injury is prevention (Chart 64-1).

Pathophysiology Research suggests that not all brain damage occurs at the moment of impact. Damage to the brain from traumatic injury takes two forms: primary injury and secondary injury. Primary injury is the initial damage to the brain that results from the traumatic event. This may include contusions, lacerations, and torn blood vessels due to impact, acceleration/deceleration, or foreign object penetration. Secondary injury evolves over the ensuing hours and days after the initial injury and results from inadequate delivery of nutrients and oxygen to the cells (McNett, Doheny, Sedlak, et al., 2010). The cranial vault contains three main components: brain, blood, and cerebrospinal fluid (CSF). According to the Monro-Kellie doctrine, the cranial vault is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume, or the intracranial pressure (ICP) increases. Any bleeding or swelling within the skull increases the volume of contents within the skull and therefore causes increased ICP (see Chapter 62). If the pressure increases enough, it can cause displacement of the brain through or against the rigid structures of the skull. This causes restriction of blood flow to the brain, decreasing oxygen delivery and waste removal. Cells within the brain become anoxic and cannot metabolize properly, producing ischemia, infarction, irreversible brain damage, and, eventually, brain death (Fig. 64-1).

SCALP INJURY Isolated scalp trauma is generally classified as a minor injury. Because its many blood vessels constrict poorly,

Glossary autonomic dysreflexia: a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency; also called autonomic hyperreflexia brain injury: an injury to the skull or brain that is severe enough to interfere with normal functioning brain injury, closed (blunt): occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura brain injury, open: occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain complete spinal cord lesion: a condition that involves total loss of sensation and voluntary muscle control below the lesion concussion: a temporary loss of neurologic function with no apparent structural damage to the brain contusion: bruising of the brain surface halo vest: a lightweight vest with an attached halo that stabilizes the cervical spine head injury: an injury to the scalp, skull, and/or brain

incomplete spinal cord lesion: a condition in which there is preservation of the sensory or motor fibres, or both, below the lesion neurogenic bladder: bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity paraplegia: paralysis of the lower extremities with dysfunction of the bowel and bladder from a lesion in the thoracic, lumbar, or sacral region of the spinal cord primary injury: initial damage to the brain that results from the traumatic event secondary injury: an insult to the brain subsequent to the original traumatic event spinal cord injury: an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma tetraplegia (quadriplegia): paralysis of both arms and legs, with dysfunction of bowel and bladder from a lesion of the cervical segments of the spinal cord transection: severing of the spinal cord itself; transection can be complete (all the way through the cord) or incomplete (partially through)

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CHART 64-1

Health Promotion: Preventing Head and Spinal Cord Injuries • Advise drivers to obey traffic laws, and to avoid speeding or driving when under the influence of drugs or alcohol. • Advise all drivers and passengers to wear seat belts and shoulder harnesses. Children younger than 12 years of age should be restrained in an age/size-appropriate system in the back seat. • Caution passengers against riding in the back of pickup trucks. • Advise motorcyclists, scooter riders, bicyclists, skateboarders, and roller skaters to wear helmets.

the scalp bleeds profusely when injured. Trauma may result in an abrasion (brush wound), contusion, laceration, or hematoma beneath the layers of tissue of the scalp (subgaleal hematoma). A large avulsion (tearing away) of the scalp may be potentially life-threatening and is a true emergency. Diagnosis of a scalp injury is based on physical examination, inspection, and palpation. Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured, to remove foreign material and to reduce the risk for infection. Subgaleal hematomas (hematomas below the outer covering of the skull) usually reabsorb and do not require any specific treatment.

Physiology/Pathophysiology

• Promote educational programs that are directed toward violence and suicide prevention in the community.

• Provide water safety instruction. • Teach patients steps that can be taken to prevent falls, particularly in older adults.

• Advise athletes to use protective devices. Recommend that coaches be educated in proper coaching techniques.

• Advise owners of firearms to keep them locked in a secure area where children cannot access them.

SKULL FRACTURES A skull fracture is a break in the continuity of the skull caused by forceful trauma. It may occur with or without damage to the brain. Skull fractures can be classified as simple, comminuted, depressed, or basilar. A simple (linear) fracture is a break in the continuity of the bone. A comminuted skull fracture refers to a splintered or multiple fracture line. Depressed skull fractures occur when the bones of the skull are forcefully displaced downward and can vary from a slight depression to bones of the skull being splintered and embedded within brain tissue. A fracture of the base of the skull is called a basilar skull fracture (Fig. 64-2) (Hannon, Pooler, & Porth, 2010). A fracture may be open, indicating a scalp laceration or tear in the dura (e.g., from a bullet or an ice pick), or closed, in which case the dura is intact.

Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for expansion of contents so intracranial pressure increases

Basilar skull fracture

Pressure on blood vessels within the brain causes blood flow to the brain to slow

Cerebral hypoxia and ischemia occur

Intracranial pressure continues to rise. Brain may herniate

Cerebral blood flow ceases FIGURE 64-1. Pathophysiology of traumatic brain injury.

FIGURE 64-2. Basilar fractures allow cerebrospinal fluid to leak from

the nose and ears. (Adapted from Hickey, J. V. (2013). The clinical practice of neurological and neurosurgical nursing (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.)

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Clinical Manifestations

Medical Management

Symptoms, apart from those of the local injury, depend on the severity and the anatomic location of the underlying brain injury. Persistent, localized pain usually suggests that a fracture is present. Fractures of the cranial vault may or may not produce swelling in the region of the fracture; therefore, an x-ray is needed for diagnosis. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone (see Fig. 64-2). Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura.

Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. Nursing personnel may observe the patient in the hospital, but if no underlying brain injury is present, the patient may be allowed to return home. If the patient is discharged home, specific instructions must be given to the family (see later discussion of concussion). Depressed skull fractures usually require surgery with elevation of the skull and debridement, usually within 24 hours of injury. Skull fractures can be a combination of open, compound, closed, or simple. Associated injuries include concurrent scalp laceration, dural tears, and brain injury directly below the fracture from compression of the tissue below the bony injury and from lacerations produced by the bony fragments (Hickey, 2013).

Assessment and Diagnostic Findings X-rays confirm the presence and extent of a skull fracture (Hannon et al., 2010). A rapid physical examination and evaluation of neurologic status detects obvious brain injuries, and a computed tomography (CT) scan uses highspeed x-ray scanning to detect less apparent abnormalities. It is a fast, accurate, and safe diagnostic procedure that shows the presence, nature, location, and extent of acute lesions. It is also helpful in the ongoing management of head injury, because it can disclose cerebral edema, contusion, intracerebral or extracerebral hematoma, subarachnoid and intraventricular hemorrhage, and late changes (infarction, hydrocephalus) (Iavagnilio, 2011). Magnetic resonance imaging (MRI) is used to evaluate patients with head injury when a more accurate picture of the anatomic nature of the injury is warranted and when the patient is stable enough to undergo this longer diagnostic procedure (Morton & Fontaine, 2013). Cerebral angiography may also be used to identify supratentorial, extracerebral, and intracerebral hematomas and cerebral contusions. Lateral and anteroposterior views of the skull are obtained.

Gerontologic Considerations Older patients must be assessed carefully. Older patients with head injuries differ from those who are younger in terms of etiology of injury, higher mortality rates, and poorer functional outcomes. The most common causes of injury in older patients are falls and motor vehicle crashes (Iavagnilio, 2011). Physiologic changes related to aging may place the older adult at increased risk for injury, alter the type and severity of injury that occurs, or promote the development of complications. Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions.

BRAIN INJURY The most important consideration in any head injury is whether the brain is injured. Even seemingly minor injury can cause significant brain damage secondary to obstructed blood flow and decreased tissue perfusion. The brain cannot store oxygen or glucose to any significant degree. Because the cerebral cells need an uninterrupted blood supply to obtain these nutrients, irreversible brain damage and cell death occur if the blood supply is interrupted for even a few minutes. Clinical manifestations of brain injury (injury to the brain that is severe enough to interfere with usual functioning) are listed in Chart 64-2. Closed (blunt) brain injury occurs when the head accelerates and then rapidly decelerates or collides with another object (e.g., a wall, the dashboard of a car) and brain tissue is damaged but there is no opening through the skull and dura. Open brain injury occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain.

CHART 64-2

Assessing Traumatic Brain Injury Be alert for the following signs and symptoms: • Altered level of consciousness • Confusion • Pupillary abnormalities (changes in shape, size, and response to light) • Altered or absent gag reflex • Absent corneal reflex • Sudden onset of neurologic deficits • Changes in vital signs (altered respiratory pattern, widened pulse pressure, bradycardia, tachycardia, hypothermia, or hyperthermia) • Vision and hearing impairment • Sensory dysfunction • Headache • Seizures

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TYPES OF BRAIN INJURY Concussion A concussion after head injury is a temporary loss of neurologic function with no apparent structural damage. A concussion (also referred to as a mild TBI) may or may not produce a brief loss of consciousness. The mechanism of injury is usually blunt trauma from an acceleration– deceleration force, a direct blow, or a blast injury (Morton & Fontaine, 2013). If brain tissue in the frontal lobe is affected, the patient may exhibit bizarre or irrational behaviour, whereas involvement of the temporal lobe can produce temporary amnesia or disorientation. There are two types of concussion: mild and classic. A mild concussion may lead to a period of observed or selfreported transient confusion, disorientation, or impaired consciousness. Commonly, there is a memory lapse at the time of injury and a loss of consciousness lasting less than 30 minutes. Other signs and symptoms of neurologic or neuropsychological dysfunction may include seizures, headache, dizziness, irritability, fatigue, or poor concentration (Hickey, 2013). A classic concussion is an injury that results in a loss of consciousness; characteristically, this usually lasts less than 6 hours. This loss of consciousness is always accompanied by some degree of posttraumatic amnesia. Diagnostic studies may show no apparent structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the concussion. The patient may be hospitalized overnight for observation or discharged from the hospital in a relatively short time after a concussion. Monitoring includes observing the patient for headache, dizziness, lethargy, irritability, emotional lability, fatigue, poor concentration, decreased attention span, memory difficulties, and intellectual dysfunction that may occur from 1 week to 1 year after the initial injury (Hickey, 2013). The occurrence of these symptoms after injury is referred to as postconcussion syndrome. Recovery may appear complete, but long-term sequelae are possible. Problems at work and at home can result in interpersonal relationship problems or the loss of employment (Bergman, Fabiano, & Blostein, 2011). The family is instructed to observe for the following signs and symptoms and to notify the physician or clinic (or bring the patient to the emergency department) if they occur: difficulty in awakening or speaking, confusion, severe headache, vomiting, and weakness of one side of the body.

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without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours. Patient outcome depends on the area and severity of the injury. Temporal lobe contusions carry a greater risk of swelling, rapid deterioration, and brain herniation. Deep contusions are more often associated with hemorrhage and destruction of the reticular activating fibres altering arousal (Hickey, 2013).

Diffuse Axonal Injury Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that produce damage throughout the brain to axons in the cerebral hemispheres, corpus callosum, and brain stem. The injured area may be diffuse, with no identifiable focal lesion. DAI is associated with prolonged traumatic coma; it is more serious and is associated with a poorer prognosis than a focal lesion or ischemia (Urden, Stacy, & Lough, 2013). The patient with DAI in severe head trauma experiences immediate coma with no lucid interval, decorticate and decerebrate posturing (see Fig. 62-1 in Chapter 62), and global cerebral edema. Diagnosis is made by clinical signs in conjunction with a CT or MRI scan. Recovery depends on the severity of the axonal injury.

Intracranial Hemorrhage Hematomas are collections of blood in the brain that may be epidural (above the dura), subdural (below the dura), or intracerebral (within the brain) (Fig. 64-3). Major symptoms are frequently delayed until the hematoma is Anterior Subdural hematoma Epidural hematoma

Contusion In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a specific area because of severe acceleration–deceleration force or blunt trauma. The impact of the brain against the skull leads to a contusion. Although a contusion may occur in any area of the brain, most are usually located in the anterior portions of the frontal and temporal lobes, around the sylvian fissure, at the orbital areas, and, less commonly, at the parietal and occipital areas. Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit

Intracerebral hematoma

Posterior

FIGURE 64-3. Location of epidural, subdural, and intracerebral

hematomas.

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large enough to cause distortion of the brain and increased ICP. The signs and symptoms of cerebral ischemia resulting from compression by a hematoma are variable and depend on the speed with which vital areas are affected and the area that is injured (American Association of Neuroscience Nurses [AANN], 2011). In general, a rapidly developing hematoma, even if small, may be fatal, whereas a larger but slowly developing one may allow compensation for increases in ICP.

After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura mater. This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery, the artery that runs between the dura and the skull inferior to a thin portion of temporal bone. Hemorrhage from this artery causes rapid pressure on the brain (Terry & Weaver, 2011). Symptoms are caused by the expanding hematoma. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help maintain a usual ICP. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma. Then, often suddenly, signs of herniation appear (usually deterioration of consciousness and signs of focal neurologic deficits, such as dilation and fixation of a pupil or paralysis of an extremity), and the patient’s condition deteriorates rapidly. The most common type of herniation syndrome associated with an epidural hematoma is uncal herniation (Baird & Bethel, 2011). An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. A drain is usually inserted after creation of burr holes or a craniotomy to prevent reaccumulation of blood.

symptoms with small collections of blood. Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention. Subacute subdural hematomas are the result of less severe contusions and head trauma. Clinical manifestations usually appear between 48 hours and 2 weeks after the injury. Signs and symptoms are similar to those of an acute subdural hematoma (Diepenbrock, 2012). If the patient can be transported rapidly to the hospital, an immediate craniotomy is performed to open the dura, allowing the subdural clot to be evacuated. Successful outcome also depends on the control of ICP and careful monitoring of respiratory function (see the discussion of intracranial surgery in Chapter 62). The mortality rate for patients with acute or subacute subdural hematoma is high because of associated brain damage. CHRONIC SUBDURAL HEMATOMA. Chronic subdural hematomas can develop from seemingly minor head injuries and are seen most frequently in the elderly. Older adults are prone to this type of head injury secondary to cerebral atrophy, which is a frequent consequence of the aging process. Seemingly minor head trauma may produce enough impact to shift the brain contents abnormally. The time between injury and onset of symptoms can be lengthy (e.g., 3 weeks to months), so the actual injury may be forgotten. A chronic subdural hematoma can resemble other conditions; for example, it may be mistaken for a stroke. The bleeding is less profuse, but compression of the intracranial contents still occurs. The blood within the brain changes in character in 2 to 4 days, becoming thicker and darker. In a few weeks, the clot breaks down and has the colour and consistency of motor oil. Eventually, calcification or ossification of the clot takes place. The brain adapts to this foreign body invasion, and the clinical signs and symptoms fluctuate. Symptoms include severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures. The patient may be labelled neurotic or psychotic if the cause is overlooked. The treatment of a chronic subdural hematoma consists of surgical evacuation of the clot. The procedure may be carried out through multiple burr holes, or a craniotomy may be performed for a sizable subdural mass that cannot be suctioned or drained through burr holes.

Subdural Hematoma

Intracerebral Hemorrhage and Hematoma

A subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. The most common cause of subdural hematoma is trauma, but it can also occur as a result of coagulopathies or rupture of an aneurysm. A subdural hemorrhage is more frequently venous in origin and is caused by the rupture of small vessels that bridge the subdural space (Terry & Weaver, 2011). The subdural hematoma that results may be acute, subacute, or chronic, depending on the onset of the symptoms (Diepenbrock, 2012). ACUTE AND SUBACUTE SUBDURAL HEMATOMA. Acute subdural hematomas are associated with major head injury involving contusion or laceration. Clinical symptoms develop over 24 to 48 hours. Signs and symptoms include changes in the level of consciousness (LOC), pupillary signs, and hemiparesis. There may be minor or even no

Intracerebral hemorrhage is bleeding into the substance of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). These hemorrhages within the brain may also result from the following:

Epidural Hematoma

• Systemic hypertension, which causes degeneration and rupture of a vessel • Rupture of a saccular aneurysm • Vascular anomalies • Intracranial tumours • Bleeding disorders such as leukemia, hemophilia, aplastic anemia, and thrombocytopenia • Complications of anticoagulant therapy Nontraumatic causes of intracerebral hemorrhage are discussed in Chapter 63.

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The onset may be insidious, beginning with the development of neurologic deficits followed by headache. Management includes supportive care, control of ICP, and careful administration of fluids, electrolytes, and antihypertensive medications. Surgical intervention by craniotomy or craniectomy permits removal of the blood clot and control of hemorrhage but may not be possible because of the inaccessible location of the bleeding or the lack of a clearly circumscribed area of blood that can be removed.

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2077

Management of Patients With Neurologic Trauma Initial management Severe head injury GCS 8 or less

Emergency diagnosis or therapeutic procedures as indicated

ATLS trauma evaluation

Management of Brain Injuries Assessment and diagnosis of the extent of injury are accomplished by the initial physical and neurologic examinations. CT and MRI scans are the primary neuroimaging diagnostic tools and are useful in evaluating the brain structure. Positron emission tomography (PET) is available in some trauma centres for assessing brain function. A flow chart developed by the Brain Trauma Foundation (2007) for the initial management of brain injury is presented in Figure 64-4. Any patient with a head injury is presumed to have a cervical spine injury until proven otherwise. The patient is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI documented. All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event (McNett et al., 2010). Common causes of secondary injury are cerebral edema, hypotension, and respiratory depression that may lead to hypoxemia and electrolyte imbalance. Treatments to prevent secondary injury include stabilization of cardiovascular and respiratory function to maintain adequate cerebral perfusion, control of hemorrhage and hypovolemia, and maintenance of optimal blood gas values.

Endotracheal intubation Fluid resuscitation Ventilation (PaCO2 35 mm Hg) Oxygenation Sedation ± Pharmacologic paralysis (short acting)

Herniation?* Deterioration?*

Yes

± Hyperventilation* ± Mannitol (1 g/kg)*

Resolution?

CT scan Yes

No Surgicial lesion?

Yes

No Intensive care unit

Operating room

Treatment of Increased Intracranial Pressure As the damaged brain swells with edema or as blood collects within the brain, an increase in ICP occurs; this requires aggressive treatment. See Chapter 62 for a discussion of the relationship of ICP to cerebral perfusion pressure (CPP). If the ICP remains elevated, it can decrease the CPP. Initial management is based on the principle of preventing secondary injury and maintaining adequate cerebral oxygenation (see Fig. 64-4). Surgery is required for evacuation of blood clots, debridement and elevation of depressed fractures of the skull, and suture of severe scalp lacerations. ICP is monitored closely; if increased, it is managed by maintaining adequate oxygenation, elevating the head of the bed, and maintaining normal blood volume. Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside using aseptic technique. The patient is cared for in the intensive care unit, where expert nursing care and medical treatment are readily available (AANN, 2011).

Supportive Measures Treatment also includes ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional

Monitor ICP

Treat intracranial hypertension FIGURE 64-4. Initial management of the patient with traumatic brain

injury (treatment option). (Copyright © 2007 Brain Trauma Foundation.) *Only in the presence of signs of herniation or progressive neurologic deterioration not attributable to extracranial factors. ATLS, Advanced Trauma Life Support; CT, computed tomography; GCS, Glasgow Coma Score; ICP, intracranial pressure.

support, and management of pain and anxiety. Comatose patients are intubated and mechanically ventilated to ensure adequate oxygenation and protect the airway. Because seizures can occur after head injury and can cause secondary brain damage from hypoxia, antiseizure agents may be administered. If the patient is very agitated, benzodiazepines may be prescribed to calm the patient without decreasing LOC. These medications do not affect ICP or CPP, making them good choices for the patient

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Neurologic Function

NURSING RESEARCH PROFILE

Chart 64-3. Effects of Nursing Interventions on Reducing Intracranial Pressure Olson, D., McNett, M., Lewis, S., et al. (2013). Effects of nursing interventions on Intracranial Pressure. American journal of critical care, 22(5), 431–438. Purpose Little data have been documented regarding the immediate effects of nursing interventions on reducing intracranial pressure (ICP). The purpose of this study was to explore the association between a wide variety of nursing interventions and ICP. Design This research is a secondary analysis of an existing set of data originally collected to describe practice variations of ICP reducing interventions performed by nurses at numerous sites. Nursing interventions were observed, and ICP was recorded at one minute and five minutes post intervention. ICP was recorded as lower, higher or equal to baseline. “Significant” change was more than 2 mm HG from baseline. Findings Nursing interventions observed included complex skills such as draining cerebrospinal fluid, administering osmotic diuretics, and adjusting sedation and repositioning endo-

with head injury. A nasogastric tube may be inserted, because reduced gastric motility and reverse peristalsis are associated with head injury, making regurgitation and aspiration common in the first few hours.

Brain Death When a patient has sustained a severe head injury incompatible with life, the physician may conduct a clinical examination to confirm neurologic determination of death (NDD) and assist in the process of organ procurement. In neurologic death, the patient has no neurologic activity on clinical examination; adjunctive tests such as electroencephalography and cerebral blood flow (CBF) studies are often used to confirm NDD (Arbour, 2013). Once NDD has been confirmed, many of these patients are potential organ donors; the nurse may provide information to the family and, in collaboration with the physician and the organ donor coordinator, assist them with the decision-making process about donation. For aspects of neuroscience-related end-of-life care, see Chart 64-3. !!"##

Nursing Process

The Patient With a Traumatic Brain Injury Assessment Depending on the patient’s neurologic status, the nurse may elicit information from the patient, from the family, or from witnesses or emergency rescue

tracheal tubes – and also included less complex skills such as talking to the patient, repositioning the patient, encouraging family communication, and limiting stimulation. Odds ratios were calculated for the top 11 interventions. Findings from the study indicate that nursing activities commonly thought to reduce ICP including CSF drainage, decreasing stimulation, and encouraging family members to speak to the patient does not significantly decrease the ICP at the 1- or 5-minute intervals; however, administration of sedatives and having family in the room speaking to each other was effective in decreasing the ICP at both the 1-minute and 5-minute intervals. Nursing Implications Although nursing interventions can affect ICP, the magnitude and context of this have yet to be defined. Administering sedation has an effect on reducing ICP, so judicious use of these medications is beneficial, provided the patient is not oversedated. Communication also appears to have a positive effect on reducing ICP and the nurse is in the best position to encourage family members in the room to converse with each other, keeping in mind the need to limit the stimulation around the patients.

personnel. Although all usual baseline data may not be collected initially, the immediate health history should include the following questions: • When did the injury occur? • What caused the injury? A high-velocity missile? An object striking the head? A fall? • What was the direction and force of the blow? A history of unconsciousness or amnesia after a head injury indicates a significant degree of brain damage, and changes that occur minutes to hours after the initial injury can reflect recovery or indicate the development of secondary brain damage. The nurse should determine if there was a loss of consciousness, the duration of the unconscious period, and if the patient could be aroused. In addition to asking questions that establish the nature of the injury and the patient’s condition immediately after the injury, the nurse examines the patient thoroughly. This assessment includes determining the patient’s LOC using the Glasgow Coma Scale (GCS) and assessing the patient’s response to tactile stimuli (if unconscious), pupillary response to light, corneal and gag reflexes, and motor function. The GCS (Chart 64-4) is based on the three criteria of eye opening, verbal responses, and motor responses to verbal commands or painful stimuli. It is particularly useful for monitoring changes during the acute phase, the first few days after a head injury. It does not take the place of an in-depth neurologic assessment. Additional detailed assessments are made initially and at frequent intervals throughout the acute phase of care (Hickey, 2013). Baseline and ongoing assessments are critical in

CHAPTER 64

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Management of Patients With Neurologic Trauma

nursing assessment of the patient with brain injury, whose condition can worsen dramatically and irrevocably if subtle signs are overlooked. More information on assessment is provided in the following sections and in Figure 64-5 and Table 64-1.

CHART 64-4

Assessment for Glasgow Coma Scale The Glasgow Coma Scale is a tool for assessing a patient’s response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response

Best verbal response

Best motor response

Total

Spontaneous To voice To pain None Oriented Confused Inappropriate words Incomprehensible sounds None Obeys command Localizes pain Withdraws Flexion Extension None

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Diagnosis Nursing Diagnoses

4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 3 to 15

Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Ineffective airway clearance and impaired gas exchange related to brain injury • Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures • Deficient fluid volume related to decreased LOC and hormonal dysfunction • Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate intake • Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage

A

B

C

D

FIGURE 64-5. Assessment parameters for the patient with a head injury include (A) eye opening and

responsiveness, (B) vital signs, and (C, D) motor response reflected in hand strength or response to painful stimulus. (Photo © B. Proud.)

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TABLE 64-1

UNIT 14

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Neurologic Function

Summary of Multisystem Assessment Measures for the Patient With Traumatic Brain Injury

System-Specific Considerations

Assessment Data

Neurologic System • Severe head injury results in unconsciousness and alters many neurologic functions. • All body functions must be supported. • Increased ICP and herniation syndromes are life-threatening. • Measures are instituted to control elevated ICP.

• • • •

Assessment of neurologic signs Assessment for signs and symptoms of ICP elevation Calculation of cerebral perfusion pressure if ICP monitor is in place Monitoring of antiseizure medication blood levels

Integumentary System (Skin and Mucous Membranes) • Immobility secondary to injury and unconsciousness contributes to the development of pressure areas and skin breakdown. • Intubation causes irritation of the mucous membrane.

• •

Assessment of skin integrity and character of the skin Assessment of oral mucous membrane

•

Assessment of range of motion of joints and development of deformities or spasticity

• •

Assessment of abdomen for bowel sounds and distention Monitoring for decreased hemoglobin

•

Intake and output record

• • • •

Assessment of fluid and electrolyte balance Recording of weight, if possible Hematocrit Electrolyte studies

•

• • • • •

Assessment of respiratory function • Auscultate chest for breath sounds. • Note the respiratory pattern if possible (not possible if a ventilator is being used). • Note the respiratory rate. • Note whether the cough reflex is intact. Arterial blood gas levels Complete blood count Chest x-ray studies Sputum cultures O2 saturation using pulse oximetry

• • • • • • • • • • •

Assessment of vital signs Monitoring for cardiac dysrhythmias Assessment for deep vein thromboses of legs Electrocardiogram Electrolyte studies Blood coagulation studies I125 fibrinogen scan of legs Blood glucose level Blood acetone level Blood osmolality Urine specific gravity

•

Collection of information about the family and the role of the headinjured person within the family Assessment of the family to determine how functional it was before the injury occurred

Musculoskeletal System • Immobility contributes to musculoskeletal changes. • Decerebrate or decorticate posturing makes proper positioning difficult. Gastrointestinal System • Administration of corticosteroids places the patient at high risk for GI hemorrhage. • Injury to the GI tract can result in paralytic ileus. • Constipation can result from bed rest, NPO status, fluid restriction, and opioids given for pain control. • Bowel incontinence is related to the patient’s unconscious state or altered mental state. Genitourinary System • Fluid restriction or use of diuretics can alter the amount of urinary output. • Urinary incontinence is related to the patient’s unconscious state. Metabolic (Nutritional) System • The patient receives all fluids IV for the first few days until the GI tract is functioning. • A nutritional consultation is initiated within the first 24–48 h; parenteral or enteral nutrition may be started. Respiratory System • Complete or partial airway obstruction will compromise the oxygen supply to the brain. • An altered respiratory pattern can result in cerebral hypoxia. • A short period of apnea at the moment of impact can result in spotty atelectasis. • Systemic disturbances from head injury can cause hypoxemia. • Brain injury can alter brain stem respiratory function. • Shunting of blood to the lungs as a result of a sympathetic discharge at the time of injury can cause neurogenic pulmonary edema. Cardiovascular System • The patient may develop cardiac dysrhythmias, tachycardia, or bradycardia. • The patient may develop hypotension or hypertension. • Because of immobility and unconsciousness, the patient is at high risk for deep vein thromboses and pulmonary emboli. • Fluid and electrolyte imbalance can be related to several problems, including alterations in antidiuretic hormone (ADH) secretion, the stress response, or fluid restriction. • Specific conditions may occur: • Diabetes insipidus (DI) • Syndrome of inappropriate secretion of ADH (SIADH) • Electrolyte imbalance • Hyperosmolar nonketotic hyperglycemia Psychological/Emotional Response • The traumatic head-injured patient is unconscious. • The family needs emotional support to deal with the crisis.

•

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• Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain • Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness • Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury • Disturbed sleep pattern related to brain injury and frequent neurologic checks • Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and the patient’s residual physical disability and emotional deficit • Deficient knowledge about brain injury, recovery, and the rehabilitation process The nursing diagnoses for the unconscious patient and the patient with increased ICP also apply (see Chapter 63).

Collaborative Problems/ Potential Complications Based on all the assessment data, the major complications include the following: • • • • •

Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance Risk of posttraumatic seizures

Planning and Goals The goals for the patient may include maintenance of a patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal body temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about the rehabilitation process, and absence of complications.

Nursing Interventions The nursing interventions for the patient with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.

Monitoring Neurologic Function The importance of ongoing assessment and monitoring of the patient with brain injury cannot be overstated. The following parameters are assessed initially and as frequently as the patient’s condition requires. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained. LEVEL OF CONSCIOUSNESS. The GCS is used to assess LOC at regular intervals, because changes in the LOC precede all other changes in vital and neurologic signs. The patient’s best responses to predeter-

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Management of Patients With Neurologic Trauma

2081

mined stimuli are recorded (see Chart 64-4). Each response is scored (the greater the number, the better the functioning), and the sum of these scores gives an indication of the severity of coma and a prediction of possible outcome. The lowest score is 3 (least responsive); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury (Stern, 2011). VITAL SIGNS. Although a change in LOC is the most sensitive neurologic indication of deterioration of the patient’s condition, vital signs also are monitored at frequent intervals to assess the intracranial status. Table 64-1 depicts the general assessment parameters for the patient with a head injury. Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing’s reflex). As brain compression increases, respirations become rapid, the blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs (Hickey, 2013). A rapid increase in body temperature is regarded as unfavourable because hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage, a poor prognostic sign. The temperature is maintained at less than 38°C. Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body. MOTOR FUNCTION. Motor function is assessed frequently by observing spontaneous movements, asking the patient to raise and lower the extremities, and comparing the strength and equality of the upper and lower extremities at periodic intervals. To assess upper extremity strength, the nurse instructs the patient to squeeze the examiner’s fingers tightly. The nurse assesses lower extremity motor strength by placing the hands on the soles of the patient’s feet and asking the patient to push down against the examiner’s hands. Examination of the motor system is discussed in Chapter 61 in more detail. The presence or absence of spontaneous movement of each extremity is also noted, and speech and eye signs are assessed. If the patient does not demonstrate spontaneous movement, responses to painful stimuli are assessed (Hickey, 2013). Motor response to pain is assessed by applying a central stimulus, such as pinching the pectoralis major muscle, to determine the patient’s best response. Peripheral stimulation may provide inaccurate assessment data because it may result in a reflex movement rather than a voluntary motor response. Abnormal responses (lack of motor response; extension responses) are associated with a poorer prognosis. OTHER NEUROLOGIC SIGNS. In addition to the patient’s spontaneous eye opening, evaluated with the GCS, the size and equality of the pupils and their reaction to light are assessed. A unilaterally dilated and poorly responding pupil may indicate a developing hematoma, with subsequent pressure on the third cranial nerve due to shifting of the brain. If both pupils become fixed and dilated, this indicates overwhelming injury and intrinsic damage to the upper brain stem and is a poor prognostic sign (Arbour, 2013).

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Neurologic Function

The patient with a head injury may develop deficits such as anosmia (lack of sense of smell), eye movement abnormalities, aphasia, memory deficits, and posttraumatic seizures or epilepsy. Patients may be left with residual psychological deficits (impulsiveness, emotional lability, or uninhibited, aggressive behaviours) and, as a consequence of the impairment, may lack insight into their emotional responses.

Maintaining the Airway One of the most important nursing goals in the management of head injury is to establish and maintain an adequate airway. The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic. Therapy is directed toward maintaining optimal oxygenation to preserve cerebral function. An obstructed airway causes carbon dioxide retention and hypoventilation, which can produce cerebral vessel dilation and increased ICP. Interventions to ensure an adequate exchange of air are discussed in Chapter 63 and include the following: • Maintaining the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure through promotion of venous outflow (Olson, McNett, Lewis, et al., 2013) • Establishing effective suctioning procedures (pulmonary secretions produce coughing and straining, which increase ICP) • Guarding against aspiration and respiratory insufficiency (Meier, 2013) • Closely monitoring arterial blood gas values to assess the adequacy of ventilation. The goal is to keep blood gas values within the expected range to ensure adequate cerebral blood flow. • Monitoring the patient who is receiving mechanical ventilation for pulmonary complications such as acute respiratory distress syndrome (ARDS) and pneumonia (Hickey, 2013)

Monitoring Fluid and Electrolyte Balance Brain damage can produce metabolic and hormonal dysfunctions. The monitoring of serum electrolyte levels is important, especially in patients receiving osmotic diuretics, those with syndrome of inappropriate antidiuretic hormone (SIADH) secretion, and those with posttraumatic diabetes insipidus. Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be accompanied by disorders of sodium regulation. Hyponatremia is common after head injury due to shifts in extracellular fluid, electrolytes, and volume. Hyperglycemia, for example, can cause an increase in extracellular fluid that lowers sodium. Hypernatremia may also occur as a result of sodium retention that may last several days, followed by sodium diuresis. Increasing lethargy, confusion, and seizures may be the result of electrolyte imbalance.

Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values, and intake and output. Urine is tested regularly for acetone. A record of daily weights is maintained, especially if the patient has hypothalamic involvement and is at risk for the development of diabetes insipidus.

Promoting Adequate Nutrition Head injury results in metabolic changes that increase calorie consumption and nitrogen excretion. Protein demand increases. Early initiation of nutritional therapy has been shown to improve outcomes in patients with head injury (AANN, 2012). Patients with brain injury are assumed to be catabolic and nutritional support consultation should be considered as soon as the patient is admitted. Parenteral nutrition via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding tube should be considered (Hickey, 2013). If CSF rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Laboratory values are monitored closely in patients receiving parenteral nutrition. Elevating the head of the bed and aspirating the enteral tube for evidence of residual feeding before administering additional feedings can help prevent distention, regurgitation, and aspiration. A continuous-drip infusion or pump may be used to regulate the feeding. The principles and technique of enteral feedings are discussed in Chapter 37. Enteral or parenteral feedings are usually continued until the swallowing reflex returns and the patient can meet caloric requirements orally.

Preventing Injury Often, as the patient emerges from coma, a period of lethargy and stupor is followed by a period of agitation. Each phase is variable and depends on the individual person, the location of the injury, the depth and duration of coma, and the patient’s age. Restlessness may be caused by hypoxia, fever, pain, or a full bladder. It may indicate injury to the brain but may also be a sign that the patient is regaining consciousness. (Some restlessness may be beneficial because the lungs and extremities are exercised.) Agitation may also be the result of discomfort from catheters, intravenous (IV) lines, restraints, and repeated neurologic checks. Alternatives to restraints must be used whenever possible. Strategies to prevent injury include the following: • The patient is assessed to ensure that oxygenation is adequate and the bladder is not distended. Dressings and casts are checked for constriction. • Padded side rails are used or the patient’s hands are wrapped in mitts to protect the patient from self-injury and dislodging of tubes. Restraints are avoided, because straining against them can increase ICP or cause other injury. Enclosed or floor-level specialty beds may be indicated. • Opioids are avoided as a means of controlling restlessness, because they depress respiration, constrict the pupils, and alter responsiveness.

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• Environmental stimuli are reduced by keeping the room quiet, limiting visitors, speaking calmly, and providing frequent orientation information (e.g., explaining where the patient is and what is being done). • Adequate lighting is provided to prevent visual hallucinations unless the patient is experiencing photophobia. • Efforts are made to minimize disruption of the patient’s sleep–wake cycles. • The patient’s skin is lubricated with oil or emollient lotion to prevent irritation due to rubbing against the sheet. • If incontinence occurs, an external sheath catheter may be used on a male patient.

Maintaining Body Temperature Fever in the patient with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the patient’s temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia (AANN, 2012). Cooling blankets should be used with caution so as not to induce shivering, which increases ICP. If infection is suspected, potential sites of infection are cultured and antibiotics are prescribed and administered. Use of mild hypothermia to 34°C to 35°C has been tested in small randomized controlled trials for at least 12 hours versus normothermia (control) in patients with closed head injury. Early research showed improvement in patient outcomes but needs to be repeated in larger trials. Because hypothermia increases the risk of pneumonia and has other side effects, this treatment is not currently recommended outside of controlled clinical trials (Brain Trauma Foundation, 2007).

Maintaining Skin Integrity Patients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Potential areas of breakdown need to be identified early to avoid the development of pressure ulcers. Specific nursing measures include the following: • Assessing all body surfaces and documenting skin integrity every 8 hours • Turning and repositioning the patient every 2 hours • Providing skin care every 4 hours • Assisting the patient to get out of bed to a chair three times a day

Improving Cognitive Functioning Although many patients with head injury survive because of resuscitative and supportive technology, they frequently have significant cognitive sequelae that may not be detected during the acute phase of injury. Cognitive impairment includes memory deficits, decreased ability to focus and sustain attention

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Management of Patients With Neurologic Trauma

2083

to a task (distractibility), reduced ability to process information, and slowness in thinking, perceiving, communicating, reading, and writing. Psychiatric, emotional, and relationship problems develop in many patients after head injury. Resulting psychosocial, behavioural, emotional, and cognitive impairments are devastating to the family as well as to the patient (Keenan & Joseph, 2010). These problems require collaboration among many disciplines. A neuropsychologist (specialist in evaluating and treating cognitive problems) plans a program and initiates therapy or counselling to help the patient reach maximal potential. Cognitive rehabilitation activities help the patient to devise new problem-solving strategies. The retraining is carried out over an extended period and may include the use of sensory stimulation and reinforcement, behaviour modification, reality orientation, computer training programs, and video games. Assistance from many disciplines is necessary during this phase of recovery. Even if intellectual ability does not improve, social and behavioural abilities may. The patient recovering from a TBI may experience fluctuations in the level of cognitive function, with orientation, attention, and memory frequently affected. Many types of sensory stimulation programs have been tried, and research on these programs is ongoing (Hickey, 2013). When pushed to a level greater than the impaired cortical functioning allows, the patient may show symptoms of fatigue, anger, and stress (headache, dizziness). The Rancho Los Amigos Level of Cognitive Function scale is frequently used to assess cognitive function and evaluate ongoing recovery from head injury. Progress through the levels of cognitive function can vary widely for individual patients. Nursing management and a description of each level are included in Table 64-2.

Preventing Sleep Pattern Disturbance Patients who require frequent monitoring of neurologic status may experience sleep deprivation as they are awakened hourly for assessment of LOC. To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. Environmental noise is decreased, and the room lights are dimmed. Back rubs and other measures to increase comfort may promote sleep and rest.

Supporting Family Coping Having a loved one sustain a TBI produces a great deal of stress in the family. This stress can result from the patient’s physical and emotional deficits, the unpredictable outcome, and altered family relationships. Families report difficulties in coping with changes in the patient’s temperament, behaviour, and personality. Such changes are associated with disruption in family cohesion, loss of leisure pursuits, and loss of work capacity, as well as social isolation of the caretaker. The family may experience marital disruption, anger, grief, guilt, and denial in recurring cycles (Keenan & Joseph, 2010).

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TABLE 64-2

UNIT 14

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Neurologic Function

Rancho Los Amigos Scale: Levels of Cognitive Function

Cognitive Level I: No response

II: Generalized response III: Localized response

IV: Confused, agitated response

V: Confused, inappropriate response

VI: Confused, appropriate response

VII: Automatic, appropriate response

VIII: Purposeful, appropriate

Description

Nursing Management

For levels I–III, the key approach is to provide stimulation. Completely unresponsive to all stimuli, Multiple modalities of sensory input should be used. including painful stimuli Examples are listed here, but management should be individualized and expanded based on available materials and patient preferences (determined by obtaining information from the family). Nonpurposeful response; responds to pain, Olfactory: perfumes, flowers, shaving lotion but in a nonpurposeful manner Visual: family pictures, card, personal items Responses more focused: withdraws to Auditory: radio, television, tapes of family voices or favorite pain; turns toward sound; follows movrecordings, talking to patient (nurse, family members). The ing objects that pass within visual field; nurse should tell patient what is going to be done, discuss pulls on sources of discomfort (e.g., the environment, provide encouragement. tubes, restraints); may follow simple Tactile: touching of skin, rubbing various textures on skin commands but inconsistently and in a Movement: range-of-motion exercises, turning, repositioning, delayed manner use of water mattress For levels IV–VI, the key approach is to provide structure. Alert, hyperactive state in which patient For level IV, which lasts 2–4 weeks, interventions are directed responds to internal confusion/agitation; at decreasing agitation, increasing environmental awarebehaviour nonpurposeful in relation to the ness, and promoting safety. environment; aggressive, bizarre behaviour • Approach patient in a calm manner, and use a soft voice. • Screen patient from environmental stimuli (e.g., sounds, common sights); provide a quiet, controlled environment. • Remove devices that contribute to agitation (e.g., tubes), if possible. • Functional goals cannot be set, because the patient is unable to cooperate. When agitation occurs, it is the result of For levels V and VI, interventions are directed at decreasing external rather than internal stimuli; confusion, improving cognitive function, and improving focused attention is difficult; memory is independence in performing ADLs. severely impaired; responses are frag• Provide supervision. mented and inappropriate to the situa• Use repetition and cues to teach ADLs. Focus the patient’s tion; there is no carryover of learning attention and help to increase his or her concentration. from one situation to the other. • Help the patient organize activity. • Clarify misinformation and reorient when confused. • Provide a consistent, predictable schedule (e.g., post daily schedule on large poster board). Follows simple directions consistently but is For levels VII–X, interventions are directed at increasing the inconsistently oriented to time and place; patient’s ability to function with minimal or no supervision short-term memory worse than long-term in the community. memory; can perform some ADLs • Reduce environmental structure. • Help the patient plan for adapting ADLs for self into the home environment. • Discuss and adapt home living skills (e.g., cleaning, cooking) to patient’s ability. For levels VII–X, the key approach is integration into the community. Appropriately responsive and oriented within • Provide stand-by assistance as needed for ADLs and home the hospital setting; needs little superviliving skills. sion in ADLs; some carryover of learning; patient has superficial insight into disabilities; has decreased judgment and problemsolving abilities; lacks realistic planning for future Alert, oriented, intact memory; has realistic • Provide assistance on request for adapting ADLs and home goals for the future. Able to complete living skills. familiar tasks for 1 hour in a distracting environment; overestimates or underestimates abilities, argumentative, easily frustrated, self-centred; uncharacteristically dependent/independent

continued >

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TABLE 64-2

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Management of Patients With Neurologic Trauma

2085

Rancho Los Amigos Scale: Levels of Cognitive Function (Continued)

Cognitive Level IX: Purposeful, appropriate

X: Purposeful, appropriate

Description Independently shifts back and forth between tasks and completes them accurately for at least 2 consecutive hours; uses assistive memory devices to recall schedule and activities; aware of and acknowledges impairments and disabilities when they interfere with task completion; depression may continue; may be easily irritable and have a low frustration tolerance Able to handle multiple tasks simultaneously in all environments but may require periodic breaks; independently initiates and carries out familiar and unfamiliar tasks but may require more than usual amount of time and/or compensatory strategies to complete them; accurately estimates abilities and independently adjusts to task demands; periodic periods of depression may occur; irritability and low frustration tolerance when sick, fatigued, and/or under stress

Nursing Management

• •

Monitor for signs and symptoms of depression. Help the patient plan, anticipate concerns, and solve problems.

Used with permission from Los Amigos Research and Education Institute, Inc., Downey, CA 2002.

To promote effective coping, the nurse can ask the family how the patient is different now, what has been lost, and what is most difficult about coping with this situation. Helpful interventions include providing family members with accurate and honest information and encouraging them to continue to set well-defined short-term goals. Family counselling helps address the family members’ overwhelming feelings of loss and helplessness and gives them guidance for the management of inappropriate behaviours. Support groups help the family members share problems, develop insight, gain information, network, and gain assistance in maintaining realistic expectations and hope. The Brain Injury Association (see Resources) serves as a clearing house for information and resources for patients with head injuries and their families, including specific information on coma, rehabilitation, behavioural consequences of head injury, and family issues. This organization can provide names of facilities and professionals who work with patients with head injuries and can assist families in organizing local support groups. Many patients with severe head injury die from their injuries, and many of those who survive experience long-term disabilities that prevent them from resuming their previous roles and functions. During the most acute phase of injury, family members need factual information and support from the health care team. Many patients with severe head injuries that result in brain death are young and otherwise healthy and are therefore considered for organ donation. Family members of patients with such injuries need support during this extremely stressful time and assistance in making decisions to end life support and permit donation of organs. They need to know that the

patient who is brain dead and whose respiratory and cardiovascular systems are maintained through life support is not going to survive and that the severe head injury, not the removal of the patient’s organs or the removal of life support, is the cause of the patient’s death. Bereavement counsellors and members of the organ procurement team are often very helpful to family members in making decisions about organ donation and in helping them cope with stress.

Monitoring and Managing Potential Complications DECREASED CEREBRAL PERFUSION PRESSURE.

Maintenance of adequate CPP is important to prevent serious complications of head injury due to decreased cerebral perfusion. Adequate CPP is greater than 60 mm Hg. If CPP falls below a patient’s threshold, a vasodilating cascade occurs, causing the volume of blood to increase inside the brain, causing ICP to increase. A decrease in CPP can impair cerebral perfusion and cause brain hypoxia and ischemia, leading to permanent brain damage. Once the threshold CPP is reached, vasoconstriction of the cerebral blood vessels occurs, causing ICP to decrease (AANN, 2011). Therapy (e.g., elevation of the head of the bed and increased IV fluids) is directed toward decreasing cerebral edema and increasing venous outflow from the brain. Systemic hypotension, which causes vasoconstriction and a significant decrease in CPP, is treated with increased IV fluids or vasopressors. CEREBRAL EDEMA AND HERNIATION. The patient with a head injury is at risk for additional complications such as increased ICP and brain stem herniation. Cerebral edema is the most common cause of increased ICP in the patient with a head injury, with the swelling peaking approximately 48 to 72 hours

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CHART 64-5

Controlling Intracranial Pressure in Patients With Severe Brain Injury • Elevate the head of the bed as prescribed. • Maintain the patient’s head and neck in neutral alignment (no twisting or flexing the neck).

• Initiate measures to prevent the Valsalva maneuvre

(e.g., stool softeners). Maintain normal body temperature. Administer O2 to maintain PaO2 >90 mm Hg. Maintain fluid balance with normal saline solution. Avoid noxious stimuli (e.g., excessive suctioning, painful procedures). • Administer sedation to reduce agitation. • Maintain cerebral perfusion pressure >70 mm Hg.

• • • •

after injury. Bleeding also may increase the volume of contents within the rigid, closed compartment of the skull, causing increased ICP and herniation of the brain stem and resulting in irreversible brain anoxia and brain death (Morton, et al., 2010). Measures to control ICP are discussed in Chapter 62 and listed in Chart 64-5. IMPAIRED OXYGENATION AND VENTILATION.

Impaired oxygen and ventilation may require mechanical ventilatory support. The patient must be monitored for a patent airway, altered breathing patterns, and hypoxemia and pneumonia (Olson et al., 2013). Interventions may include endotracheal intubation, mechanical ventilation, and positive end-expiratory pressure. These topics are discussed in further detail in Chapters 26 and 62. IMPAIRED FLUID, ELECTROLYTE, AND NUTRITIONAL BALANCE. Fluid, electrolyte, and

nutritional imbalances are common in the patient with a head injury. Common imbalances include hyponatremia, which is often associated with SIADH (see Chapters 15 and 43), hypokalemia, and hyperglycemia. Modifications in fluid intake with tube feedings or IV fluids, including hypertonic saline, may be necessary to treat these imbalances (Hickey, 2013). Insulin administration may be prescribed to treat hyperglycemia. Undernutrition is also a common problem in response to the increased metabolic needs associated with severe head injury. Decisions about early feeding should be individualized; options include IV hyperalimentation or placement of a feeding tube (jejunal or gastric). Caloric expenditure can increase up to 120% to 140% with TBI, requiring close monitoring of nutritional status. Feeding tubes should be placed 3 to 7 days after neurologic injury to replace energy and nitrogen losses, prevent increased mortality, and improve outcomes (Hickey, 2013). POSTTRAUMATIC SEIZURES. Patients with head injury are at an increased risk for posttraumatic seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury) (Hickey, 2013). Seizure prophylaxis is the

practice of administering antiseizure medications to patients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation (Baird & Bethel, 2011). However, many antiseizure medications impair cognitive performance and can prolong the duration of rehabilitation. Therefore, it is important to weigh the overall benefit of these medications against their side effects. Research evidence supports the use of prophylactic antiseizure agents to prevent immediate and early seizures after head injury, but not for prevention of late seizures (Baird & Bethel, 2011). The nursing management of seizures is addressed in Chapter 62.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Teaching early in the course of head injury often focuses on reinforcing information given to the family about the patient’s condition and prognosis. As the patient’s status and expected outcome change over time, family teaching may focus on interpretation and explanation of changes in the patient’s physical and psychological responses. If the patient’s physical status allows discharge to home, the patient and family are instructed about limitations that can be expected and complications that may occur. The nurse explains to the patient and family, verbally and in writing, how to monitor for complications that merit contacting the neurosurgeon. Depending on the patient’s prognosis and physical and cognitive status, the patient may be included in teaching about self-care management strategies. If the patient is at risk for late posttraumatic seizures, antiseizure medications may be prescribed at discharge. The patient and family require instruction about the side effects of these medications and the importance of continuing to take them as prescribed. CONTINUING CARE. The rehabilitation phase of care for the patient with a TBI begins at hospital admission. Admission to the rehabilitation unit is a milestone in a patient’s recovery and requires intense work by the patient to complete the daily schedule of therapies. The goals of rehabilitation are to maximize the patient’s ability to return to his or her highest level of functioning and to his or her home and the community, address concerns before discharge for a smooth transition to home or rehabilitation, and promote independence with adaptation to deficits (Hickey, 2013). The patient is encouraged to continue the rehabilitation program after discharge, because improvement in status may continue 3 or more years after injury. Changes in the patient with a TBI and the effects of long-term rehabilitation on the family and their coping abilities need ongoing assessment. Continued teaching and support of the patient and family are essential as their needs and the patient’s status change. Teaching points to address with the family of the patient who is about to return home are described in Chart 64-6. Depending on his or her status, the patient is encouraged to return to normal activities gradually.

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CHART 64-6

HOME CARE CHECKLIST •

The Patient With a Traumatic Brain Injury

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

✔

✔

• Explain the need for monitoring for changes in neurologic status and for complications. • Identify changes in neurologic status and signs and symptoms of complications that should be

✔

• Demonstrate safe techniques to assist patient with self-care, hygiene, and ambulation.

✔

reported to the neurosurgeon or nurse.

• Demonstrate safe technique for eating, feeding patient, or assisting patient with eating.

✔

✔

• Explain rationale for taking medications as prescribed.

✔

✔

• Identify need for close monitoring of behaviour due to changes in cognitive functioning.

✔

• Describe household modifications needed to ensure safe environment for the patient.

✔

• Describe strategies for reinforcing positive behaviours.

✔

• State importance of continuing follow-up by health care team. Referral to support groups and to the Brain Injury Association may be warranted. During the acute and rehabilitation phases of care, the focus of teaching is on obvious needs, issues, deficits, and complications. Complications after TBI include infections (e.g., pneumonia, urinary tract infection [UTI], septicemia, wound infection, osteomyelitis, meningitis, ventriculitis, brain abscess) and heterotrophic ossification (painful bone overgrowth in weight-bearing joints). The nurse reminds the patient and family of the need for continuing health promotion and screening practices after the initial phase of care (Keenan & Joseph, 2010). Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care professionals.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Attains or maintains effective airway clearance, ventilation, and brain oxygenation a. Achieves expected blood gas values and has appropriate breath sounds on auscultation b. Mobilizes and clears secretions 2. Achieves satisfactory fluid and electrolyte balance a. Demonstrates serum electrolytes within expected range b. Has no clinical signs of dehydration or overhydration 3. Attains adequate nutritional status a. Has less than 50 mL of aspirate in stomach before each tube feeding b. Is free of gastric distention and vomiting c. Shows minimal weight loss

✔

✔

4. Avoids injury a. Shows lessening agitation and restlessness b. Is oriented to time, place, and person 5. Maintains appropriate body temperature a. Absence of fever b. Absence of hypothermia 6. Demonstrates intact skin integrity a. Exhibits no redness or breaks in skin integrity b. Exhibits no pressure ulcers 7. Shows improvement in cognitive function and improved memory 8. Demonstrates usual sleep–wake cycle 9. Demonstrates absence of complications a. Exhibits expected vital signs and body temperature, and increasing orientation to time, place, and person b. Demonstrates usual or reduced ICP 10. Experiences no posttraumatic seizures a. Takes antiseizure medications as prescribed b. Identifies side effects/adverse effects of antiseizure medications 11. Family demonstrates adaptive family processes a. Joins support group b. Shares feelings with appropriate health care personnel c. Makes end-of-life decisions, if needed 12. Participates in rehabilitation process as indicated for patient and family members a. Takes active role in identifying rehabilitation goals and participating in recommended patient care activities b. Prepares for discharge

SPINAL CORD INJURY SCI is a major health disorder. Approximately 40,000 Canadians live with SCI. Approximately 1,000 new injuries occur each year. For example, from 2003 to 2004,

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950 spinal cord injuries occurred in Canada (Canadian Institute for Health Information, 2006). SCI is primarily an injury of young adult males and an overwhelming majority of those injured are between 16 and 30 years of age (Urden et al., 2013). Motor vehicle crashes account for 31.5% of reported cases of SCI, falls (25.3%), and with violence primarily from gunshot wounds, recreational sporting activities, and other events accounting for the remaining injuries (Chen, Tang, Vogel, et al., 2013). Paraplegia (paralysis of the lower body) and tetraplegia (formerly quadriplegia— paralysis of all four extremities) can occur, with incomplete tetraplegia the largest category, followed by complete paraplegia, complete tetraplegia, and paraplegia. The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI serves to emphasize the importance of primary prevention. The same interventions suggested earlier in this chapter for head injury prevention serve to decrease the incidence of SCI as well (see Chart 64-1). Most (80%) people who live with SCIs are men. Life expectancy continues to increase for people with SCI because of improved health care but remains slightly lower than for those without SCI. The major causes of death are pneumonia, pulmonary emboli (PE), and septicemia (Hickey, 2013).

Pathophysiology Damage in SCI ranges from transient concussion (from which the patient fully recovers), to contusion, laceration, and compression of the spinal cord substance (either alone or in combination), to complete transection (severing) of the spinal cord (which renders the patient paralyzed below the level of the injury). The vertebrae most frequently involved are the 5th, 6th, and 7th cervical vertebrae (C5 to C7), the 12th thoracic vertebra (T12), and the 1st lumbar vertebra (L1). These vertebrae are most susceptible because there is a greater range of mobility in the vertebral column in these areas (Chen et al., 2013). SCIs can be separated into two categories: primary injuries and secondary injuries. Primary injuries are the result of the initial insult or trauma and are usually permanent. Secondary injuries are usually the result of a contusion or tear injury, in which the nerve fibres begin to swell and disintegrate. A secondary chain of events produces ischemia, hypoxia, edema, and hemorrhagic lesions, which in turn result in destruction of myelin and axons. The secondary injury is of primary concern for critical care nurses. Experts believe secondary injury is the principal cause of spinal cord degeneration at the level of injury and that it is reversible during the first 4 to 6 hours after injury. Methods of early treatment are essential to prevent partial damage from becoming total and permanent (Urden et al., 2013).

Clinical Manifestations Manifestations of SCI depend on the type and level of injury (Chart 64-7). The type of injury refers to the extent of injury to the spinal cord itself. Incomplete spinal cord lesions (the sensory or motor fibres, or both, are pre-

served below the lesion) are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. The American Spinal Injury Association (ASIA) provides classification of SCI according to the degree of sensory and motor function present after injury (Chart 64-8). “Neurologic level” refers to the lowest level at which sensory and motor functions are appropriate. Below the neurologic level, there is total sensory and motor paralysis, loss of bladder and bowel control (usually with urinary retention and bladder distention), loss of sweating and vasomotor tone, and marked reduction of blood pressure from loss of peripheral vascular resistance. A complete spinal cord lesion (total loss of sensation and voluntary muscle control below the lesion) can result in paraplegia or tetraplegia. If conscious, the patient usually reports of acute pain in the back or neck, which may radiate along the involved nerve. However, absence of pain does not rule out spinal injury, and a careful assessment of the spine isconducted if there has been a significant force and mechanism of injury (i.e., concomitant head injury). Often the patient speaks of fear that the neck or back is broken. Respiratory dysfunction is related to the level of injury. The muscles contributing to respiration are the abdominals and intercostals (T1 to T11) and the diaphragm (C4). In high cervical cord injury, acute respiratory failure is the leading cause of death. Functional abilities by level of injury are described in Table 64-3.

Assessment and Diagnostic Findings A detailed neurologic examination is performed. Diagnostic x-rays (lateral cervical spine x-rays) and CT scanning are usually performed initially. An MRI scan may be ordered as a further workup if a ligamentous injury is suspected, because significant spinal cord damage may exist even in the absence of bony injury (Hickey, 2013). If an MRI scan is contraindicated, a myelogram may be used to visualize the spinal axis. An assessment is made for other injuries, because spinal trauma often is accompanied by concomitant injuries, commonly to the head and chest. Continuous electrocardiographic monitoring may be indicated if an SCI is suspected, because bradycardia (slow heart rate) and asystole (cardiac standstill) are common in patients with acute spinal cord injuries.

Emergency Management The immediate management at the scene of the injury is critical, because improper handling of the patient can cause further damage and loss of neurologic function. Any patient who is involved in a motor vehicle crash, a diving or contact sports injury, a fall, or any direct trauma to the head and neck must be considered to have SCI until such an injury is ruled out. Initial care must include a rapid assessment, immobilization, extrication, and stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility. Immediate transportation to a trauma centre with the capacity to manage major neurologic trauma is then necessary (Hickey, 2013).

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CHART 64-7

Effects of Spinal Cord Injuries Central Cord Syndrome

Area of cord damage

• Characteristics: Motor deficits (in the upper extremities compared to

the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. • Cause: Injury or edema of the central cord, usually of the cervical area. May be caused by hyperextension injuries.

Loss of motor power and sensation Incomplete loss

Central Cord Syndrome

Anterior Cord Syndrome

Area of cord damage

• Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact. • Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture-dislocation of vertebra. It also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two thirds of the spinal cord.

Loss of motor power, pain, and temperature sensation, with preservation of position, vibration, and touch sense.

Anterior Cord Syndrome

Brown-Séquard Syndrome (Lateral Cord Syndrome)

Area of cord damage

• Characteristics: Ipsilateral paralysis or paresis is noted, together with

ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature. • Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture-dislocation of a unilateral articular process, or possibly an acute ruptured disk.

Loss of pain and temperature sensation on opposite side Loss of voluntary motor control on the same side as the cord damage ‘ Brown-Sequard Syndrome Adapted from Hickey, L. (2013). The clinical practice of neurological and neurosurgical nursing (7th ed.). Philadelphia,PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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CHART 64-8

ASIA Impairment Scale A = Complete: No motor or sensory function is preserved in the sacral segments S4–S5. B = Incomplete: Sensory but not motor function is preserved below the neurologic level, and includes the sacral segments S4–S5. C = Incomplete: Motor function is preserved below the neurologic level, and more than half of key muscles below the neurologic level have a muscle grade less than 3. D = Incomplete: Motor function is preserved below the neurologic level, and at least half of key muscles below the neurologic level have a muscle grade of 3 or greater. E = Normal: Motor and sensory function are normal. Used with permission of American Spinal Injury Association.

At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. One member of the team must assume control of the patient’s head to prevent flexion, rotation, or extension; this is done by placing the hands on both sides of the patient’s head at about ear level to limit movement and maintain alignment while a spinal board or cervical immobilizing device is applied. If possible, at least four people should slide the patient carefully

TABLE 64-3

onto a board for transfer to the hospital. Any twisting movement may irreversibly damage the spinal cord by causing a bony fragment of the vertebra to cut into, crush, or sever the cord completely. The standard of care is that the patient is referred to a regional spinal injury or trauma centre because of the experienced multidisciplinary personnel and support services required to counteract the destructive changes that occur in the first 24 hours after injury. During treatment in the emergency and x-ray departments, the patient is kept on the transfer board. The patient must always be maintained in an extended position. No part of the body should be twisted or turned, and the patient is not allowed to sit up (Baird & Bethel, 2011). Once the extent of the injury has been determined, the patient may be placed on a rotating specialty bed (Fig. 64-6) or in a cervical collar (Fig. 64-7). Later, if SCI and bone instability have been ruled out, the patient may be moved to a conventional bed or the collar may be removed without harm. If a specialty bed is needed but not available, the patient should be placed in a cervical collar and on a firm mattress.

Medical Management (Acute Phase) The goals of management are to prevent secondary injury, to observe for symptoms of progressive neurologic deficits, and to prevent complications. The patient is resuscitated as necessary, and oxygenation and cardiovascular stability are maintained. SCI is a devastating event; new

Functional Abilities by Level of Cord Injury

Injury Level

Segmental Sensorimotor Function

Dressing, Eating

Elimination

Mobility*

C1

Little or no sensation or control of head and neck; no diaphragm control; requires continuous ventilation Head and neck sensation; some neck control; independent of mechanical ventilation for short periods Good head and neck sensation and motor control; some shoulder elevation; diaphragm movement Full head and neck control; shoulder strength; elbow flexion

Dependent

Dependent

Limited. Voice or sip-n-puff controlled electric wheelchair

Dependent

Dependent

Same as for C1

Dependent, may be able to eat with adaptive sling Independent with assistance

Dependent

Fully innervated shoulder; wrist extension or dorsiflexion Full elbow extension; wrist plantar flexion; some finger control Full hand and finger control; use of intercostal and thoracic muscles Abdominal muscle control, partial to good balance with trunk muscles Hip flexors, hip abductors (L1–L3); knee extension (L2–L4); knee flexion and ankle dorsiflexion (L4–L5) Full leg, foot, and ankle control; innervation of perineal muscles for bowel, bladder, and sexual function (S2–S4)

Independent or with minimal assistance Independent

Independent or with minimal assistance Independent

Limited to voice, mouth, head, chin, or shoulder-controlled electric wheelchair Electric or modified manual wheelchair, needs transfer assistance Independent in transfers and wheelchair Independent; manual wheelchair

Independent

Independent

Independent; manual wheelchair

Independent

Independent

Independent; manual wheelchair

Independent

Independent

Short distance to full ambulation with assistance

Independent

Normal to impaired bowel and bladder function

Ambulate independently with or without assistance

C2 to C3

C4

C5

C6 C7 to C8 T1 to T5 T6 to T10 T11 to L5

S1 to S5

Maximal assistance

*Assistance refers to adaptive equipment, setup, or physical assistance. From Hanron, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.) Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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cal practice in most trauma centres in the United States (Hickey, 2013).

Respiratory Therapy Oxygen is administered to maintain a high partial pressure of oxygen (PaO2), because hypoxemia can create or worsen a neurologic deficit of the spinal cord. If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient’s neck, which can result in extension of a cervical injury. In high cervical spine injuries, spinal cord innervation to the phrenic nerve, which stimulates the diaphragm, is lost. Diaphragmatic pacing stimulation (electrical stimulation of the phrenic nerve) attempts to stimulate the diaphragm to help with the weaning of ventilator-dependent patients (Malave, Alhomsi, Demirer, et al., 2010).

Skeletal Fracture Reduction and Traction

FIGURE 64-6. Roro Rest bed. (Courtesy of Kinetic Concepts, San

Antonio, TX.)

treatment methods and medications are continually being investigated for the acute and chronic phases of care (Urden et al., 2013).

Pharmacologic Therapy Administration of high-dose IV corticosteroids or methylprednisolone sodium succinate in the first 24 or 48 hours is controversial. Despite the ongoing controversy surrounding the practice, the use of IV high-dose methylprednisolone is accepted as standard therapy for SCI in many countries and remains an established clini-

FIGURE 64-7. Cervical collar. (Courtesy of Aspen Medical Products,

Irvine, CA.)

Management of SCI requires immobilization and reduction of dislocations (restoration of normal position) and stabilization of the vertebral column. Cervical fractures are reduced, and the cervical spine is aligned with some form of skeletal traction, such as skeletal tongs or calipers, or with use of the halo device (Morton & Fontaine, 2013). A variety of skeletal tongs are available, all of which involve fixation in the skull in some manner. The Gardner-Wells tongs require no predrilled holes in the skull. Crutchfield and Vinke tongs are inserted through holes made in the skull with a special drill under local anesthesia. Traction is applied to the skeletal traction device by weights, the amount depending on the size of the patient and the degree of fracture displacement. The traction force is exerted along the longitudinal axis of the vertebral bodies, with the patient’s neck in a neutral position. The traction is then gradually increased by adding more weights. As the amount of traction is increased, the spaces between the intervertebral disks widen and the vertebrae are given a chance to slip back into position. Reduction usually occurs after correct alignment has been restored. Once reduction is achieved, as verified by cervical spine x-rays and neurologic examination, the weights are gradually removed until the amount of weight needed to maintain the alignment is identified. The weights should hang freely so as not to interfere with the traction. Traction is sometimes supplemented with manual manipulation of the neck by a surgeon to help achieve realignment of the vertebral bodies. Due to potential complications of immobility, long-term traction with tongs is seldom used, and the halo vest is preferred. A halo device may be used initially with traction, or may be applied after removal of the tongs. It consists of a stainless steel halo ring that is fixed to the skull by four pins. The ring is attached to a removable halo vest, a device that suspends the weight of the unit circumferentially around the chest. A metal frame connects the ring to the chest (Morton & Fontaine, 2013). Halo devices provide immobilization of the cervical spine while allowing early ambulation (Fig. 64-8). Thoracic and lumbar injuries are usually treated with surgical intervention followed by immobilization with a

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Management of Acute Complications of Spinal Cord Injury Spinal and Neurogenic Shock

FIGURE 64-8. Halo and vest for cervical and thoracic injuries. (Cour-

tesy of Acromed Corp., Cleveland, OH.)

fitted brace. Traction is not indicated either before or after surgery, due to the relative stability of the spine in these regions.

!

NURSING ALERT

The patient’s vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system has recovered from the traumatic insult; this can take up to 4 months (Hickey, 2013).

Surgical Management Surgery is indicated in any of the following situations: • Compression of the cord is evident. • The injury results in a fragmented or unstable vertebral body. • The injury involves a wound that penetrates the cord. • Bony fragments are in the spinal canal. • The patient’s neurologic status is deteriorating. Research indicates that early surgical stabilization improves the clinical outcome of patients compared to surgery performed later during the clinical course. The goals of surgical treatment are to preserve neurologic function by removing pressure from the spinal cord and to provide stability (Pelatt, 2010).

The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. The muscles innervated by the part of the spinal cord segment below the level of the lesion are without sensation, paralyzed, and flaccid, and the reflexes are absent. In particular, the reflexes that initiate bladder and bowel function are affected. Bowel distention and paralytic ileus can be caused by depression of the reflexes and are treated with intestinal decompression by insertion of a nasogastric tube (Sarhan, Saif & Saif, 2013). Neurogenic shock develops as a result of the loss of autonomic nervous system function below the level of the lesion (Sarhan et al., 2013). The vital organs are affected, causing decreases in blood pressure, heart rate, and cardiac output, as well as venous pooling in the extremities and peripheral vasodilation. In addition, the patient does not perspire in the paralyzed portions of the body, because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever. Further discussion of neurogenic shock can be found in Chapter 16. With injuries to the cervical and upper thoracic spinal cord, innervation to the major accessory muscles of respiration is lost and respiratory problems develop. These include decreased vital capacity, retention of secretions, increased partial pressure of arterial carbon dioxide (PaCO2) levels and decreased oxygen levels, respiratory failure, and pulmonary edema.

Deep Vein Thrombosis Deep vein thrombosis (DVT) is a potential complication of immobility and is common in patients with SCI. Patients who develop DVT are at risk for PE, a life-threatening complication. Manifestations of PE include pleuritic chest pain, anxiety, shortness of breath, and abnormal blood gas values (increased PaCO2 and decreased PaO2). Low-dose anticoagulation therapy usually is initiated to prevent DVT and PE, along with the use of antiembolism stockings or pneumatic compression devices. In some cases, permanent indwelling filters (see Chapter 24) may be placed prophylactically in the vena cava to prevent emboli (dislodged clots) from migrating to the lungs and causing a PE (Hickey, 2013).

!

NURSING ALERT

The calves or thighs should never be massaged because of the danger of dislodging an undetected thromboemboli.

Other Complications In addition to respiratory complications (respiratory failure, pneumonia) and autonomic dysreflexia (characterized by pounding headache, profuse sweating, nasal congestion, piloerection [“goose bumps”], bradycardia,

CHAPTER 64

and hypertension), other complications that may occur include pressure ulcers and infection (urinary, respiratory, and local infection at the skeletal traction pin sites) (Morton & Fontaine, 2013).

!!"##

Nursing Process

The Patient With Acute Spinal Cord Injury Assessment The patient’s breathing pattern and the strength of the cough are assessed, and the lungs are auscultated, because paralysis of abdominal and respiratory muscles diminishes coughing and makes clearing of bronchial and pharyngeal secretions difficult. Reduced excursion of the chest also results. The patient is monitored closely for any changes in motor or sensory function and for symptoms of progressive neurologic damage. In the early stages of SCI, determining whether the cord has been severed may not be possible, because signs and symptoms of cord edema are indistinguishable from those of cord transection. Edema of the spinal cord may occur with any severe cord injury and may further compromise spinal cord function. Motor and sensory functions are assessed through careful neurologic examination. These findings are recorded on a flow sheet so that changes in the baseline neurologic status can be monitored closely and accurately. The ASIA classification is commonly used to describe level of function for patients with SCI (see Chart 64-8). Chart 64-7 gives examples of the effects of altered spinal cord function. At the minimum: • Motor ability is tested by asking the patient to spread the fingers, squeeze the examiner’s hand, and move the toes or turn the feet. • Sensation is evaluated by gently pinching the skin or touching it lightly with an object such as a tongue blade, starting at shoulder level and working down both sides of the extremities. The patient should have both eyes closed so that the examination reveals true findings, not what the patient hopes to feel. The patient is asked where the sensation is felt. • Any decrease in neurologic function is reported immediately. The patient is also assessed for spinal shock, a complete loss of all reflex, motor, sensory, and autonomic activity below the level of the lesion that causes bladder paralysis and distention. The lower abdomen is palpated for signs of urinary retention and overdistention of the bladder. Further assessment is made for gastric dilation and paralytic ileus caused by an atonic bowel, a result of autonomic disruption. Temperature is monitored, because the patient may have periods of hyperthermia as a result of alteration in temperature control due to autonomic disruption.

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Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal muscles and inability to clear secretions • Ineffective airway clearance related to weakness of intercostal muscles • Impaired bed and physical mobility related to motor and sensory impairments • Disturbed sensory perception related to motor and sensory impairment • Risk for impaired skin integrity related to immobility and sensory loss • Impaired urinary elimination related to inability to void spontaneously • Constipation related to presence of atonic bowel as a result of autonomic disruption • Acute pain and discomfort related to treatment and prolonged immobility

Collaborative Problems/ Potential Complications Based on the assessment data, potential complications that may develop include: • DVT • Orthostatic hypotension • Autonomic dysreflexia

Planning and Goals The goals for the patient may include improved breathing pattern and airway clearance, improved mobility, improved sensory and perceptual awareness, maintenance of skin integrity, relief of urinary retention, improved bowel function, promotion of comfort, and absence of complications.

Nursing Interventions Promoting Adequate Breathing and Airway Clearance Possible impending respiratory failure is detected by observing the patient, measuring vital capacity, monitoring oxygen saturation through pulse oximetry, and monitoring arterial blood gases. Early and vigorous attention to clearing bronchial and pharyngeal secretions can prevent retention of secretions and atelectasis. Suctioning may be indicated, but it should be used with caution to avoid stimulating the vagus nerve and producing bradycardia and cardiac arrest. If the patient cannot cough effectively because of decreased inspiratory volume and inability to generate sufficient expiratory pressure, chest physical therapy and assisted coughing may be indicated. Specific breathing exercises are supervised by the nurse to increase the strength and endurance of the inspiratory

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muscles, particularly the diaphragm. Assisted coughing promotes clearing of secretions from the upper respiratory tract and is similar to the use of abdominal thrusts to clear an airway (see Chapter 26). Proper humidification and hydration are important to prevent secretions from becoming thick and difficult to remove even with coughing. The patient is assessed for signs of respiratory infection (e.g., cough, fever, dyspnea). Ascending edema of the spinal cord in the acute phase may cause respiratory difficulty that requires immediate intervention. Therefore, the patient’s respiratory status must be monitored closely.

Improving Mobility Proper body alignment is maintained at all times. The patient is repositioned frequently and is assisted out of bed as soon as the spinal column is stabilized. The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours. Trochanter rolls, applied from the crest of the ilium to the midthigh of both legs, help prevent external rotation of the hip joints. Patients with lesions above the midthoracic level have loss of sympathetic control of peripheral vasoconstrictor activity, leading to hypotension. These patients may tolerate changes in position poorly and require monitoring of blood pressure when positions are changed. If not on a rotating specialty bed, the patient should not be turned unless the spine is stable and the physician has indicated that it is safe to do so. Contractures can develop rapidly with immobility and muscle paralysis. A joint that is immobilized too long becomes fixed as a result of contractures of the tendon and joint capsule. Atrophy of the extremities results from disuse. Contractures and other complications may be prevented by range-of-motion exercises that help preserve joint motion and stimulate circulation. Passive range-of-motion exercises should be implemented as soon as possible after injury. Toes, metatarsals, ankles, knees, and hips should be put through a full range of motion at least four, and ideally five, times daily. For most patients who have a cervical fracture without neurologic deficit, reduction in traction followed by rigid immobilization for 6 to 8 weeks restores skeletal integrity. These patients are allowed to move gradually to an erect position. A neck brace or molded collar is applied when the patient is mobilized after traction is removed (see Fig. 64-7).

Promoting Adaptation to Sensory and Perceptual Alterations The nurse assists the patient to compensate for sensory and perceptual alterations that occur with SCI. The intact senses above the level of the injury are stimulated through touch, aromas, flavorful food and beverages, conversation, and music. Additional strategies include the following: • Providing prism glasses to enable the patient to see from the supine position

• Encouraging use of hearing aids, if indicated, to enable the patient to hear conversations and environmental sounds • Providing emotional support to the patient • Teaching the patient strategies to compensate for or cope with sensory deficits

Maintaining Skin Integrity Pressure ulcers are a significant complication of SCI. The most common sites are over the ischial tuberosity, the greater trochanter, the sacrum, and the occiput (back of head). In the acute care setting, during the initial phase of hospitalization, it may be necessary to delay rehabilitation in 20% to 30% of patients because of pressure ulcers. Pressure ulcers may begin within hours of an acute SCI where pressure is continuous and where the peripheral circulation is inadequate as a result of spinal shock and a recumbent position. It is important to move the patient from the backboard as soon as possible and inspect the skin. In addition, patients who wear cervical collars for prolonged periods may develop breakdown from the pressure of the collar under the chin, on the shoulders, and at the occiput. In addition, pressure ulcers can add substantially to the personal and economic costs of living with a SCI. The prevalence of this complication ranges from 17% for people 2 months after injury to 33% for those living with an SCI. The most effective approach to addressing this costly complication of SCI is prevention (Pelatt, 2010). The patient’s position is changed at least every 2 hours. Turning not only assists in the prevention of pressure ulcers but also prevents pooling of blood and edema in the dependent areas. Careful inspection of the skin is made each time the patient is turned. The skin over the pressure points is assessed for redness or breaks; the perineum is checked for soilage, and the catheter is observed for adequate drainage. The patient’s general body alignment and comfort are assessed. Special attention should be given to pressure areas in contact with the transfer board. In addition, the patient’s skin should be kept clean by washing with a mild soap, rinsing well, and blotting dry. Pressure-sensitive areas should be kept well lubricated and soft with hand cream or lotion. The patient is educated about the danger of pressure ulcers and is encouraged to take control and make decisions about appropriate skin care (Hickey, 2013). See Chapter 12 for other aspects of the prevention of pressure ulcers.

Maintaining Urinary Elimination Immediately after SCI, the urinary bladder becomes atonic and cannot contract by reflex activity. Urinary retention is the immediate result. Because the patient has no sensation of bladder distention, overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function. Intermittent catheterization is carried out to avoid overdistention of the bladder and UTI. If this is not feasible, an indwelling catheter is inserted temporarily. At an early stage, family members are shown how

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to carry out intermittent catheterization and are encouraged to participate in this facet of care, because they will be involved in long-term follow-up and must be able to recognize complications so that treatment can be instituted. The patient is taught to record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual sensations that may occur. The management of a neurogenic bladder (bladder dysfunction that results from a disorder or dysfunction of the nervous system) is discussed in detail in Chapter 12.

Immediately after SCI, a paralytic ileus usually develops as a result of neurogenic paralysis of the bowel; therefore, a nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. Bowel activity usually returns within the first week. As soon as bowel sounds are heard on auscultation, the patient is given a high-calorie, high-protein, high-fibre diet, with the amount of food gradually increased. The nurse administers prescribed stool softeners to counteract the effects of immobility and analgesic agents. A bowel program is instituted as early as possible.

ally they readily adapt to it because the device provides comfort for the unstable neck (see Fig. 64-8). The patient may complain of being caged in and of noise created by any object coming in contact with the steel frame of a halo device, but he or she can be reassured that adaptation will occur. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. A torque screwdriver should be readily available in case the screws on the frame need tightening. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet, because dampness causes skin excoriation. Powder is not used inside the vest, because it may contribute to the development of pressure ulcers. The liner should be changed periodically to promote hygiene and good skin care. If the patient is to be discharged with the vest, detailed instructions must be given to the family, with time allowed for them to demonstrate the necessary skills of halo vest care (Chart 64-9).

Providing Comfort Measures: The Patient in Halo Traction

Monitoring and Managing Potential Complications

A patient who has had pins, tongs, or calipers placed for cervical stabilization may have a slight headache or discomfort for several days after the pins are inserted. Patients initially may be bothered by the rather startling appearance of these devices, but usu-

THROMBOPHLEBITIS. Thrombophlebitis is a relatively common complication in patients after SCI (Pelatt 2010). The patient must be assessed for symptoms of thrombophlebitis and PE. Chest pain, shortness of breath, and changes in arterial blood gas values

Improving Bowel Function

CHART 64-9

HOME CARE CHECKLIST •

The Patient With a Halo Vest

At the completion of the home care instruction, the patient or caregiver will be able to:

• Describe the rationale for use of the halo vest.

Patient ✔

Caregiver ✔

• Demonstrate assessment of frame, traction, tongs, and pins.

✔

• Describe emergency measures if respiratory or other complications develop while patient is in

✔

• Demonstrate pin care using correct technique.

✔

halo vest or if frame becomes dislodged.

• Identify signs and symptoms of infection.

✔

✔

• Assess the skin for reddened or irritated areas and breakdown.

✔

• Demonstrate care of skin.

✔

• Explain the reasons for and the method for changing the vest liner.

✔

✔

• Demonstrate safe techniques to assist patient with self-care, hygiene, and ambulation.

✔

• Identify signs and symptoms of complications (DVT, respiratory impairment, urinary tract

✔

infection).

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must be reported promptly to the physician. The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies are performed if a significant increase is noted. Patients remain at high risk for thrombophlebitis for several months after the initial injury. Patients with paraplegia or tetraplegia are at increased risk for the rest of their lives. Immobilization and the associated venous stasis, as well as varying degrees of autonomic disruption, contribute to the high risk and susceptibility for DVT (Hickey, 2013). Anticoagulation is initiated once head injury and other systemic injuries have been ruled out. Lowdose fractionated or unfractionated heparin may be followed by long-term oral anticoagulation (i.e., warfarin or rivaroxabam) or subcutaneous fractionated heparin injections. Additional measures such as range-of-motion exercises, antiembolism stockings, and adequate hydration are important preventive measures. Pneumatic compression devices may also be used to reduce venous pooling and promote venous return. It is also important to avoid external pressure on the lower extremities that may result from flexion of the knees while the patient is in bed. ORTHOSTATIC HYPOTENSION. For the first 2 weeks after SCI, the blood pressure tends to be unstable and quite low due to a reduction in vasomotor tone (Pelatt, 2010). It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Interruption in the reflex arcs that usually produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in blood pressure readings of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypotension is a particularly common problem for patients with lesions above T7. In some patients with tetraplegia, even slight elevations of the head can result in dramatic decreases in blood pressure. A number of techniques can be used to reduce the frequency of hypotensive episodes. Close monitoring of vital signs before and during position changes is essential. Vasopressor medication can be used to treat the profound vasodilation. Antiembolism stockings should be applied to improve venous return from the lower extremities. Range of motion exercises will help prevent venous pooling (Baird & Bethel, 2011). Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright. Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Tilt tables frequently are helpful in assisting patients to make this transition. AUTONOMIC DYSREFLEXIA. Autonomic dysreflexia (autonomic hyperreflexia) is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without an SCI. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphore-

sis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level). The sudden increase in blood pressure may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer) (Terry & Weaver, 2011). Because this is an emergency situation, the objectives are to remove the triggering stimulus and to avoid the possibly serious complications. The following measures are carried out: • The patient is placed immediately in a sitting position to lower blood pressure. • Rapid assessment is performed to identify and alleviate the cause. • The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. • The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. • The skin is examined for any areas of pressure, irritation, or broken skin. • Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. • If these measures do not relieve the hypertension and excruciating headache, a ganglionic blocking agent (hydralazine hydrochloride [Apresoline]) is prescribed and administered slowly by the IV route. • The medical record or chart is labelled with a clearly visible note about the risk of autonomic dysreflexia. • The patient is instructed about prevention and management measures. • Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. In most cases, patients with SCI (i.e., patients with tetraplegia or paraplegia) need long-term rehabilitation. The process begins during hospitalization, as acute symptoms begin to subside or come under better control and the overall deficits and long-term effects of the injury become clear. The goals begin to shift from merely surviving the injury to learning strategies necessary to cope with the alterations that the injury imposes on activities of daily living (ADLs). The emphasis shifts from ensuring that the patient is stable and free of complications to specific assessment and planning designed to meet the patient’s rehabilitation needs. Patient teaching may initially focus on the injury and its effects on mobility, dressing, and bowel, bladder,

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and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, the focus of teaching broadens to address issues necessary for carrying out the tasks of daily living and taking charge of their lives (Griffiths & Kennedy, 2012). Teaching begins in the acute phase and continues throughout rehabilitation and throughout the patient’s life as changes occur, the patient ages, and problems arise. Caring for the patient with SCI at home may at first seem a daunting task to the family. They will require dedicated nursing support to gradually assume full care of the patient. Although maintaining function and preventing complications will remain important, goals regarding self-care and preparation for discharge will assist in a smooth transition to rehabilitation and eventually to the community. CONTINUING CARE. The goal of the rehabilitation process is independence. The nurse becomes a support to both the patient and the family, assisting them to assume responsibility for increasing aspects of patient care and management. Care for the patient with SCI involves members of all the health care disciplines, which may include nursing, medicine, rehabilitation, respiratory therapy, physical and occupational therapy, case management, and social services. The nurse often serves as coordinator of the management team and as a liaison with rehabilitation centres and home care agencies. The patient and family often require assistance in dealing with the psychological impact of the injury and its consequences; referral to a psychiatric clinical nurse specialist or other mental health care professional often is helpful. The nurse should reassure female patients with SCI that pregnancy is not contraindicated and fertility is relatively unaffected, but that women who are pregnant with acute or chronic SCI pose unique management challenges. The usual physiologic changes of pregnancy may predispose women with SCI to many potentially life-threatening complications, including autonomic dysreflexia, pyelonephritis, respiratory insufficiency, thrombophlebitis, PE, and unattended delivery. Preconception assessment and counselling are strongly recommended to ensure that the woman is in optimal health and to increase the likelihood of an uneventful pregnancy and healthy outcomes (Ghidini & Simonson, 2011). As more patients survive acute SCI, they face the changes associated with aging with a disability. Therefore, teaching in the home and community focuses on health promotion and addresses the need to minimize risk factors (e.g., smoking, alcohol and drug abuse, obesity). Routine health screening and preventive services are needed for the older adult with SCI (McCauley, 2010). Home care nurses and others who have contact with patients with SCI are in a position to teach patients about healthy lifestyles, remind them of the need for health screenings, and make referrals as appropriate. Assisting patients to identify accessible health care professionals, clinical facilities, and imaging centres may increase the likelihood that they will participate in health screening.

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2097

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Demonstrates improvement in gas exchange and clearance of secretions, as evidenced by usual breath sounds on auscultation a. Breathes easily without shortness of breath b. Performs hourly deep-breathing exercises, coughs effectively, and clears pulmonary secretions c. Is free of respiratory infection (i.e., has appropriate temperature, respiratory rate, and pulse; normal breath sounds; absence of purulent sputum) 2. Moves within limits of the dysfunction and demonstrates completion of exercises within functional limitations 3. Demonstrates adaptation to sensory and perceptual alterations a. Uses assistive devices (e.g., prism glasses, hearing aids, computers) as indicated b. Describes sensory and perceptual alterations as a consequence of injury 4. Demonstrates optimal skin integrity a. Exhibits usual skin turgor; skin is free of reddened areas or breaks b. Participates in skin care and monitoring procedures within functional limitations 5. Regains urinary bladder function a. Exhibits no signs of UTI (i.e., has appropriate temperature; voids clear, dilute urine) b. Has adequate fluid intake c. Participates in bladder training program within functional limitations 6. Regains bowel function a. Reports regular pattern of bowel movement b. Consumes adequate dietary fibre and oral fluids c. Participates in bowel training program within functional limitations 7. Reports absence of pain and discomfort 8. Is free of complications a. Demonstrates no signs of thrombophlebitis, DVT, or PE b. Maintains blood pressure within expected limits c. Reports no lightheadedness with position changes d. Exhibits no manifestations of autonomic dysreflexia (i.e., absence of headache, diaphoresis, nasal congestion, bradycardia, or diaphoresis)

Medical Management of LongTerm Complications of Spinal Cord Injury The patient faces a lifetime of disability, requiring ongoing follow-up and care. The expertise of a number of health professionals, including physicians (specifically a physiatrist), rehabilitation nurses, occupational therapists, physical

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therapists, psychologists, social workers, rehabilitation engineers, and vocational counsellors, is necessary at different times as the need arises. As people with SCI age, they have the same medical problems as other people. In addition, they face the threat of complications associated with their disability (Hickey, 2013). Usually, patients are encouraged to attend a spine clinic when complications and other issues arise. Lifetime care includes assessment of the urinary tract at prescribed intervals, because there is the likelihood of continuing alteration in detrusor and sphincter function, and the patient is prone to UTI. Long-term issues and complications of SCI include premature aging, disuse syndrome, autonomic dysreflexia (discussed earlier), bladder and kidney infections, spasticity, and depression (Hickey, 2013). Pressure ulcers with potential complications of sepsis, osteomyelitis, and fistulas occur in about 10% of patients. Spasticity may be particularly disabling. Heterotopic ossification (overgrowth of bone) in the hips, knees, shoulders, and elbows occurs in many patients after SCI. Both of these complications are painful and can produce a loss of range of motion (Hickey). Management includes observing for and addressing any alteration in physiologic status and psychological outlook, as well as the prevention and treatment of long-term complications. The nursing role involves emphasizing the need for vigilance in self-assessment and care.

patient and family and by listening to their concerns. Documenting these assessments and reviewing the plan with the entire team on a regular basis provide insight into how both the patient and the family are coping with the changes in lifestyle and body functioning. Additional information frequently can be gathered from the social worker or psychiatric/ mental health worker. It takes time for the patient and family to comprehend the magnitude of the disability. They may go through stages of grief, including shock, disbelief, denial, anger, depression, and acceptance. During the acute phase of the injury, denial can be a protective mechanism to shield the patient from the overwhelming reality of what has happened. As the patient realizes the permanent nature of paraplegia or tetraplegia, the grieving process may be prolonged and all-encompassing because of the recognition that long-held plans and expectations are interrupted or permanently altered. A period of depression often follows as the patient experiences a loss of selfesteem in areas of self-identity, sexual functioning, and social and emotional roles (Arango-Lasprilla, Ketchum, Starkweather, et al., 2011). Exploration and assessment of these issues can assist in developing a meaningful plan of care.

Diagnosis !!"##

Nursing Process

The Patient With Tetraplegia or Paraplegia Assessment Assessment focuses on the patient’s general condition, complications, and how the patient is managing at that particular point in time. A head-to-toe assessment and review of systems should be part of the database, with emphasis on the areas that are prone to problems in this population. A thorough inspection of all areas of the skin for redness or breakdown is critical. The nurse reviews the established bowel and bladder program with the patient, because the program must continue uninterrupted. Patients with tetraplegia or paraplegia have varying degrees of loss of motor power, deep and superficial sensation, vasomotor control, bladder and bowel control, and sexual function. They are faced with potential complications related to immobility, skin breakdown and pressure ulcers, recurring UTIs, and contractures. Knowledge about these particular issues can further guide the assessment in any setting. Nurses in all settings, including home care, must be aware of these potential complications in the lifetime management of these patients. An understanding of the emotional and psychological responses to tetraplegia or paraplegia is achieved by observing the responses and behaviours of the

Nursing Diagnoses Based on the assessment data, the major nursing diagnoses of the patient with tetraplegia or paraplegia may include the following: • Impaired bed and physical mobility related to loss of motor function • Risk for disuse syndrome • Risk for impaired skin integrity related to permanent sensory loss and immobility • Impaired urinary elimination related to level of injury • Constipation related to effects of spinal cord disruption • Sexual dysfunction related to neurologic dysfunction • Ineffective coping related to impact of disability on daily living • Deficient knowledge about requirements for longterm management

Collaborative Issues/Potential Complications Based on all the assessment data, potential complications of tetraplegia or paraplegia that may develop include: • Spasticity • Infection and sepsis

Planning and Goals The goals for the patient may include attainment of some form of mobility; maintenance of healthy, intact skin; achievement of bladder management without

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infection; achievement of bowel control; achievement of sexual expression; strengthening of coping mechanisms; and absence of complications.

Nursing Interventions The patient requires extensive rehabilitation, which is less difficult if appropriate nursing management has been carried out during the acute phase of the injury or illness. Nursing care is one of the key factors determining the success of the rehabilitation program. The main objective is for the patient to live as independently as possible in the home and community.

Increasing Mobility EXERCISE PROGRAMS. The unaffected parts of the body are built up to optimal strength to promote maximal self-care. The muscles of the hands, arms, shoulders, chest, spine, abdomen, and neck must be strengthened in the patient with paraplegia, because he or she must bear full weight on these muscles to ambulate. The triceps and the latissimus dorsi are important muscles used in crutch walking. The muscles of the abdomen and the back also are necessary for balance and for maintaining the upright position. To strengthen these muscles, the patient can do push-ups when in a prone position and sit-ups when in a sitting position. Extending the arms while holding weights (traction weights can be used) also develops muscle strength. Squeezing rubber balls or crumbling newspaper promotes hand strength. With encouragement from all members of the rehabilitation team, the patient with paraplegia can develop the increased exercise tolerance needed for gait training and ambulation activities. The importance of maintaining cardiovascular fitness is stressed to the patient. Alternative exercises to increase the heart rate to target levels are designed within the patient’s abilities. MOBILIZATION. After the spine is stable enough to allow the patient to assume an upright posture, mobilization activities are initiated. A brace or vest may be used, depending on the level of the lesion. A patient whose paralysis is a result of complete transection of the cord can begin weight bearing early, because no further damage can be incurred. The sooner muscles are used, the less chance there is of disuse atrophy. The earlier the patient is brought to a standing position, the less opportunity there is for osteoporotic changes to take place in the long bones. Weight bearing also reduces the possibility of renal calculi and enhances many other metabolic processes. Braces and crutches enable some patients with paraplegia to ambulate for short distances. Ambulation using crutches requires a high expenditure of energy. Motorized wheelchairs and specially equipped vans can provide greater independence and mobility for patients with high-level SCI or other lesions. Every effort should be made to encourage the patient to be as mobile and active as possible.

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Management of Patients With Neurologic Trauma

2099

Preventing Disuse Syndrome Patients are at high risk for development of contractures as a result of disuse syndrome due to the musculoskeletal system changes (atrophy) brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. Contractures can complicate day-to-day care, increasing the difficulty of positioning and decreasing mobility. A number of surgical procedures have been tried with varying degrees of success. These techniques are used if more conservative approaches fail, but the best treatment is prevention.

Promoting Skin Integrity Because these patients spend a great portion of their lives in wheelchairs, pressure ulcers are an ever-present threat. Contributing factors are permanent sensory loss over pressure areas; immobility, which makes relief of pressure difficult; trauma from bumps (against the wheelchair, toilet, furniture, and so forth) that cause unnoticed abrasions and wounds; loss of protective function of the skin from excoriation and maceration due to excessive perspiration and possible incontinence; and poor general health (anemia, edema, malnutrition), leading to poor tissue perfusion. The prevention and management of pressure ulcers are discussed in detail in Chapter 12. The person with tetraplegia or paraplegia must take responsibility for monitoring (or directing monitoring) of his or her skin status. This involves relieving pressure and not remaining in any position for longer than 2 hours, in addition to ensuring that the skin receives meticulous attention and cleansing. The patient is taught that ulcers develop over bony prominences that are exposed to unrelieved pressure in the lying and sitting positions. The most vulnerable areas are identified. The patient with paraplegia is instructed to use mirrors, if possible, to inspect these areas morning and night, observing for redness, slight edema, or any abrasions. While in bed, the patient should turn at 2-hour intervals and then inspect the skin again for redness that does not fade on pressure. The bottom sheet should be checked for wetness and for creases. The patient with tetraplegia or paraplegia who cannot perform these activities is encouraged to direct others to check these areas and prevent ulcers from developing. The patient is taught to relieve pressure while in the wheelchair by doing push-ups, leaning from side to side to relieve ischial pressure, and tilting forward while leaning on a table. The caregiver for the patient with tetraplegia will need to perform these activities if the patient cannot do so independently. A wheelchair cushion is prescribed to meet individual needs, which may change in time with changes in posture, weight, and skin tolerance. A referral can be made to

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a rehabilitation engineer, who can measure pressure levels while the patient is sitting and then tailor the cushion and other necessary aids and assistive devices to the patient’s needs. The diet for the patient with tetraplegia or paraplegia should be high in protein, vitamins, and calories to ensure minimal wasting of muscle and the maintenance of healthy skin, and high in fluids to maintain well-functioning kidneys. Excessive weight gain and obesity should be avoided, because they further limit mobility.

Improving Bladder Management The effect of the spinal cord lesion on the bladder depends on the level of injury, the degree of cord damage, and the length of time after injury. A patient with tetraplegia or paraplegia usually has either a reflex or a nonreflex bladder (see Chapter 12). Both bladder types increase the risk of UTI. The nurse emphasizes the importance of maintaining an adequate flow of urine by encouraging a fluid intake of about 2.5 L daily. The patient should empty the bladder frequently so that there is minimal residual urine and should pay attention to personal hygiene, because infection of the bladder and kidneys almost always occurs by the ascending route. The perineum must be kept clean and dry, and attention must be given to the perianal skin after defecation. Underwear should be cotton (which is more absorbent) and should be changed at least once a day. If an external catheter (condom catheter) is used, the sheath is removed nightly; the penis is cleansed to remove urine and is dried carefully, because warm urine on the periurethral skin promotes the growth of bacteria. Attention also is given to the collection bag. The nurse emphasizes the importance of monitoring for signs of UTI: cloudy, foul-smelling urine or hematuria (blood in the urine); fever; or chills. The female patient who cannot achieve reflex bladder control or self-catheterization may need to wear pads or waterproof undergarments. Surgical intervention may be indicated in some patients to create a urinary diversion.

Establishing Bowel Control The objective of a bowel training program is to establish bowel evacuation through reflex conditioning, a technique described in Chapter 12. If the SCI occurs above the sacral segments or nerve roots and there is reflex activity, the anal sphincter may be massaged (digital stimulation) to stimulate defecation. If the cord lesion involves the sacral segment or nerve roots, anal massage is not performed, because the anus may be relaxed and lack tone. Massage is also contraindicated if there is spasticity of the anal sphincter. The anal sphincter is massaged by inserting a gloved finger (which has been adequately lubricated) 2.5 to 3.7 cm into the rectum and moving it in a circular motion or from side to side. It soon becomes apparent which area triggers the defecation response. This procedure should be

performed at regular time intervals (usually every 48 hours), after a meal, and at a time that will be convenient for the patient at home. The patient also is taught the symptoms of impaction (frequent loose stools; constipation) and is cautioned to watch for hemorrhoids. A diet with sufficient fluids and fibre is essential to developing a successful bowel training program, avoiding constipation, and decreasing the risk of autonomic dysreflexia.

Counselling on Sexual Expression Many patients with tetraplegia and paraplegia can have some form of meaningful sexual relationship, although modifications are necessary. The patient and partner benefit from counselling about the range of sexual expression possible, special techniques and positions, exploration of body sensations offering sensual feelings, and urinary and bowel hygiene as related to sexual activity (Morton & Fontaine, 2013). For men with erectile failure, penile prostheses enable them to have and sustain an erection, and impotence drugs may be helpful. Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), for example, are oral smooth muscle relaxants that cause blood to flow into the penis, resulting in an erection (see Chapter 50). Sexual education and counselling services are included in the rehabilitation services at spinal centres. Small-group meetings in which patients can share their feelings, receive information, and discuss sexual concerns and practical aspects are helpful in producing effective attitudes and adjustments.

Enhancing Coping Mechanisms The impact of the disability and loss becomes marked when the patient returns home. Each time something new enters the patient’s life (e.g., a new relationship, going to work), the patient is reminded anew of his or her limitations. Grief reactions and depression are common Arango-Lasprilla et al., 2011). To work through this depression, the patient must have some hope for relief in the future. The nurse can encourage the patient to feel confident in his or her ability to achieve self-care and relative independence. The role of the nurse ranges from caretaker during the acute phase to teacher, counsellor, and facilitator as the patient gains mobility and independence. The patient’s disability affects not only the patient but also the entire family. In many cases, family therapy is helpful in working through issues as they arise (Simpson & Jones, 2012). Adjustment to the disability leads to the development of realistic goals for the future, making the best of the abilities that are left intact and reinvesting in other activities and relationships. Rejection of the disability causes selfdestructive neglect and noncompliance with the therapeutic program, which leads to more frustration and depression. Crises for which interventions may be sought include social, psychological, marital, sexual, and psychiatric problems. The family usually requires counselling, social services, and other support systems to help them cope with the changes in their lifestyle and socioeconomic status.

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A major goal of nursing management is to help the patient overcome his or her sense of futility and to encourage the patient in the emotional adjustment that must be made before he or she is willing to venture into the outside world. However, an excessively sympathetic attitude on the part of the nurse may cause the patient to develop an overdependence that defeats the purpose of the entire rehabilitation program. The patient is taught and assisted when necessary, but the nurse should avoid performing activities that the patient can do independently with a little effort. This approach to care more than repays itself in the satisfaction of seeing a patient who is demoralized and helpless become independent and find meaning in a newly emerging lifestyle.

Monitoring and Managing Potential Complications SPASTICITY. Muscle spasticity is one of the most problematic complications of tetraplegia and paraplegia. These incapacitating flexor or extensor spasms, which occur below the level of the spinal cord lesion, interfere with both the rehabilitation process and ADLs. Spasticity results from an imbalance between the facilitatory and inhibitory effects on neurons that exist normally. The area of the cord distal to the site of injury or lesion becomes disconnected from the higher inhibitory centres located in the brain, so facilitatory impulses, which originate from muscles, skin, and ligaments, predominate. Spasticity is defined as a condition of increased muscle tone in a muscle that is weak. Initial resistance to stretching is quickly followed by sudden relaxation. The stimulus that precipitates spasm can be obvious, such as movement or a position change, or subtle, such as a slight jarring of the wheelchair. Most patients with tetraplegia or paraplegia have some degree of spasticity. With SCI, the onset of spasticity usually occurs from a few weeks to 6 months after the injury. The same muscles that are flaccid during the period of spinal shock develop spasticity during recovery. The intensity of spasticity tends to peak approximately 2 years after the injury, after which the spasms tend to regress. Management of spasticity is based on the severity of symptoms and the degree of incapacitation. The antispasmodic medication baclofen (Lioresal) is one of the most commonly used agents because it is available in an oral and an intrathecal form. Other medications such as diazepam (Valium) and dantrolene (Dantrium) are also effective in controlling spasm (Morton & Fontaine, 2013). All of the antispasmodic medications cause drowsiness, weakness, and vertigo in some patients. Passive range-of-motion exercises and frequent turning and repositioning are helpful, because stiffness tends to increase spasticity. These activities also are essential in the prevention of contractures, pressure ulcers, and bowel and bladder dysfunction. INFECTION AND SEPSIS. Patients with tetraplegia and paraplegia are at increased risk for infection and sepsis from a variety of sources: urinary tract, respiratory tract, and pressure ulcers. Sepsis remains a major

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cause of complications and death in these patients. Prevention of infection and sepsis is essential through maintenance of skin integrity, complete emptying of the bladder at regular intervals, and prevention of urinary and fecal incontinence. The risk for respiratory infection can be decreased by avoiding contact with people who have symptoms of respiratory infection, performing coughing and deep-breathing exercises to prevent pooling of respiratory secretions, receiving yearly influenza vaccines, and giving up smoking. A high-protein diet is important in maintaining an adequate immune system, as is avoiding factors that may reduce immune system function, such as excessive stress, drug abuse, and excessive alcohol intake. If infection occurs, the patient requires thorough assessment and prompt treatment. Antibiotic therapy and adequate hydration, in addition to local measures (depending on the site of infection), are initiated immediately. UTIs are minimized or prevented by aseptic technique in catheter management, adequate hydration, bladder training program, and prevention of overdistention of the bladder and urinary stasis. Skin breakdown and infection are prevented by maintenance of a turning schedule; frequent back care; regular assessment of all skin areas; regular cleaning and lubrication of the skin; passive rangeof-motion exercise to prevent contractures; pressure relief over broken skin areas, bony prominences, and heels; and wrinkle-free bed sheets. Pulmonary infections are managed and prevented by frequent coughing, turning, and deep-breathing exercises and chest physiotherapy; aggressive respiratory care and suctioning of the airway if a tracheostomy is present; assisted coughing as needed; and adequate hydration. Infections of any kind can be life-threatening. Aggressive nursing interventions are key to prevention, detection, and early management.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients with tetraplegia or paraplegia are at risk for complications for the rest of their lives. Therefore, a major aspect of nursing care is teaching the patient and family about these complications and about strategies to minimize risks. UTIs, contractures, infected pressure ulcers, and sepsis may necessitate hospitalization. Other late complications that may occur include lower extremity edema, joint contractures, respiratory dysfunction, and pain. To avoid these and other complications, the patient and a family member are taught skin care, catheter care, range-of-motion exercises, breathing exercises, and other care techniques. Teaching is initiated as soon as possible and extends into the rehabilitation or long-term care facility and home. In all aspects of care, it is important for the nurse and patient to set mutual goals and discuss the tasks the patient is capable of doing independently and which tasks the patient needs assistance to complete. (See Chapter 12 for a more detailed discussion of rehabilitation.)

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CONTINUING CARE. Referral for home care is often appropriate for assessment of the home setting, patient teaching, and evaluation of the patient’s physical and emotional status. During visits by the home care nurse, teaching about strategies to prevent or minimize potential complications is reinforced. The home environment is assessed for adequacy for care and for safety. Environmental modifications are made, and specialized equipment is obtained, ideally before the patient goes home. The home care nurse also assesses the patient’s and the family’s adherence to recommendations and their use of coping strategies. The use of inappropriate coping strategies (e.g., drug and alcohol use) is assessed, and referrals to counselling are made for the patient and family. Appropriate and effective coping strategies are reinforced. The nurse reviews previous teaching and determines the need for further physical or psychological assistance. The patient’s self-esteem and body image may be very poor at this time. Because people with high levels of social support often report feelings of well-being despite major physical disability, it is beneficial for the nurse to assess and promote further development of the support system and effective coping strategies for each patient. The patient requires continuing, lifelong follow-up by the physician, physical therapist, and other rehabilitation team members, because the neurologic deficit is usually permanent and new deficits, complications, and secondary conditions can develop. These require prompt attention before they take their toll in additional physical impairment, time, morale, and financial costs. It is also useful for the patient to meet with vocational counsellors as he or she may have to change occupation and may require assistance with additional educational or vocational training. The nurse is in a good position to remind patients and family members of the need for continuing health promotion and screening practices. Referral to accessible health care providers and imaging centres is important in health promotion and health screening. Chapter 10 has more information on chronic illness and disability.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. 2. 3. 4. 5. 6. 7.

Attains some form of mobility Contractures do not develop Maintains healthy, intact skin Achieves bladder control, absence of UTI Achieves bowel control Reports sexual satisfaction Shows improved adaptation to environment and others 8. Exhibits reduction in spasticity a. Reports understanding of the precipitating factors b. Uses measures to reduce spasticity 9. Describes long-term management required 10. Exhibits absence of complications

Critical Thinking Exercises 1 A 75-year-old man is brought to the emergency department by his family, who report that he fell approximately 2 weeks ago in the bathroom. The patient does not recall the event. His family states that he is sleeping more than usual and seems forgetful. The patient is prescribed warfarin (Coumadin) daily. What type of injury has he most likely sustained? What type of medical treatment might he undergo? What discharge instructions are warranted for this patient’s family or caregiver? 2 A 19-year-old man with a spinal cord injury at the T6 level reports a severe headache. He is diaphoretic and flushed above the level of injury. His blood pressure is 230/110 mm Hg. What do you suspect is happening? What are the possible causes of his condition, and how would you intervene? What is included in your teaching plan for the patient and family before discharge? 3

A 56-year-old man who is married and the father of two children was involved in a motor vehicle crash 2 days ago, and he sustained a C4 fracture with spinal cord injury. As a result, he has tetraplegia and is on a mechanical ventilator in a neurologic intensive care unit. What recommendations would you make for the care of this patient to prevent secondary injury? What is the evidence base for these recommendations? Identify the criteria used to evaluate the strength of the evidence for these practices.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisk indicates classic reference.

BOOKS American Association of Neuroscience Nurses. (2011). Guide to the care of the patient with intracranial pressure monitoring/external ventricular drainage or lumbar drainage: AANN clinical practice guideline series. Glenview, IL: Author. American Association of Neuroscience Nurses. (2012). Nursing management of adults with severe traumatic brain injury. AANN clinical practice guidelines series. Glenview, IL: Author. Baird, M., & Bethel, S. (2011). Manual of critical care nursing; Nursing interventions and collaborative management (6th ed.). St. Louis, MO: Elsevier/Mosby. Diepenbrock, N. (2012). Quick reference to critical care. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hickey, J. V. (2013). The clinical practice of neurological & neurosurgical nursing (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. McCauley, K. (2010). Continuity of Care. In M. Foreman, K. Milisen & T. Fulmer (Eds.), Critical care nursing of older adults. New York, NY: Springer. Morton, P. G., Fontaine, D., Hudak, C., et al. (2010). Critical care nursing a holistic approach (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Morton, P., & Fontaine, D. (2013). Critical care nursing; A holistic approach (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Terry, C., & Weaver A. (2011). Critical care nursing demystified. New York, NY: McGraw Hill. Urden, L., Stacy, K., & Lough, M. (2013). Critical care nursing; Diagnosis and management (7th ed.). St Louis, MO. Elsevier/Mosby.

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JOURNALS AND ELECTRONIC DOCUMENTS Head Injury Arbour, R. (2013). Brain death: Assessment, controversy, and confounding factors. American Journal of Critical Care Nurses, 33(6), 27–48. **Brain Trauma Foundation. (2007). Guidelines for the management of severe traumatic brain injury (3rd ed.). Available at: www.braintrauma.org *Bergman, K., Fabiano, R., & Blostein, P. (2011). Symptoms selfmanagement measure for TBI. Journal of Trauma Nursing, 18 (3), 143– 148. Iavagnilio, C. (2011). Traumatic brain injury: Improving the patient’s outcome demands timely and accurate diagnosis. Journal of Legal Nurse Consulting, 22(3), 3–10. *Keenan, A., & Joseph, A. (2010). The needs of family members of severe traumatic brain injured patients during critical and acute care: A qualitative study. Canadian Journal of Neuroscience Nursing, 32(3), 25–35. *McNett, M., Doheny, M., Sedlak, C., et al. (2010). Judgments of critical care nurses about risk for secondary brain injury. American Journal of Critical Care, 19 (3), 250–260. Meier, C. (2013). Airway management in patients with brain injury. Emergency Nurse, 21(8), 18–23. *Olson, D., McNett, M., Lewis, L., et al. (2013). Effects of nursing interventions on intracranial pressure. American Journal of Critical Care, 22(5), 431–438. Simpson, G., & Jones, K. (2012). How important is resilience among family members supporting relatives with traumatic brain injury or spinal cord injury? Clinical Rehabilitation, 27 (4), 367–377. Stern, S. (2011). Observing and recording neurological dysfunction. Emergency Nurse, 18 (10), 28–31. Tator, C. (2010). Brain injury is a major problem in Canada and annual incidence is not declining. Canadian Journal of Neurological Sciences, 37 (6), 714–715. Spinal Cord Injury Adams, M. G., & Pelter, M. M. (2005) Bedside monitoring of spinal cord injuries. American Journal of Critical Care, 14(1), 85–86. Arango-Lasprilla, J., Ketchum, J., Starkweather, A., et al. (2011). Factors predicting depression among persons with spinal cord injury 1 to 5 years post injury. Neuro Rehabilitation, 29 , 9–21.

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Canadian Institute for Health Information (2006). Life After Traumatic Spinal Cord Injury: From Inpatient Rehabilitation Back to the Community. Ottawa: Author. Retrieved from https://secure.cihi.ca/free_products/ life_after_spinal_cord_injury_e.pdf Chen, Y., Tang, T., Vogel, L., et al. (2013) Causes of spinal cord injury. Topics in Spinal Cord Injury, 19 (1), 1–8. Ghidini, A., & Simonson, M. (2011). Pregnancy after spinal cord injury; A review of the literature. Topics in Spinal Cord Injury, 16 (3), 93–103. Griffiths, H., & Kennedy, P. (2012). Continuing with life as normal: Positive outcomes following spinal cord surgery. Topics in Spinal Cord Injury, 18 (3), 241–252. Malave, A., Alhomsi, M., Demirer, E., et al. (2010). Impact of diaphragmatic pacing in weaning of critically ill spinal cord injury patients. Chest, 143(5), 1206–1207. Pelatt, G. (2010). Spinal surgery for acute traumatic spinal cord injury: Implications for nursing. British Journal of Neuroscience Nursing, 6 (6), 271–275. Sarhan, F., Saif, D. & Saif, A. (2013). An overview of traumatic spinal cord injury: Part 2. Acute management. British Journal of Neuroscience Nursing, 9 (3), 138–144.

RESOURCES American Association of Neuroscience Nurses (AANN); http://www. aann.org American Association of Spinal Cord Injury Nurses (AASCIN): http:// www.geronurseonline.org/MainMenuCategory/PartnerOrganizations/ AASCIN.html American Spinal Injury Association (ASIA); http://www.asia-spinalinjury.org/ Brain Injury Association of Canada; http://www.biac-aclc.ca/ Canadian and American Spinal Research Organization; http://www.csro.com/ Canadian Association of Neuroscience Nurses; http://www.cann.ca/ Canadian Disabled Individuals Association; http://www.disabledindivid uals.ca/ Canadian Paraplegic Association; http://www.spinalcordinjurycanada.ca/ World Federation of Neuroscience Nurses; http://www.wfnn.nu/

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65 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies Adapted by Jim M. Wohlgemuth

Learning Objectives On completion of this chapter, the learner will be able to: 1. Differentiate among the infectious disorders of the nervous system according to causes, manifestations, medical care, and nursing management. 2. Describe the pathophysiology, clinical manifestations, and medical and nursing management of multiple sclerosis, myasthenia gravis, and Guillain–Barré syndrome. 3. Use the nursing process as a framework for care of patients with multiple sclerosis and Guillain–Barré syndrome. 4. Describe disorders of the cranial nerves, their manifestations, and indicated nursing interventions. 5. Develop a plan of nursing care for the patient with a cranial nerve disorder.

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The diverse group of neurologic disorders that make up infectious and autoimmune disorders and cranial and peripheral neuropathies presents unique challenges for nursing care. Infectious processes of the nervous system may cause death or permanent dysfunction. Cranial and peripheral nerve disorders may affect the patient’s comfort, functional independence, and self-esteem. Autoimmune disorders usually have a slow, progressive course which requires the nurse to manage symptoms and to facilitate the patient and family’s understanding of the disease process. Nurses caring for patients with these disorders must have a clear understanding of the pathologic processes, clinical outcomes, and other issues patients and their families may confront, such as adaptation to the effects of the disease, potential changes in family dynamics, and, possibly, end-of-life issues.

INFECTIOUS NEUROLOGIC DISORDERS The infectious disorders of the nervous system include meningitis, brain abscesses, various types of encephalitis, and Creutzfeldt–Jakob and variant Creutzfeldt–Jakob disease. The clinical manifestations, assessment, and diagnostic findings as well as the medical and nursing management are related to the specific infectious process.

Meningitis Meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid (CSF)-filled subarachnoid space (Hannon, Pooler, & Porth, 2010). Meningitis is classified as aseptic or septic. In aseptic meningitis, bacteria are not the cause of the inflammation; the cause is viral or secondary to lymphoma, leukemia, or brain abscess. Septic meningitis, also named bacterial meningitis, refers to meningitis caused by bacteria, most commonly Neisseria meningitidis, although Haemophilus influenzae and Streptococcus pneumoniae are also causative agents. Factors that increase the risk for developing bacterial meningitis include tobacco use and viral upper respiratory infection because they increase the amount of droplet production. Otitis media and mastoiditis increase the risk of

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bacterial meningitis because the bacteria can cross the epithelium membrane and enter the subarachnoid space. Persons with immune system deficiencies are also at greater risk for developing bacterial meningitis. Outbreaks of N. meningitidis infection are most likely to occur in dense community groups, such as college campuses and military installations. Although infections occur year round, the peak incidence is in the winter and early spring. Factors that increase the risk of bacterial meningitis include tobacco use and viral upper respiratory infection, because they increase the amount of droplet production. Otitis media and mastoiditis increase the risk of bacterial meningitis, because the bacteria can cross the epithelial membrane and enter the subarachnoid space. People with immune system deficiencies are also at greater risk for development of bacterial meningitis.

Pathophysiology Meningeal infections generally originate in one of two ways: through the bloodstream as a consequence of other infections or by direct spread, such as might occur after a traumatic injury to the facial bones or secondary to invasive procedures. N. meningitidis concentrates in the nasopharynx and is transmitted by secretion or aerosol contamination. Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS) and as a complication of Lyme disease (Chart 65-1). Once the causative organism enters the bloodstream, it crosses the blood–brain barrier and proliferates in the CSF. The host immune response stimulates the release of cell wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. Because the cranial vault contains little room for expansion, the inflammation may cause increased intracranial pressure (ICP). CSF circulates through the subarachnoid space, where inflammatory cellular materials from the affected meningeal tissue enter and accumulate. The prognosis for bacterial meningitis depends on the causative organism, the severity of the infection and illness, and the timeliness of treatment. Acute fulminant presentation may include adrenal damage, circulatory collapse, and widespread hemorrhages (Waterhouse– Friderichsen syndrome). This syndrome is the result of endothelial damage and vascular necrosis caused by the

Glossary ataxia: impaired coordination of movements bulbar paralysis: immobility of muscles innervated by cranial nerves with their cell bodies in the lower portion of the brain stem diplopia: double vision, or the awareness of two images of the same object occurring in one or both eyes dyskinesia: impaired ability to execute voluntary movements dysphagia: difficulty swallowing, causing the patient to be at risk for aspiration dysphonia: voice impairment or altered voice production

neuropathy: general term indicating a disorder of the nervous system paresthesia: sensation of numbness or tingling or a “pins and needles” sensation prion: particle smaller than a virus that is resistant to standard sterilization procedures spasticity: muscular hypertonicity with increased resistance to stretch often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes spongiform: having the appearance or quality of a sponge

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CHART 65-1

Meningitis in Specific Populations Meningitis can occur as a complication of other diseases and is an opportunistic infection seen with greater frequency in patients who are immunocompromised.

Meningitis in Patients With Acquired Immunodeficiency Syndrome (AIDS) • Aseptic, cryptococcal, and tuberculous forms of meningitis have been reported in patients with AIDS.

• Acute and chronic forms of aseptic meningitis may occur

with AIDS; both are accompanied by headache, but signs of meningeal irritation usually occur with the acute form. • Aseptic meningitis may be accompanied by cranial nerve palsies. The meningitis is thought to be related to direct infection of the central nervous system by human immunodeficiency virus (HIV) because it can be isolated from the cerebrospinal fluid (CSF). • Cryptococcal meningitis is the most common fungal infection of the central nervous system in patients with AIDS. Patients may experience headache, nausea, vomiting, seizures, confusion, and lethargy. Treatment consists of IV administration of amphotericin B followed by fluconazole. Maintenance therapy with fluconazole may be necessary to prevent relapse. • Some immunosuppressed patients develop few if any symptoms because of blunted inflammatory responses; others develop atypical features.

Meningitis in Patients With Lyme Disease • Lyme disease is a multisystem inflammatory process • • • • • •

caused by the tick-transmitted spirochete Borrelia burgdorferi. Neurologic abnormalities are seen in later stages (stages 2 or 3). Stage 2 occurs with the start of a characteristic rash or 1 to 6 months after the rash has disappeared. Neurologic abnormalities include aseptic meningitis, chronic lymphocytic meningitis, and encephalitis. Cranial nerve inflammation, including Bell’s palsy and other peripheral neuropathies, is common. Stage 3 (the chronic form of the disease) begins years after the initial tick infection and is characterized by arthritis, skin lesions, and neurologic abnormalities. Most patients with stage 2 and 3 Lyme disease are treated with IV antibiotics, usually ceftriaxone or penicillin G. Meningeal and systemic symptoms begin to improve within days, although other symptoms, such as headache, may persist for weeks.

bacteria. Complications include visual impairment, deafness, seizures, paralysis, hydrocephalus, and septic shock.

Clinical Manifestations Headache and fever are frequently the initial symptoms. Fever tends to remain high throughout the course of the illness. The headache is usually either steady or throbbing and very severe as a result of meningeal irritation (Stephen, Skillen, & Day, 2012). Meningeal irritation results in a number of other well-recognized signs common to all types of meningitis: • Neck mobility: A stiff and painful neck (nuchal rigidity) can be an early sign and any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Normally the neck is supple, and the patient can easily bend the head and neck forward. • Positive Kernig’s sign: When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended (Fig. 65-1). • Positive Brudzinski’s sign: When the patient’s neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity (see Fig. 65-1). Brudzinski’s sign is a more sensitive indicator of meningeal irritation than Kernig’s sign. • Photophobia (extreme sensitivity to light): This finding is common, although the cause is unclear. A rash can be a striking feature of N. meningitidis infection, occurring in about half of patients with this type of meningitis. Skin lesions develop, ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. Disorientation and memory impairment are common early in the course of the illness. The changes depend on the severity of the infection as well as the individual response to the physiologic processes. Behavioural manifestations are also common. As the illness progresses, lethargy, unresponsiveness, and coma may develop. Seizures can occur and are the result of areas of irritability in the brain. ICP increases secondary to diffuse brain swelling or hydrocephalus (van de Beek, de Gans, Tunkel, et al., 2006). The initial signs of increased ICP include decreased level of consciousness (LOC) and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may herniate through the tentorium, causing pressure

Pain Pain

Kernig’s sign

Brudzinski’s sign

FIGURE 65-1. Testing for meningeal irritation. A, Kernig’s sign. B, Brudzinski’s sign.

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on the brain stem. Brain stem herniation is a life-threatening event that causes cranial nerve dysfunction and depresses the centres of vital functions, such as the medulla. See Chapter 62 for discussion of the patient with a change in LOC or increased ICP. An acute fulminant infection occurs in about 10% of patients with meningococcal meningitis, producing signs of overwhelming septicemia: an abrupt onset of high fever, extensive purpuric lesions (over the face and extremities), shock, and signs of disseminated intravascular coagulation (DIC). Death may occur within a few hours after onset of the infection.

Assessment and Diagnostic Findings If the clinical presentation suggests meningitis, diagnostic testing is conducted to identify the causative organism. A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is used to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture. Bacterial culture and Gram staining of CSF and blood are key diagnostic tests. CSF studies demonstrate low glucose, high protein levels, and high white blood cell count (Hannon et al., 2010). Gram staining allows for rapid identification of the causative bacteria and initiation of appropriate antibiotic therapy (Hannon et al., 2010).

Prevention There are five serogroups of invasive meningococcal disease (IMD): A, B, C, Y, and W135, with serogroup C being the most common cause of meningococcal outbreaks in Canada (National Advisory Committee on Communicable Diseases, 2013). Since 1985, the incidence of IMD in Canada is 2 per 100,000 people per year, or about 298 cases each year, occurring mainly during the winter months. Incidence is highest in children younger than 1 year of age, then declines, and then there is a smaller peak in the 15- to 19-year age group. While there have been no outbreaks of meningitis in college/university residences in Canada, increased numbers of cases have been noted in the United States and the United Kingdom. Routine immunization is recommended for military recruits: meningococcal C conjugate for those staying in Canada and quadrivalent polysaccharide meningococcal vaccine for those posted outside of Canada. For infants, two doses of meningococcal C conjugate vaccine are given 2 to 3 months apart, beginning at 3 months of age. Routine immunization for health care workers is not recommended. Household contacts of people with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin) (Karch, 2014). Therapy should be started as soon as possible after contact; a delay in the initiation of therapy will limit the effectiveness of the prophylaxis. Vaccination should also be considered as an adjunct to antibiotic chemoprophylaxis for anyone living with a person who develops meningococcal infection. Vaccination for children and at-risk adults should be encouraged to avoid meningitis caused by H. influenzae and S. pneumoniae.

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Medical Management Successful outcomes depend on the early administration of an antibiotic that crosses the blood–brain barrier into the subarachnoid space in sufficient concentration to halt the multiplication of bacteria. Initial choices of antibiotics are broad spectrum coverage with a third-generation cephalosporin, vancomycin, and a Penicillin antibiotic such as ampicillin, with adjustment of antibiotic regimen as required by CSF culture results (Hannon et al., 2010). The resulting rapid death of the pathogen caused by the antibiotics may potentially produce inflammation which is treated with adjunctive corticosteroid therapy administered with the initial dose of antibiotics (Hannon et al., 2010). Dehydration and shock are treated with fluid volume expanders. Seizures, which may occur early in the course of the disease, are controlled with phenytoin (Dilantin). Increased ICP is treated as necessary (see Chapter 62).

Nursing Management The patient with meningitis is critically ill; therefore, many of the nursing interventions are collaborative with the physician, respiratory therapist, and other members of the health care team. The patient’s prognosis may depend on sound nursing judgment and supportive care. Neurologic status and vital signs are continually assessed. Pulse oximetry and arterial blood gas values are used to quickly identify the need for respiratory support if increasing ICP compromises the brain stem. Insertion of a cuffed endotracheal tube (or tracheotomy) and mechanical ventilation may be necessary to maintain adequate tissue oxygenation. Blood pressure (usually monitored using an arterial line) is assessed for incipient shock, which precedes cardiac or respiratory failure. Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload. Fever also increases the workload of the heart and cerebral metabolism. ICP will increase in response to increased cerebral metabolic demands. Therefore, measures are taken to reduce body temperature as quickly as possible. Other important components of nursing care include the following measures: • Protecting the patient from injury secondary to seizure activity or altered LOC • Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected • Preventing complications associated with immobility, such as pressure ulcers and pneumonia • Instituting droplet precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious) Any sudden, critical illness can be devastating to the family. Because the patient’s condition is often critical and the prognosis guarded, the family needs to be informed about the patient’s condition and permitted to see the patient at intervals, even though the priority is to address the patient’s need for immediate and intensive treatment. An important aspect of the nurse’s role is to support the family and assist them in identifying others who can be supportive to them during the crisis.

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Brain Abscess Brain abscesses are rare in immunocompetent people; they are more frequently diagnosed in people who are immunosuppressed as a result of an underlying disease or use of immunosuppressive medications.

Pathophysiology A brain abscess is a collection of infectious material within the tissue of the brain. Bacteria are the most common causative organisms. An abscess may occur by direct contact with brain tissue from intracranial trauma or surgery, penetrating head injury, tongue piercing, or by the spread of infection from the lungs, gums, tongue, or heart, or from a wound or intra-abdominal infection (Hannon et al., 2010). To prevent brain abscess, otitis media, mastoiditis, rhinosinusitis, dental infections, and systemic infections should be treated promptly.

Clinical Manifestations The clinical manifestations of a brain abscess result from alterations in intracranial dynamics (edema, brain shift), infection, or the location of the abscess (Chart 65-2). Headache, usually worse in the morning, is the most prevalent symptom. Fever and vomiting is also common. Focal deficits such as weakness and decreasing vision may occur, depending on the area of brain that is involved. As the abscess expands, symptoms of increased ICP such as decreasing LOC and seizures are observed.

Assessment and Diagnostic Findings Neuroimaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scanning identify

CHART 65-2

Assessing for Brain Abscesses Be alert for the following signs and symptoms:

Frontal Lobe Hemiparesis Aphasia (expressive) Seizures Frontal headache

Temporal Lobe Localized headache Changes in vision Facial weakness Aphasia

Cerebellar Abscess Occipital headache Ataxia (inability to coordinate movements) Nystagmus (rhythmic, involuntary movements of the eye)

the size and location of the abscess. The MRI or CT scans reveal a ring around a hypodense area (Mazzoni, Pearson, & Rowland, 2006). Aspiration of the abscess, guided by CT or MRI, is the best method to culture and identify the infectious organism. Blood cultures are obtained if the abscess is believed to arise from a distant source. Chest x-ray is performed to rule out predisposing lung infections and an electroencephalogram (EEG) may help localize the lesion (Hickey, 2009).

Medical Management Treatment is aimed at controlling increased ICP, draining the abscess, and providing antimicrobial therapy directed at the abscess and the primary source of infection. Large IV doses of antibiotics are administered to penetrate the blood–brain barrier and reach the abscess. The choice of the specific antibiotic medication is based on culture and sensitivity testing and directed at the causative organism. A stereotactic CT-guided aspiration may be used to drain the abscess and identify the causative organism. Corticosteroids may be prescribed to help reduce the inflammatory cerebral edema if the patient shows evidence of an increasing neurologic deficit. Antiseizure medications (phenytoin, phenobarbital) may be prescribed to prevent or treat seizures.

Nursing Management Nursing care focuses on continuing to assess the neurologic status, administering medications, assessing the response to treatment, and providing supportive care. Ongoing neurologic assessment alerts the nurse to changes in ICP, which may indicate a need for more aggressive intervention. The nurse also assesses and documents the responses to medications. Blood laboratory test results, specifically blood glucose and serum potassium levels, need to be closely monitored when corticosteroids are prescribed. Administration of insulin or electrolyte replacement may be required to return these values to normal or acceptable levels. Patient safety is another key nursing responsibility. Injury may result from decreased LOC or falls related to motor weakness or seizures (Hughes, 2008). The patient with a brain abscess is very ill, and neurologic deficits, such as hemiparesis, seizures, visual deficits, and cranial nerve palsies, may remain after treatment. Seizures are common sequelae. The nurse must assess the family’s ability to express distress at the patient’s condition, cope with the patient’s illness and deficits, and obtain support.

Herpes Simplex Virus Encephalitis Encephalitis is an acute inflammatory process of the brain tissue. Herpes simplex virus (HSV) encephalitis is the most common form of acute nonepidemic viral encephalitis in the world. There are two herpes simplex viruses: HSV-1 and HSV-2. HSV-1 typically affects children and adults.

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Pathophysiology The pathology of encephalitis involves local necrotizing hemorrhage that becomes more generalized, followed by edema. There is also progressive deterioration of nerve cell bodies (Hannon et al., 2010).

Clinical Manifestations The initial symptoms of HSV-1 encephalitis include fever, headache, and confusion. Focal neurologic symptoms reflect the areas of cerebral inflammation and necrosis and include fever, headache, behavioural changes, focal seizures, dysphasia, hemiparesis, and altered LOC (Hannon et al., 2010).

Assessment and Diagnostic Findings Neuroimaging studies, such as EEG and CSF examination, are used to diagnose HSV encephalitis. MRI is the neuroimaging study of choice for detection of early changes caused by HSV-1; the study shows edema in the temporal lobe. The EEG reveals diffuse slowing or focal changes in the temporal lobe. Lumbar puncture often reveals a high opening pressure and low glucose and high protein levels in CSF samples. Viral cultures are almost always negative. The polymerase chain reaction (PCR) is the standard test for early diagnosis of HSV-1 encephalitis. PCR identifies the DNA bands of HSV-1 in the CSF. The validity of PCR is very high between the 3rd and 10th days after symptom onset.

Medical Management Acyclovir (Zovirax), an antiviral agent, is the medication of choice in the treatment of HSV (Hannon et al., 2010). Early administration of antiviral agents is usually well tolerated by the patient and improves the prognosis associated with HSV-1 encephalitis. The mode of action is inhibition of viral DNA replication. To prevent relapse, treatment should continue for up to 3 weeks. Slow IV administration over 1 hour prevents crystallization of the medication in the urine. The usual dose of acyclovir is decreased if the patient has a history of renal insufficiency. Studies are in progress to determine the effectiveness of an oral agent, valacyclovir hydrochloride (Valtrex), in the treatment of HSV-1 encephalitis.

Nursing Management Assessment of neurologic function is key to monitoring the progression of disease. Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Seizures and altered LOC require care directed at injury prevention and safety. Nursing care addressing patient and family anxieties is ongoing throughout the illness. Monitoring of blood chemistry test results and urinary output alert the nurse to the presence of renal complications related to antiviral therapy.

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Arthropod-Borne Virus Encephalitis Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito. In cases of West Nile virus, humans are the secondary host; birds are the primary host. Arbovirus infection (transmitted by arthropod vectors) occurs in specific geographic areas during the summer and fall. In the United States, West Nile and St. Louis are the most common types of arboviral encephalitis; both are members of the Japanese encephalitis serogroup. West Nile virus, which may cause encephalitis, was first detected in North America in 1999 and is now present in Canada, the United States, and Mexico.

Pathophysiology Viral replication occurs at the site of the mosquito bite. The host immune response attempts to control viral replication. If the immune response is inadequate, viremia will ensue. The virus gains access to the central nervous system (CNS) via the cerebral capillaries, resulting in encephalitis. It spreads from neuron to neuron, predominantly affecting the cortical grey matter, the brain stem, and the thalamus. Meningeal exudates compound the clinical presentation by irritating the meninges and increasing ICP.

Clinical Manifestations All arboviral encephalitis begins with early flulike symptoms, but specific neurologic manifestations depend on the viral type. A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. Signs and symptoms specific to West Nile encephalitis include a maculopapular or morbilliform rash on the neck, trunk, and arms; enlarged lymph nodes and legs; and flaccid paralysis (Hannon et al., 2010). Both West Nile and St. Louis encephalitis can result in parkinsonianlike movements, reflecting inflammation of the basal ganglia. Seizures, a poor prognostic indicator, are present in both types of encephalitis but are more common in the St. Louis type (Hannon et al., 2010).

Assessment and Diagnostic Findings After a brief febrile prodrome, neurologic symptoms reflect the area of the brain that is involved. Neuroimaging and CSF evaluation are useful in the diagnosis of arboviral encephalitis. The MRI scan demonstrates inflammation of the basal ganglia in cases of St. Louis encephalitis and inflammation in the periventricular area in cases of West Nile encephalitis. Immunoglobulin M antibodies to West Nile virus are observed in serum and CSF. Serum cultures are not useful, because the viremia is brief. PCR evaluation of CSF may demonstrate viral ribonucleic acid (RNA) (National Institute of Allergies and Infectious Diseases [NIAID] 2008).

Medical Management No specific medication for arboviral encephalitis exists. Medical management includes controlling the seizures

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and the increased ICP. Interferon may be useful in treating St. Louis encephalitis. Neuropsychiatric complications, such as emotional outbursts and other behaviour changes, occur frequently. Although no vaccine is publically available for St. Louis encephalitis, evidence suggests that a vaccine may decrease the risk of acquiring West Nile encephalitis, and a new vaccine is being tested in the United States (NIAID, 2008).

Nursing Management If the patient is very ill, hospitalization may be required. The nurse carefully assesses neurologic status and identifies improvement or deterioration in the patient’s condition. Injury prevention is key in light of the potential for falls or seizures. Arboviral encephalitis may result in death or lifelong residual health issues such as neurologic deficits and seizures. The family will need support and teaching to cope with these outcomes. Public education addressing the prevention of arboviral encephalitis is a key nursing role. Clothing that provides coverage and insect repellents containing 25% to 30% diethyltoluamide (DEET) should be used on exposed clothing and skin in high-risk areas to decrease mosquito and tick bites. Screens should be in good repair in the home, and standing water should be removed.

Fungal Encephalitis Fungal infections of the CNS occur rarely in healthy people. The presentation of fungal encephalitis is related to geographic area or to an immune system that is compromised due to disease or immunosuppressive medication. Causes of fungal infections include Cryptococcus neoformans, Blastomyces dermatitidis, Histoplasma capsulatum, Aspergillus fumigatus, Candida, and Coccidioides immitis (Goetz, 2007). C. immitis is found mainly in California, Arizona, New Mexico, and Texas. B. dermatitidis exists in the Southeastern United States and in the Ohio, St. Lawrence, and Mississippi River basins. It is a risk for coal miners, construction workers, and farmers. C. neoformans is associated with exposure to bird droppings and may be seen in bird handlers.

Pathophysiology The fungal spores enter the body via inhalation. They initially infect the lungs, causing vague respiratory symptoms. The fungi may enter the bloodstream, causing a fungemia. If the fungemia overwhelms the person’s immune system, the fungus may spread to the CNS. The fungal invasion may cause meningitis, encephalitis, or brain abscess (Goetz, 2007).

Clinical Manifestations The common symptoms of fungal encephalitis include fever, malaise, headache, meningeal signs, and change in LOC or cranial nerve dysfunction. Symptoms of increased ICP related to hydrocephalus often occur. C. neoformans and C. immitis are associated with specific skin lesions. H. capsulatum is associated with seizures, and A. fumigatus may cause ischemic or hemorrhagic strokes (Goetz, 2007).

Assessment and Diagnostic Findings A history of immunosuppression associated with AIDS or use of immunosuppressive medications may indicate fungal disease of the brain. Occupational and travel history may point to a fungal cause of CNS infection. Infections caused by H. capsulatum and C. immitis will demonstrate fungal antibodies in serologic tests. The CSF usually demonstrates elevated white cell and protein levels; glucose levels are decreased. C. neoformans is easily identified in CSF fungal cultures. Candida may be cultured from the blood or CSF. To identify B. dermatitidis, cisternal or ventricular cultures of CSF may need to be obtained. A. fumigatus is difficult to isolate in CSF and is diagnosed by lung biopsy (Goetz, 2007). Neuroimaging is used to identify CNS changes related to fungal infection. MRI is the study of choice; it demonstrates areas of hemorrhage, abscess, or enhanced meninges indicating inflammation.

Medical Management Medical management is directed at the causative fungus and the neurologic consequences of the infection. Seizures are controlled by standard antiseizure medications. Increased ICP is controlled by repeated lumbar punctures or shunting of CSF. Antifungal agents are administered for a specific period to cure the infection in patients with competent immune systems. Patients with compromised immune systems receive antifungal therapy until the infection is controlled, after which they receive a maintenance dose of the medication for an indefinite period. Although the dose and duration of treatment depend on the causative fungi, amphotericin B is the standard antifungal agent used in treatment (Karch, 2014). Dosing depends on the causative organism, and it is usually administered by IV. The most common adverse reactions are fever, chills, nausea and vomiting, and hypokalemia (Karch, 2014). Renal insufficiency is a serious reaction to amphotericin B that can occur. Fluconazole (Diflucan) or flucytosine (Ancobon) may be administered orally in conjunction with amphotericin B as maintenance therapy. Potential side effects of fluconazole include nausea, vomiting, and a transient increase in liver enzymes. The most common adverse reaction to flucytosine is bone marrow suppression. Therefore, patients receiving flucytosine should have leukocyte and platelet counts monitored regularly.

Nursing Management ICP will increase if hydrocephalus develops and the inflammatory response progresses. Nursing assessment aimed at early identification of increased ICP is necessary to ensure early control and management. (See Chapter 62 for management of the patient with increased ICP.) Administering nonopioid analgesic agents, limiting environmental stimuli, and positioning may optimize patient comfort. Administering diphenhydramine (Benadryl) and acetaminophen (Tylenol) approximately 30 minutes before giving amphotericin B may prevent flulike side effects. If renal insufficiency develops, the dose may need

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to be reduced. Increasing levels of serum creatinine and blood urea nitrogen (BUN) may alert the nurse to the development of renal insufficiency and the need to address the patient’s renal status. Providing support assists the patient and family to cope with the illness. Workup of the patient for immunodeficiency diseases such as AIDS may put additional stress on the family. The nurse may need to mobilize community support systems for the patient and family, because the recovery may be long.

Creutzfeldt–Jakob and Variant Creutzfeldt–Jakob Disease Creutzfeldt–Jakob disease (CJD) and variant Creutzfeldt– Jakob disease (vCJD) belong to a group of degenerative, infectious neurologic disorders called transmissible spongiform encephalopathies (TSEs). CJD is very rare and has no identifiable cause. vCJD is the human variation of bovine spongiform encephalopathy (BSE); it results from the ingestion by humans of prions in infected beef. TSEs are caused by prions, proteinaceous particles that are smaller than a virus and are resistant to standard methods of sterilization. Although CJD and vCJD have distinct clinical features, one characteristic they share is a lack of CNS inflammation. In both diseases, the symptoms are progressive, there is no definitive treatment, and the outcome is fatal. Approximately 1 to 2 persons per 1 million are affected worldwide. To date there have been about 676 definite or probable death from CJD in Canada (Public Health Agency of Canada, 2014).

Pathophysiology The prion is a unique pathogen because it lacks nucleic acid, which enables the organism to withstand conventional means of sterilization. How the prion replicates in the absence of nucleic acid is unknown (Glatzel, Stoeck, Seeger, et al., 2005). In both CJD and vCJD, the prion crosses the blood–brain barrier and is deposited in brain tissue and causes degeneration of brain tissue. Cell death occurs, and spongy vacuoles are produced in the brain (spongiform changes). The spongiform vacuoles are surrounded by amyloid plaque. Ninety percent of the cases of CJD appear sporadically (Goetz, 2007). Although it is not transmittable by typical human contact, 5% of cases of sporadic CJD result from contaminated neurosurgical instruments, cadaver-derived growth factor, or corneal transplants. Ten percent of cases appear to be familial (Goetz, 2007). In the mid-1980s, BSE was identified in dairy cattle herds in the United Kingdom. One-third of the cattle were infected, and 200,000 animals died of the disease. Researchers believed that BSE could not be transmitted to humans; however, in 1996, the first case of vCJD was described. The mode of transmission was linked to the ingestion of beef contaminated with neurologic tissue. As well, all of the people who develop vCJD have a specific, shared genotype (Goetz, 2007). Following an outbreak of BSE in Alberta, Canada now prohibits feeding cattle food

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containing ground-up animal materials, including neurologic tissue.

Clinical Manifestations Creutzfeldt–Jakob disease and vCJD have several clinically distinct features. Psychiatric symptoms occur early in vCJD, whereas they are a late symptom in CJD. The presenting symptoms of vCJD include affective symptoms (i.e., behavioural changes), sensory disturbance, and limb pain. Muscle spasms and rigidity, dysarthria, incoordination, cognitive impairment, and sleep disturbances follow (Goetz, 2007). Patients with sporadic CJD present with mental deterioration, ataxia, and visual disturbance. Memory loss, involuntary movement, paralysis, and mutism occur as the disease progresses. After clinical presentation, people with vCJD survive an average of 14 months; those with CJD survive for about 6 months (Goetz, 2007).

Assessment and Diagnostic Findings Historically, brain biopsy was used to diagnose CJD. The three diagnostic tests currently used in suspicious clinical presentations to support the diagnosis of CJD are immunologic assessment, electroencephalography, and MRI scanning. Immunologic assessment of CSF detects a protein kinase inhibitor called 14-3-3. The presence of this inhibitor indicates neuronal cell death, which is not specific to CJD but does support the diagnosis. The EEG reveals a characteristic pattern over the duration of the disease. After initial slowing, the EEG shows periodic activity. Later in the course of the disease, the EEG shows burst-suppressions characterized by periodic spikes alternating with slow periods. The MRI scan demonstrates symmetric or unilateral hyperintense signals arising from the basal ganglia. Patients with vCJD do not demonstrate EEG or CSF changes, and the MRI scan shows bilateral hyperintensity of the posterior thalamus (Goetz, 2007). The prion associated with vCJD has been shown to accumulate in the tonsils and other lymphoreticular tissues; therefore, tonsillar biopsy may be used in the diagnosis of vCJD.

Medical Management After the onset of specific neurologic symptoms, progression of disease occurs quickly. There is no effective treatment for CJD or vCJD (Public Health Agency of Canada, 2012). The care of the patient is supportive and palliative. Goals of care include prevention of injury related to immobility and dementia, promotion of patient comfort, and provision of support and education for the family.

Nursing Management The nursing care of patients is primarily supportive and palliative. Psychological and emotional support of patients and families throughout the course of the illness is needed. Care includes providing for a dignified death and supporting the family through the processes of grief and loss. Hospice services are appropriate either at home or at an

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inpatient facility. (See Chapter 18 for an in-depth discussion of end-of-life issues.) Prevention of disease transmission is an important part of nursing care. Although patient isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. In the operating room, it is recommended that disposable instruments be used and then incinerated, because conventional methods of sterilization do not destroy the prion. The World Health Organization has guidelines that outline the stringent sterilization methods that must be used to destroy prions on surfaces.

AUTOIMMUNE PROCESSES Autoimmune nervous system disorders include multiple sclerosis (MS), myasthenia gravis, and Guillain–Barré syndrome.

Multiple Sclerosis Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the CNS. Demyelination refers to the destruction of myelin, the fatty and protein material that surrounds certain nerve fibres in the brain and spinal cord; it results in impaired transmission of nerve impulses (Fig. 65-2). MS may occur at any age but typically manifests in young adults between the ages of 20 and 40 years; it affects women more frequently than men (Hannon et al., 2010).

Neuron Myelin sheath

Axon of nerve fibre

A Nerve fibre

B

Myelin

C

D FIGURE 65-2. The process of demyelination. A and B depict a normal

nerve cell and axon with myelin. C and D show the slow disintegration of myelin, resulting in a disruption in axon function.

The precise cause of MS remains unknown (Ward-Abel, Vernon, & Warner, 2014). Autoimmune activity results in demyelination, but the sensitized antigen has not been identified. Multiple factors play a role in the initiation of the immune process. Geographic prevalence is highest in countries that are in Northern latitudes (Nazarko, 2013). It is believed that some environmental exposure at a young age may play a role in the development of MS later in life. Genetic predisposition is indicated by the presence of a specific cluster (haplotype) of human leukocyte antigens (HLAs) on the cell wall. Its presence may increase susceptibility to factors, such as viruses, that trigger the autoimmune response activated in MS. A specific virus capable of initiating the autoimmune response has not been identified.

Pathophysiology Sensitized T and B lymphocytes cross the blood–brain barrier; their function is to check the CNS for antigens and then leave. In MS, sensitized T cells remain in the CNS and promote the infiltration of other agents that damage the immune system. The immune system attack leads to inflammation that destroys myelin (which normally insulates the axon and speeds the conduction of impulses along the axon) and the oligodendroglial cells that produce myelin in the CNS. Demyelination interrupts the flow of nerve impulses and results in a variety of manifestations, depending on the nerves affected. Plaques appear on demyelinated axons, further interrupting the transmission of impulses. Demyelinated axons are scattered irregularly throughout the CNS (Fig. 65-3). The areas most frequently affected are the optic nerves, chiasm, and tracts; the cerebrum; the brain stem and cerebellum; and the spinal cord. The axons themselves begin to degenerate, resulting in permanent and irreversible damage (Hannon et al., 2010).

Clinical Manifestations The course of MS may assume many different patterns (Fig. 65-4) (Lublin & Reingold, 1996). In some patients, the disease follows a benign course, and symptoms are so mild that the patient does not seek health care or treatment. There are four types of MS: relapsing remitting (RR), primary progressive, secondary progressive, and progressive relapsing. Between 80% and 85% of MS cases begin with an RR course with complete recovery between clearly defined symptomatic exacerbations. With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline. About 50% of those with the RR course of MS progress to a secondary progressive course, in which disease progression occurs with or without relapses. Around 10% of patients have a primary progressive course, in which disabling symptoms steadily increase, with rare plateaus and temporary improvement. Primary progressive MS may result in quadriparesis, cognitive dysfunction, visual loss, and brain stem syndromes. The least common presentation (about 5% of cases) is the progressive relapsing course. It is characterized by relapses with continuous disabling progression between exacerbations (Hannon et al., 2010).

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3. Secondary progressive

4. Progressive-relapsing Increasing disability

Time

Increasing disability

Time

Time

A

B FIGURE 65-3. Multiple sclerosis. A, A computed tomography scan of

brain demonstrates an area of demyelination in the periventricular white matter of the right frontal lobe. The plaque is perpendicular to the lateral ventricle, a typical finding in multiple sclerosis. B, A magnetic resonance image of the spinal cord in the same patient highlights another typical finding: a flame-shaped area of demyelination within the midcervical region of the spinal cord. (Courtesy of the Danbury Hospital Department of Radiology.)

2. Primary progressive Increasing disability

Increasing disability

1. Relapsing-remitting

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Time

FIGURE 65-4. Types and courses of multiple sclerosis (MS). 1, Relapsingremitting (RR) MS is characterized by clearly acute attacks with full recovery or with sequelae and residual deficit upon recovery. Periods between disease relapses are characterized by lack of disease progression. 2, Primary progressive (PP) MS is characterized by disease showing progression of disability from onset, without plateaus and temporary minor improvements. 3, Secondary progressive (SP) MS begins with an initial RR course, followed by progression of variable rate, which may also include occasional relapses and minor remissions. 4, Progressive-relapsing (PR) MS shows progression from onset but with clear acute relapses with or without recovery. (From Lublin, F. D., & Reingold, S. C. (1996). Defining the clinical course of multiple sclerosis: Results of an international survey. Neurology, 46(64), 907–911. Used with permission from Lippincott Williams & Wilkins.)

The signs and symptoms of MS are varied and multiple, reflecting the location of the lesion (plaque) or combination of lesions. The primary symptoms most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, and pain. Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness. Fatigue is one of the most common problems; affects most people with MS and is often the most disabling symptom. Heat, depression, anemia, deconditioning, and medication may contribute to fatigue. Avoiding hot temperatures, effective treatment of depression and anemia, and occupational and physical therapies may help control fatigue. Additional strategies include a balance of rest and activities, good nutrition, and a healthy lifestyle including avoidance of alcohol and cigarette smoking (Hannon et al., 2010; Lemon & Clark, 2014). Pain is another common symptom of MS that can contribute to social isolation. Lesions on the sensory pathways cause pain. Additional sensory manifestations include paresthesias, dysesthesias, and proprioception loss (Stern, 2005). Many people with MS need daily analgesic medications. In some cases, pain is managed with opioids, antiseizure medications, or antidepressants. Rarely, surgery may be needed to interrupt pain pathways. Among perimenopausal women, those with MS are more likely to have pain related to osteoporosis. In addition

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to estrogen loss, immobility and corticosteroid therapy play a role in the development of osteoporosis among women with MS. Bone mineral density testing is recommended for this high-risk group. Diagnosis and treatment of osteoporosis are discussed in Chapter 69. Spasticity (muscle hypertonicity) of the extremities and loss of the abdominal reflexes result from involvement of the main motor pathways (pyramidal tracts) of the spinal cord. Disruption of the sensory axons may produce sensory dysfunction (paresthesias, pain). Cognitive and psychosocial problems may reflect frontal or parietal lobe involvement. Some degree of cognitive change (e.g., memory loss, decreased concentration) occurs in about half of patients, but severe cognitive changes with dementia (progressive organic mental disorder) are rare. Involvement of the cerebellum or basal ganglia can produce ataxia (impaired coordination of movements) and tremor. Loss of the control connections between the cortex and the basal ganglia may occur and cause emotional lability and euphoria. Bladder, bowel, and sexual dysfunctions are common. Secondary complications of MS include urinary tract infections, constipation, pressure ulcers, contracture deformities, dependent pedal edema, pneumonia, reactive depression, and osteoporosis. Emotional, social, marital, economic, and vocational problems may also occur. Exacerbations and remissions are characteristic of MS. During exacerbations, new symptoms appear and existing ones worsen; during remissions, symptoms decrease or disappear. Relapses may be associated with emotional and physical stress.

Assessment and Diagnostic Findings The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding (several bands of immunoglobulin G bonded together, indicating an immune system abnormality). Evoked potential studies can help define the extent of the disease process and monitor changes. Underlying bladder dysfunction is diagnosed by urodynamic studies. Neuropsychological testing may be indicated to assess cognitive impairment. A sexual history helps identify changes in sexual function.

Gerontologic Considerations The life expectancy for patients with MS is not dramatically different from that of patients without MS. Patients with MS who are elderly have specific physical and psychosocial challenges. They may have chronic health problems, for which they may be taking additional medications that could interact with medications prescribed for MS. The absorption, distribution, metabolism, and excretion of medications are altered in the elderly as a result of age-related changes in renal and liver functions. Therefore, elderly patients must be monitored closely for adverse and toxic effects of MS medications and for osteoporosis (particularly with frequent corticosteroid use that may be needed to treat exacerbations). The cost of

medications may lead to poor adherence to the prescribed regimen in elderly patients on fixed incomes. Older patients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Immobility resulting in fewer social opportunities contributes to loneliness and depression. Along with functional loss, spasticity, pain and bladder dysfunction, impaired sleep, and an increased need for assistance with self-care contribute to the physical challenges experienced by the older patient with MS (Stern, 2005).

Medical Management No cure exists for MS. An individual treatment program is indicated to relieve the patient’s symptoms and provide continuing support, particularly for patients with cognitive changes, who may need more structure and support. The goals of treatment are to delay the progression of the disease, manage chronic symptoms, and treat acute exacerbations. Many patients with MS have a stable disease course and require only intermittent treatment, whereas others experience steady progression of their disease. Symptoms requiring intervention include spasticity, fatigue, bladder dysfunction, and ataxia. Management strategies target the various motor and sensory symptoms and effects of immobility that can occur.

Pharmacologic Therapy Interferon beta-1a (Rebif) and interferon beta-1b (Betaseron) are administered subcutaneously. Researchers have investigated the clinical effectiveness of beta-1b compared with beta-1a. Another preparation of interferon beta-1a, Avonex, is administered intramuscularly once a week. Side effects of all interferon beta medications include flulike symptoms that can be managed with acetaminophen and ibuprofen and resolve after a few months. Additional side effects include potential liver damage, fetal abnormalities, and depression. For optimal control of disability, diseasemodifying medications should be started early in the course of the disease (Ross, Hackbarth, Rohl, et al., 2008). Glatiramer acetate (Copaxone) reduces the rate of relapse in the RR course of MS. It decreases the number of plaques noted on MRI and increases the time between relapses. Copaxone is administered subcutaneously daily. It acts by increasing the antigen-specific suppressor T cells. Side effects are minimal and manageable (Miller & Jezewski, 2006). Copaxone is an option for those with an RR course; however, it may take 6 months for evidence of an immune response to appear. IV methylprednisolone, the key agent in treating acute relapse in the RR course, shortens the duration of relapse. It exerts anti-inflammatory effects by acting on T cells and cytokines. One gram is administered IV daily for 3 days, followed by an oral taper of prednisone. Side effects include mood swings, weight gain, and electrolyte imbalances (Karch, 2014). The medication mitoxantrone (Novantrone) is administered via IV infusion every 3 months. Novantrone can reduce the frequency of clinical relapses in patients with secondary-progressive or worsening relapsing-remitting MS. Patients must be very closely monitored for side effects, especially cardiac toxicity (Karch, 2014).

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Medications are also prescribed for management of specific symptoms. Baclofen (Lioresal), a gamma-aminobutyric acid (GABA) agonist, is the medication of choice for treating spasticity. It can be administered orally or by intrathecal injection for severe spasticity (Karch, 2014). Benzodiazepines (Valium), tizanidine (Zanaflex), and dantrolene (Dantrium) may also be used to treat spasticity. Patients with disabling spasms and contractures may require nerve blocks or surgical intervention. Fatigue that interferes with activities of daily living (ADLs) may be treated with amantadine (Symmetrel), pemoline (Cylert), or fluoxetine (Prozac). Ataxia is a chronic problem most resistant to treatment. Medications used to treat ataxia include beta-adrenergic blockers (Inderal), antiseizure agents (Neurontin), and benzodiazepines (Klonopin). Bladder and bowel problems are often among the most difficult ones for patients, and a variety of medications (anticholinergic agents, alpha-adrenergic blockers, antispasmodic agents) may be prescribed. Nonpharmacologic strategies also assist in establishing effective bowel and bladder elimination (see later discussion). Urinary tract infection is often superimposed on the underlying neurologic dysfunction. Ascorbic acid (vitamin C) may be prescribed to acidify the urine, making bacterial growth less likely. Antibiotics are prescribed when appropriate.

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• Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervous system dysfunction • Impaired speech and risk for aspiration related to cranial nerve involvement • Disturbed thought processes (loss of memory, dementia, euphoria) related to cerebral dysfunction • Ineffective individual coping related to uncertainty of course of MS • Impaired home maintenance management related to physical, psychological, and social limits imposed by MS • Potential for sexual dysfunction related to spinal cord lesions or psychological reaction to disease process

Planning and Goals The major goals for the patient may include promotion of physical mobility, avoidance of injury, achievement of bladder and bowel continence, promotion of speech and swallowing mechanisms, improvement of cognitive function, development of coping strengths, improved home maintenance management, and adaptation to sexual dysfunction.

Nursing Interventions !!"##

Nursing Process

The Patient With Multiple Sclerosis Assessment Nursing assessment addresses neurologic deficits, secondary complications, and the impact of the disease on the patient and family. The patient’s mobility and balance are observed to determine whether there is risk of falling. Assessment of function is carried out both when the patient is well rested and when fatigued. The patient is assessed for weakness, spasticity, visual impairment, incontinence, and disorders of swallowing and speech. Additional areas of assessment include how MS has affected the patient’s lifestyle, how the patient is coping, and what the patient would like to improve.

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Impaired bed and physical mobility related to weakness, muscle paresis, spasticity • Risk for injury related to sensory and visual impairment

An individualized program of physical therapy, rehabilitation, and education is combined with emotional support. An educational plan of care is developed to enable the person with MS to deal with the physiologic, social, and psychological problems that accompany chronic disease. Research shows that depression, pain, fatigue, and walking difficulty all decrease physical activity (Motl, Snook, & Schapiro, 2007). Assisting patients with management of these symptoms may help increase the level of physical activity and overall sense of well-being (Chart 65-3).

Promoting Physical Mobility Relaxation and coordination exercises promote muscle efficiency. Progressive resistive exercises are used to strengthen weak muscles, because diminishing muscle strength is often significant in MS. EXERCISES. Walking improves the gait, particularly the problem of loss of position sense of the legs and feet. If certain muscle groups are irreversibly affected, other muscles can be trained to compensate. Instruction in the use of assistive devices may be needed to ensure their safe and correct use. MINIMIZING SPASTICITY AND CONTRACTURES.

Muscle spasticity is common and, in its later stages, is characterized by severe adductor spasm of the hips with flexor spasm of the hips and knees. Without relief, fibrous contractures of these joints occur. Warm packs may be beneficial, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. Special attention is

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NURSING RESEARCH PROFILE

Chart 65-3. Physical Activity in People With Multiple Sclerosis Motl, R. W., Snook, E. M., & Schapiro, R. T. (2007). Symptoms and physical activity behavior in individuals with multiple sclerosis. Research in Nursing and Health, 31 (5), 466–475. Purpose Physical activity is a unique challenge for people with multiple sclerosis (MS). This study examined the relationships among overall and specific symptoms, such as difficulty walking and other physical activity issues in people with MS. Design In this cross-sectional descriptive study, 133 people (104 women and 78 men) with MS completed questionnaires measuring overall and specific symptoms (i.e., depression, pain, and fatigue), difficulty walking, and physical activity. The purpose was to examine the relationships between overall and specific symptoms, difficulty walking, and physical activity. Participants in the study were recruited from local MS support groups over a 6-month time period.

given to the hamstrings, gastrocnemius muscles, hip adductors, biceps, and wrist and finger flexors. Muscle spasticity is common and interferes with normal function. A stretch–hold–relax routine is helpful for relaxing and treating muscle spasticity. Swimming and stationary bicycling are useful, and progressive weight bearing can relieve spasticity in the legs. The patient should not be hurried in any of these activities, because this often increases spasticity. ACTIVITY AND REST. The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable, because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. MINIMIZING EFFECTS OF IMMOBILITY. Because of the decrease in physical activity that often occurs with MS, complications associated with immobility, including pressure ulcers, expiratory muscle weakness, and accumulation of bronchial secretions, need to be considered and steps taken to prevent them. Measures to prevent such complications include assessing and maintaining skin integrity and having the patient perform coughing and deep-breathing exercises.

Preventing Injury If motor dysfunction causes problems of incoordination and clumsiness, or if ataxia is apparent, the patient is at risk for falling. To overcome this disability, the patient is taught to walk with feet apart to widen the base of support and to increase walking stability. If loss of position sense occurs, the patient is taught to watch the feet while walking. Gait training may require assistive devices (walker, cane, braces, crutches, parallel bars) and instruction about their use by a physical therapist. If the gait remains

Findings The descriptive findings of the study showed that those with MS who have more intense overall symptoms had more difficulty walking and lower levels of physical activity. The path analysis suggested that higher levels of physical symptoms were directly and indirectly related to lower levels of physical activity. Another important finding was that the indirect pathway involved difficulty walking. Nursing Implications People with MS who have intense overall symptoms have a reduction in physical activity in comparison to those with MS and less intense overall symptoms. This study found that the reduction in physical activity can be partly explained by walking difficulty. The authors suggest that nursing interventions to promote physical activity in people with MS might need to include adaptive activities that do not require a lot of walking.

inefficient, a wheelchair or motorized scooter may be the solution. The occupational therapist is a valuable resource person in suggesting and securing aids to promote independence. If incoordination is a problem and tremor of the upper extremities occurs when voluntary movement is attempted (intention tremor), weighted bracelets or wrist cuffs are helpful. The patient is trained in transfer and activities of daily living (ADLs). Because sensory loss may occur in addition to motor loss, pressure ulcers are a continuing threat to skin integrity. The need to use a wheelchair continuously increases the risk. See Chapter 11 for a discussion of the prevention and treatment of pressure ulcers.

Enhancing Bladder and Bowel Control Generally, bladder symptoms fall into the following categories: (1) inability to store urine (hyperreflexic, uninhibited); (2) inability to empty the bladder (hyporeflexic, hypotonic); and (3) a mixture of both types. The patient with urinary frequency, urgency, or incontinence requires special support. The sensation of the need to void must be heeded immediately, so the bedpan or urinal should be readily available. A voiding time schedule is set up (every 1.5 to 2 hours initially, with gradual lengthening of the interval). The patient is instructed to drink a measured amount of fluid every 2 hours and then attempt to void 30 minutes after drinking. Use of a timer or wristwatch with an alarm may be helpful for the patient who does not have enough sensation to signal the need to empty the bladder. The nurse encourages the patient to take the prescribed medications to treat bladder spasticity, because this allows greater independence. Intermittent self-catheterization (see Chapter 12) has been successful in maintaining bladder control in patients with MS. If a female patient has permanent

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urinary incontinence, urinary diversion procedures may be considered. The male patient may wear a condom appliance for urine collection. Bowel problems include constipation, fecal impaction, and incontinence. Adequate fluids, dietary fibre, and a bowel-training program are frequently effective in solving these problems. See Chapter 12 for a discussion of promoting bowel continence.

Enhancing Communication and Managing Swallowing Difficulties When the cranial nerves that control the mechanisms of speech and swallowing are affected, dysarthrias (defects of articulation) marked by slurring, low volume of speech, and difficulties in phonation may occur. Dysphagia (difficulty swallowing) may also occur. A speech therapist evaluates speech and swallowing and instructs the patient, family, and health team members about strategies to compensate for speech and swallowing problems. The nurse reinforces this instruction and encourages the patient and family to adhere to the plan. Impaired swallowing increases the patient’s risk of aspiration; therefore, strategies such as having suction apparatus available, careful feeding, and proper positioning for eating are needed to reduce that risk.

Improving Sensory and Cognitive Function Measures may be taken if visual defects or changes in cognitive status occur. VISION. The cranial nerves affecting vision may be affected by MS. An eye patch or a covered eyeglass lens may be used to block the visual impulses of one eye if the patient has diplopia (double vision). Prism glasses may be helpful for patients who are confined to bed and have difficulty reading in the supine position. People who are unable to read regular-print materials may obtain large-print or audio books from local libraries and from the Canadian National Institute for the Blind (CNIB). The CNIB also has books available in Braille. COGNITION AND EMOTIONAL RESPONSES.

Cognitive impairment and emotional lability occur early in MS in some patients and may impose numerous stresses on the patient and family. Some patients with MS are forgetful and easily distracted and may exhibit emotional lability. Patients adapt to illness in a variety of ways, including denial, depression, withdrawal, and hostility. Emotional support assists patients and their families to adapt to the changes and uncertainties associated with MS and to cope with the disruption in their lives. The patient is assisted to set meaningful and realistic goals, to remain as active as possible, and to maintain interests and activities. Hobbies may help the patient’s morale and provide satisfying interests if the disease progresses to the stage in which formerly enjoyed activities can no longer be pursued. The family should be made aware of the nature and degree of cognitive impairment. The occupational therapist can be helpful in formulating a structured daily routine.

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STRENGTHENING COPING MECHANISMS. The diagnosis of MS is always distressing to the patient and family. They need to know that no two patients with MS have identical symptoms or courses of illness. Although some patients do experience significant disability early, others have a near-normal lifespan with minimal disability. Some families, however, face overwhelming frustrations and problems. MS affects people who are often in a productive stage of life and concerned about career and family responsibilities. Family conflict, disintegration, separation, and divorce are not uncommon. Often, very young family members assume the responsibility of caring for a parent with MS. Nursing interventions in this area include alleviating stress and making appropriate referrals for counselling and support to minimize the adverse effects of dealing with chronic illness. The nurse, mindful of these complex problems, initiates home care and coordinates a network of services, including social services, speech therapy, physical therapy, and homemaker services. To strengthen the patient’s coping skills, as much information as possible is provided. Patients need an updated list of available assistive devices, services, and resources. Coping through problem solving involves helping the patient define the problem and develop alternatives for its management. Careful planning and maintaining flexibility and a hopeful attitude are useful for psychological and physical adaptation.

Improving Self-Care Abilities MS can affect every facet of daily living. Certain abilities are often impossible to regain after they are lost. Physical function may vary from day to day. Modifications that allow independence in self-care should be implemented (e.g., assistive eating devices, raised toilet seat, bathing aids, telephone modifications, long-handled comb, tongs, modified clothing). Physical and emotional stresses should be avoided as much as possible, because these may worsen symptoms and impair performance. Exposure to heat increases fatigue and muscle weakness, so air conditioning is recommended in at least one room. Exposure to extreme cold may increase spasticity.

Promoting Sexual Functioning Patients with MS and their partners face problems that interfere with sexual activity, both as a direct consequence of nerve damage and also from psychological reactions to the disease. Easy fatigability, conflicts arising from dependency and depression, emotional lability, and loss of self-esteem compound the problem. Erectile and ejaculatory disorders in men and orgasmic dysfunction and adductor spasms of the thigh muscles in women can make sexual intercourse difficult or impossible. Bladder and bowel incontinence and urinary tract infections add to the difficulties. An experienced sexual counsellor can help bring into focus the patient’s or partner’s sexual resources and suggest relevant information and supportive therapy. Sharing and communicating feelings, planning for sexual activity (to minimize the effects of

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fatigue), and exploring alternative methods of sexual expression may open up a wide range of sexual enjoyment and experiences.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. As the disease progresses, the patient and family need to learn new strategies to maintain optimal independence. Teaching of new self-care techniques may be initiated in the hospital or clinic setting and reinforced in the home. Self-care education may address the use of assistive devices, self-catheterization, and administration of medications that affect the course of the disease or treat complications. Although the diseasemodifying medications (the “ABC and R medications”) may slow the progression of disease and disability in many persons with MS, they are not effective in all patients. Patients who receive these medications will require teaching and support, while those unable to take them or for whom the medications have not been effective need continued support and assistance in coping with this reality. Exercises that enable the patient to continue some form of activity or that maintain or improve swallowing, speech, or respiratory function may be taught to the patient and family (Chart 65-4). CONTINUING CARE. After discharge, the home care nurse often provides teaching and reinforcement of new interventions in the patient’s home. Nurses in the home setting assess for changes in the patient’s physical and emotional status, provide physical care to the patient if required, coordinate

outpatient services and resources, and encourage health promotion, appropriate health screenings, and adaptation. If changes in the disease or its course are noted, the home care nurse encourages the patient to contact the primary care provider, because treatment of an acute exacerbation or new problem may be indicated. Continuing health care and follow-up are recommended. The patient with MS is encouraged to contact the local chapter of the Multiple Sclerosis Society of Canada for services, publications, and contact with others who have MS (see Resources). Local chapters also provide direct services to patients. Through group participation, the patient has an opportunity to meet others with similar problems, share experiences, and learn self-help methods in a social environment.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Improves physical mobility a. Participates in gait-training and rehabilitation program b. Establishes a balanced program of rest and exercise c. Uses assistive devices correctly and safely 2. Is free of injury a. Uses visual cues to compensate for decreased sense of touch or position b. Asks for assistance when necessary

CHART 65-4

HOME CARE CHECKLIST •

The Patient With Multiple Sclerosis (MS) Patient

Caregiver

• State how to access the local chapter of the National MS Society and available resources.

✔

✔

• Discuss the clinical course of MS.

✔

✔

• Identify strategies to manage symptoms (pain, cognitive responses, dysphagia, tremors,

✔

✔

• State how to prevent complications (pressure ulcers, pneumonia, depression).

✔

✔

• Identify coping strategies.

✔

✔

• Identify ways to minimize fatigue.

✔

✔

• Explain how to prevent injury.

✔

✔

• State ways to adapt to sexual dysfunction.

✔

✔

• Discuss ways to control bowel and bladder function.

✔

✔

• Name benefits of exercise and physical activity.

✔

✔

• Identify ways to minimize immobility and spasticity.

✔

✔

• Describe medication regimen and potential adverse effects.

✔

✔

• Demonstrate correct techniques of administering injectable medications, if prescribed.

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

visual disturbances).

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3. Attains or maintains control of bladder and bowel patterns a. Monitors self for urine retention and employs intermittent self-catheterization technique, if indicated b. Identifies the signs and symptoms of urinary tract infection c. Maintains adequate fluid and fibre intake 4. Participates in strategies to improve speech and swallowing a. Practices exercises recommended by speech therapist b. Maintains adequate nutritional intake without aspiration 5. Compensates for altered thought processes a. Uses lists and other aids to compensate for memory losses b. Discusses problems with trusted advisor or friend c. Substitutes new activities for those that are no longer possible 6. Demonstrates effective coping strategies a. Maintains sense of control b. Modifies lifestyle to fit goals and limitations c. Verbalizes desire to pursue goals and developmental tasks of adulthood 7. Adheres to plan for home maintenance management a. Uses appropriate techniques to maintain independence b. Engages in health promotion activities and health screenings as appropriate 8. Adapts to changes in sexual function a. Is able to discuss problem with partner and appropriate health professional b. Identifies alternative means of sexual expression

Myasthenia Gravis Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of

weakness of the voluntary muscles. Women are affected more frequently than men, and they tend to develop the disease at an earlier age (20 to 30 years of age, versus 60 to 70 years for men) (Hannon et al., 2010).

Pathophysiology Normally, a chemical impulse precipitates the release of acetylcholine from vesicles on the nerve terminal at the myoneural junction. The acetylcholine attaches to receptor sites on the motor endplate and stimulates muscle contraction. Continuous binding of acetylcholine to the receptor site is required for muscular contraction to be sustained. In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction (Hannon et al., 2010). Therefore, fewer receptors are available for stimulation, resulting in voluntary muscle weakness that escalates with continued activity (Fig. 65-5). These antibodies are found in 80% to 90% of people with myasthenia gravis (Hickey, 2009). Eighty percent of people with myasthenia gravis have either thymic hyperplasia or a thymic tumour, and the thymus gland is believed to be the site of antibody production. In patients who are antibody negative, researchers believe that the offending antibody is directed at a portion of the receptor site rather than the whole complex.

Clinical Manifestations The initial manifestation of myasthenia gravis in two thirds of patients involves the ocular muscles. Diplopia (double vision) and ptosis (drooping of the eyelids) are common (Hannon et al., 2010). Many patients also experience weakness of the muscles of the face and throat (bulbar symptoms) and generalized weakness. Weakness of the facial muscles results in a bland facial expression. Laryngeal involvement produces dysphonia (voice impairment) and increases the risk of choking and aspiration. Generalized weakness affects all the extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure. Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination.

Axon

Axon

ACh vesicles Nerve Antibodies

ACh receptors

A

Muscle endplate

B

Muscle endplate

FIGURE 65-5. Myasthenia gravis. A, Normal acetylcholine (Ach) receptor site. B, ACh receptor site in

myasthenia gravis.

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Assessment and Diagnostic Findings An acetylcholinesterase inhibitor test is used to diagnose myasthenia gravis. The acetylcholinesterase inhibitor stops the breakdown of acetylcholine, thereby increasing availability at the neuromuscular junction. Edrophonium chloride (Tensilon), a fast-acting acetylcholinesterase inhibitor, is administered IV to diagnose myasthenia gravis. Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping (Karch, 2014). The acetylcholine receptor antibody titres are elevated as indicated previously. Repetitive muscle stimulation demonstrates a decrease in successive action potentials. The thymus gland, a site of acetylcholine receptor antibody production, may be enlarged in myasthenia gravis, and may be identified by MRI scan. A single-fibre electromyography (EMG) detects a delay or failure of neuromuscular transmission and is about 99% sensitive in confirming the diagnosis of myasthenia gravis (Hickey, 2009).

Medical Management Management of myasthenia gravis is directed at improving function and reducing and removing circulating antibodies. Therapeutic modalities include administration of anticholinesterase medications and immunosuppressive therapy, plasmapheresis, and thymectomy. There is no cure for myasthenia gravis; treatments do not stop the production of the acetylcholine receptor antibodies.

Pharmacologic Therapy Pyridostigmine bromide (Mestinon), an anticholinesterase medication, is the first line of therapy. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. The dosage is gradually increased to a daily maximum and is administered in divided doses (usually four times a day). Adverse effects of anticholinesterase medications include fasciculations, abdominal pain, diarrhea, and increased oropharyngeal secretions (Allen, 2006). Pyridostigmine tends to have fewer side effects than other anticholinesterase medications (Chart 65-5). If pyridostigmine bromide does not improve muscle strength and control fatigue, the next agents used are the immunomodulating drugs. The goal of immunosuppressive therapy is to reduce production of the antibody. Corticosteroids suppress the patient’s immune response, decreasing the amount of antibody production, and this correlates with clinical improvement. An initial dose of prednisone is given daily; as symptoms improve, the medication is tapered and a maintenance dose may be given indefinitely (Hannon et al., 2010). As the corticosteroid medications take effect the dosage of anticholinesterase medication can usually be lowered. Cytotoxic medications are used to treat myasthenia gravis if there is inadequate response to steroids. Azathioprine (Imuran) inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Therapeutic effects may not be evident for 3 to 12 months. Leukopenia and hepatotoxicity are serious adverse effects, so monthly evaluation of liver enzymes and white blood cell count is necessary. Intravenous immune globulin (IVIG) is also used to treat exacerbations, and, in selected patients, it is used on a long-term adjunctive basis. IVIG treatment is easy to administer and involves the administration of pooled

CHART 65-5

Pharmacology: Potential Adverse Effects of Anticholinesterase Medications Central Nervous System

Gastrointestinal

Irritability Anxiety Insomnia Headache Dysarthria Syncope Seizures Coma Diaphoresis

Abdominal cramps Nausea Vomiting Diarrhea Anorexia Increased salivation

Respiratory Bronchial relaxation Increased bronchial secretions

Cardiovascular Tachycardia Hypotension

Skeletal Muscles Fasciculations Spasms Weakness

Genitourinary Frequency Urgency

Integumentary Rash Flushing

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human gamma-globulin, and improvement occurs in a few days (Hickey, 2009). A number of medications are contraindicated for patients with myasthenia gravis because they exacerbate the symptoms. The physician and the patient should weigh risks and benefits before any new medications are prescribed, including antibiotics, cardiovascular medications, antiseizure and psychotropic medications, morphine, quinine and related agents, beta-blockers, and nonprescription medications (Allen, 2006). Procaine (Novocain) should be avoided, and the patient’s dentist is informed of the diagnosis of myasthenia gravis.

Plasmapheresis Plasmapheresis (plasma exchange) is a technique used to treat exacerbations. The patient’s plasma and plasma components are removed through a centrally placed large-bore double-lumen catheter. The blood cells and antibodycontaining plasma are separated, after which the cells and a plasma substitute are reinfused. Plasma exchange produces a temporary reduction in the level of circulating antibodies. The typical course of plasmapheresis consists of daily or alternate-day treatment, and the number of treatments is determined by the patient’s response. Plasma exchange improves symptoms in 75% of patients; however, improvement lasts only a few weeks after treatment is completed (Stephen, Skillen, Day, et al., 2012).

Surgical Management Thymectomy (surgical removal of the thymus gland) can produce antigen-specific immunosuppression and result in clinical improvement. The procedure results in either partial or complete remission. A course of preoperative plasmapheresis decreases the time needed for postoperative mechanical ventilation. The entire gland must be removed for optimal clinical outcomes; therefore, surgeons prefer the transsternal surgical approach. After surgery, the patient is monitored in an intensive care unit, with special attention to respiratory function. The patient is weaned from mechanical ventilation after thorough respiratory assessment. After the thymus gland is removed, it may take up to 3 years for the patient to benefit from the procedure, because of the long life of circulating T cells (Allen, 2006).

Complications

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compromise. Weak respiratory muscles do not support inhalation. An inadequate cough and an impaired gag reflex, caused by bulbar weakness, result in poor airway clearance. A downward trend of two respiratory function tests, the negative inspiratory force and vital capacity, is the first clinical sign of respiratory compromise. Endotracheal intubation and mechanical ventilation may be needed (see Chapter 25). Noninvasive positivepressure ventilation uses an external device that provides respiratory support without endotracheal intubation. Cholinesterase inhibitors are stopped when respiratory failure occurs and gradually restarted after the patient demonstrates improvement with a course of plasmapheresis or IVIG. Nutritional support may be needed if the patient is intubated for a long period.

Nursing Management Because myasthenia gravis is a chronic disease and most patients are seen on an outpatient basis, much of the nursing care focuses on patient and family teaching. Educational topics for outpatient self-care include medication management, energy conservation, strategies to help with ocular manifestations, and prevention and management of complications. Medication management is a crucial component of ongoing care. Understanding the actions of the medications and taking them on schedule is emphasized, as are the consequences of delaying medication and the signs and symptoms of myasthenic and cholinergic crises. The patient can determine the best times for daily dosing by keeping a diary to determine fluctuation of symptoms and to learn when the medication is wearing off. The medication schedule can then be manipulated to maximize strength throughout the day.

!

NURSING ALERT

Maintenance of stable blood levels of anticholinesterase medications is imperative to stabilize muscle strength. Therefore, the anticholinesterase medications must be administered on time. Any delay in administration of medications may exacerbate muscle weakness and make it impossible for the patient to take medications orally.

Respiratory Failure A myasthenic crisis is an exacerbation of the disease process characterized by severe generalized muscle weakness and respiratory and bulbar weakness that may result in respiratory failure. Crisis may result from disease exacerbation or a specific precipitating event. The most common precipitator is respiratory infection; others include medication change, surgery, pregnancy, and medications that exacerbate myasthenia. A cholinergic crisis caused by overmedication with cholinesterase inhibitors is rare; atropine sulfate should be on hand to treat bradycardia or respiratory distress (Karch, 2014). Neuromuscular respiratory failure is the critical complication in myasthenic and cholinergic crises. Respiratory muscle and bulbar weakness combine to cause respiratory

The patient is also taught strategies to conserve energy. To do this, the nurse helps the patient identify the optimal times for rest throughout the day. If the patient lives in a two-story home, the nurse can suggest that frequently used items (e.g., hygiene products, cleaning products, snacks) be kept on each floor to minimize travel between floors. The patient is encouraged to apply for a handicapped license plate to minimize walking from parking spaces, and to schedule activities to coincide with peak energy and strength levels. To minimize the risk of aspiration, mealtimes should coincide with the peak effects of anticholinesterase medication. In addition, rest before meals is encouraged to reduce muscle fatigue. The patient is advised to sit upright

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during meals, with the neck slightly flexed to facilitate swallowing. Soft foods in gravy or sauces can be swallowed more easily; if choking occurs frequently, the nurse can suggest puréed food with a puddinglike consistency. Suction should be available at home, with the patient and family instructed in its use. Supplemental feedings may be necessary in some patients to ensure adequate nutrition (Randell, Byars, Williams, et al., 2008). Impaired vision results from ptosis of one or both eyelids, decreased eye movement, or double vision. To prevent corneal damage when the eyelids do not close completely, the patient is instructed to tape the eyes closed for short intervals and to regularly instill artificial tears. Patients who wear eyeglasses can have “crutches” attached to help lift the eyelids. Patching of one eye can help with double vision. The patient is reminded of the importance of maintaining health promotion practices and of following health care screening recommendations. Factors that exacerbate symptoms and potentially cause crisis should be noted and avoided: emotional stress, infections (particularly respiratory infections), vigorous physical activity, some medications, and high environmental temperature. The Myasthenia Gravis Foundation of Canada provides support groups, services, and educational materials for patients, families, and health care providers (see Resources).

Myasthenic Crisis Respiratory distress and varying degrees of dysphagia (difficulty swallowing), dysarthria (difficulty speaking), eyelid ptosis, diplopia, and prominent muscle weakness are symptoms of myasthenic crisis. The patient is placed in an intensive care unit for constant monitoring because of associated intense and sudden fluctuations in clinical condition. Providing ventilatory assistance takes precedence in the immediate management of the patient with myasthenic crisis. Ongoing assessment for respiratory failure is essential. The nurse assesses the respiratory rate, depth, and breath sounds and monitors pulmonary function parameters (vital capacity and negative inspiratory force) to detect pulmonary problems before respiratory dysfunction progresses. Blood is drawn for arterial blood gas analysis. Endotracheal intubation and mechanical ventilation may be needed (see Chapter 26). If the abdominal, intercostal, and pharyngeal muscles are severely weak, the patient cannot cough, take deep breaths, or clear secretions. Chest physical therapy, including postural drainage to mobilize secretions and suctioning to remove secretions, may have to be performed frequently. (Postural drainage should not be performed for 30 minutes after feeding.) Assessment strategies and supportive measures include the following: • Arterial blood gases, serum electrolytes, input and output, and daily weight are monitored. • If the patient cannot swallow, nasogastric tube feedings may be prescribed. • Sedatives and tranquilizers are avoided, because they aggravate hypoxia and hypercapnia and can cause respiratory and cardiac depression.

Guillain–Barré Syndrome Guillain–Barré syndrome is an autoimmune attack on the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (numbness). An antecedent event (most often a viral infection) precipitates clinical presentation (Winer, 2014). Campylobacter jejuni, cytomegalovirus, Epstein–Barr virus, Mycoplasma pneumoniae, H. influenzae, and HIV are the most common infectious agents that are associated with the development of Guillain–Barré syndrome. Results of studies on recovery rates differ, but most indicate that 60% to 75% of patients recover completely. Residual deficits of varying degree occur in 20% to 25% of patients. Residual deficits are most likely in patients with rapid disease progression, those who require mechanical ventilation, and those 60 years of age or older.

Pathophysiology Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain–Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. Guillain–Barré syndrome is the result of a cell-mediated and humoral immune attack on peripheral nerve myelin proteins that causes inflammatory demyelination. The best-accepted theory of cause is molecular mimicry, in which an infectious organism contains an amino acid that mimics the peripheral nerve myelin protein. The immune system cannot distinguish between the two proteins and attacks and destroys peripheral nerve myelin. The exact location of the immune attack within the peripheral nervous system is the ganglioside GM1b. With the autoimmune attack, there is an influx of macrophages and other immune-mediated agents that attack myelin and cause inflammation and destruction, interruption of nerve conduction, and axonal loss (Ho, Thakur, Gorson, et al., 2008).

Clinical Manifestations Guillain–Barré syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Hyporeflexia and weakness may progress to tetraplegia. Demyelination of the nerves that innervate the diaphragm and intercostal muscles results in neuromuscular respiratory failure. Sensory symptoms include paresthesias of the hands and feet and pain related to the demyelination of sensory fibres. The antecedent event usually occurs 2 weeks before symptoms begin. Weakness usually begins in the legs and progresses upward. Maximum weakness, the plateau, varies in length but usually includes neuromuscular respiratory failure and bulbar weakness. The duration of the symptoms is variable; complete functional recovery may

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take up to 2 years. Any residual symptoms are permanent and reflect axonal damage from demyelination. Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension. The symptoms of autonomic dysfunction occur and resolve rapidly. Guillain–Barré syndrome does not affect cognitive function or LOC. Although the classic clinical features include areflexia and ascending weakness, variation in presentation occurs. There may be a sensory presentation, with progressive sensory symptoms; an atypical axonal destruction; or the Miller-Fisher variant, which includes paralysis of the ocular muscles, ataxia, and areflexia (Iggulden, 2006).

Assessment and Diagnostic Findings The patient presents with symmetric weakness, diminished reflexes, and upward progression of motor weakness. A history of a viral illness in the previous few weeks suggests the diagnosis. Changes in vital capacity and negative inspiratory force are assessed to identify impending neuromuscular respiratory failure. Serum laboratory tests are not useful in the diagnosis. However, elevated protein levels are detected in CSF evaluation, without an increase in other cells. Evoked potential studies demonstrate a progressive loss of nerve conduction velocity.

Medical Management Because of the possibility of rapid progression and neuromuscular respiratory failure, Guillain–Barré syndrome is a medical emergency, requiring management in an intensive care unit. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the clinician to the physical and respiratory needs of the patient. Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation. Mechanical ventilation may be required for an extended period. The patient is weaned from mechanical ventilation after the respiratory muscles can again support spontaneous respiration and maintain adequate tissue oxygenation. Other interventions are aimed at preventing the complications of immobility. These may include the use of anticoagulant agents and anti-embolism stockings or sequential compression boots to prevent thrombosis and pulmonary emboli. Plasmapheresis and IVIG are used to directly affect the peripheral nerve myelin antibody level (Mazzoni et al., 2006). Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. Studies indicate that IVIG and plasmapheresis are equally effective in treating Guillain–Barré syndrome; however, IVIG is the therapy

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of choice because it is associated with fewer side effects. The cardiovascular risks posed by autonomic dysfunction require continuous electrocardiographic (ECG) monitoring. Tachycardia and hypertension are treated with short-acting medications such as alpha-adrenergic blocking agents. The use of short-acting agents is important, because autonomic dysfunction is very labile. Hypotension is managed by increasing the amount of IV fluid administered.

!!"##

Nursing Process

The Patient With Guillain– Barré Syndrome Assessment Ongoing assessment for disease progression is critical. The patient is monitored for life-threatening complications (respiratory failure, cardiac dysrhythmias, deep vein thrombosis [DVT]) so that appropriate interventions can be initiated. Because of the threat to the patient in this sudden, potentially lifethreatening disease, the nurse must assess the patient’s and family’s ability to cope and their use of coping strategies.

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Ineffective breathing pattern and impaired gas exchange related to rapidly progressive weakness and impending respiratory failure • Impaired bed and physical mobility related to paralysis • Imbalanced nutrition, less than body requirements, related to inability to swallow • Impaired verbal communication related to cranial nerve dysfunction • Fear and anxiety related to loss of control and paralysis

Collaborative Problems/ Potential Complications Based on the assessment data, potential complications that may develop include the following: • Respiratory failure • Autonomic dysfunction

Planning and Goals The major goals for the patient may include improved respiratory function, increased mobility, improved nutritional status, effective communication, decreased fear and anxiety, and absence of complications.

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Nursing Interventions Maintaining Respiratory Function Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Monitoring for changes in vital capacity and negative inspiratory force are key to early intervention for neuromuscular respiratory failure. Mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. The potential need for mechanical ventilation should be discussed with the patient and family on admission to provide time for psychological preparation and decision making. Intubation and mechanical ventilation result in less anxiety if they are initiated on a nonemergency basis to a well-informed patient. The patient may require mechanical ventilation for a long period. Nursing management of the patient requiring mechanical ventilation is discussed in Chapter 26. Bulbar weakness that impairs the ability to swallow and clear secretions is another factor in the development of respiratory failure in the patient with Guillain–Barré syndrome. Suctioning may be needed to maintain a clear airway. The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction, so that interventions can be initiated quickly if needed. Medications are administered or a temporary pacemaker is placed for clinically significant bradycardia.

Enhancing Physical Mobility Nursing interventions to enhance physical mobility and prevent the complications of immobility are key to the function and survival of patients. The paralyzed extremities are supported in functional positions, and passive range-of-motion exercises are performed at least twice daily. DVT and pulmonary embolism are threats to the paralyzed patient. Nursing interventions are aimed at preventing DVT. Range-of-motion exercises, position changes, anticoagulation, the use of anti-embolism stockings or sequential compression boots, and adequate hydration will decrease the risk of DVT. Padding may be placed over bony prominences, such as the elbows and heels, to reduce the risk of pressure ulcers (Iggulden, 2006). The need for consistent position changes every 2 hours cannot be overemphasized. The nurse evaluates laboratory test results that may indicate malnutrition or dehydration, both of which increase the risk of pressure ulcers. The nurse collaborates with the physician and dietitian to develop a plan to meet the patient’s nutritional and hydration needs.

Providing Adequate Nutrition Paralytic ileus may result from insufficient parasympathetic activity. In this event, the nurse administers IV fluids and parenteral nutrition as a supplement and monitors for the return of bowel sounds. If the patient cannot swallow due to bulbar paralysis (immobility

of muscles, a gastrostomy tube may be placed to administer nutrients. The nurse carefully assesses the return of the gag reflex and bowel sounds before resuming oral nutrition.

Improving Communication Because of paralysis, the patient cannot talk, laugh, or cry and therefore has no method for communicating needs or expressing emotion. Establishing some form of communication with picture cards or an eye blink system provides a means of communication. Collaboration with the speech therapist may be helpful in developing a communication mechanism that is most effective for a specific patient.

Decreasing Fear and Anxiety The patient and family are faced with a sudden, potentially life-threatening disease, and anxiety and fear are constant themes for them. The impact of disease on the family depends on the patient’s role within the family. Referral to a support group may provide information and support to the patient and family. The family may feel helpless in caring for the patient. Mechanical ventilation and monitoring devices may frighten and intimidate them. Family members often want to participate in physical care; with instruction and support by the nurse, they should be allowed and encouraged to do so. In addition to fear, the patient may experience isolation, loneliness, and lack of control. Nursing interventions that increase the patient’s sense of control include providing information about the condition, emphasizing a positive appraisal of coping resources, and teaching relaxation exercises and distraction techniques. The positive attitude and atmosphere of the multidisciplinary team are important to promote a sense of well-being. Diversional activities are encouraged to decrease loneliness and isolation. Encouraging visitors, engaging visitors or volunteers to read to the patient, listening to music or audio-books, and watching television are ways to alleviate the patient’s sense of isolation.

Monitoring and Managing Potential Complications Thorough assessment of respiratory function at regular and frequent intervals is essential, because respiratory insufficiency and subsequent failure due to weakness or paralysis of the intercostal muscles and diaphragm may develop quickly. Respiratory failure is the major cause of mortality. In addition to the respiratory rate and the quality of respirations, vital capacity is monitored frequently and at regular intervals, so that respiratory insufficiency can be anticipated. Decreasing vital capacity with associated muscle weakness indicates impending respiratory failure. Signs and symptoms include breathlessness while speaking, shallow and irregular breathing, use

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of accessory muscles, tachycardia, weak cough, and changes in respiratory pattern. Other complications include cardiac dysrhythmias, which necessitate ECG monitoring; transient hypertension; orthostatic hypotension; DVT; pulmonary embolism; urinary retention; and other threats to any immobilized and paralyzed patient. These require monitoring and attention to prevent them and prompt treatment if indicated.

Patients who have experienced total or prolonged paralysis require intensive rehabilitation; the extent depends on the patient’s needs. Approaches include a comprehensive inpatient program if deficits are significant, an outpatient program if the patient can travel by car, or a home program of physical and occupational therapy. The recovery phase may be long and requires patience as well as involvement on the part of the patient and family. During acute care, the focus is on immediate issues and deficits. The nurse needs to remind or instruct patients and family members of the need for continuing health promotion and screening practices after this initial phase of care.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients with Guillain–Barré syndrome and their families are usually frightened by the sudden onset of life-threatening symptoms and their severity. Therefore, teaching the patient and family about the disorder and its generally favourable prognosis is important (Chart 65-6). During the acute phase of the illness, the patient and family are instructed about strategies they can implement to minimize the effects of immobility and other complications. As function begins to return, family members and other home care providers are instructed about care of the patient and their role in the rehabilitation process. Preparation for discharge is an interdisciplinary effort requiring family or caregiver education by all team members, including the nurse, physician, occupational and physical therapists, speech therapist, and respiratory therapist. CONTINUING CARE. Most patients with Guillain– Barré syndrome experience complete recovery.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Maintains effective respirations and airway clearance a. Has normal breath sounds on auscultation b. Demonstrates gradual improvement in respiratory function 2. Shows increasing mobility a. Regains use of extremities b. Participates in rehabilitation program c. Demonstrates no contractures and minimal muscle atrophy

CHART 65-6

HOME CARE CHECKLIST •

The Patient With Guillain–Barré Syndrome

At the completion of the home care instruction, the patient or caregiver will be able to:

• Describe the disease process of Guillain–Barré syndrome.

Patient

Caregiver

✔

✔

• Manage respiratory needs: tracheostomy care, suctioning.

✔

• Demonstrate proper body mechanics regarding lifting and transfers.

✔

• Practice gait training and strength endurance.

✔

✔

• Perform range-of-motion exercises.

✔

✔

• Perform activities of daily living and manage self-care: • Nutrition • Bowel and bladder management • Skin care • Adaptive equipment for bathing, hygiene, grooming, dressing

✔ ✔ ✔ ✔

✔ ✔ ✔ ✔

• Operate and explain function of medical equipment and mobility aids: walkers, wheelchairs,

✔

✔

• Use coping mechanisms and diversional activities appropriately.

✔

✔

• Implement safety measures in the home.

✔

✔

• Know how to contact and use community resources and the Guillain–Barré Syndrome

✔

✔

bedside commodes, tub transfer benches, adaptive devices.

Foundation International.

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3. Receives adequate nutrition and hydration a. Consumes diet adequate to meet nutritional needs b. Swallows without aspiration 4. Demonstrates recovery of speech a. Communicates needs through alternative strategies b. Practices exercises recommended by the speech therapist 5. Shows lessening fear and anxiety 6. Has absence of complications a. Breathes spontaneously b. Has vital capacity within normal range c. Exhibits normal arterial blood gases and pulse oximetry

Ophthalmic division (V1)

Trigeminal nerve

V1 V2 V3

Mandibular division (V3) Maxillary division (V2)

CRANIAL NERVE DISORDERS Because the brain stem and cranial nerves involve vital motor, sensory, and autonomic functions of the body, these nerves may be affected by conditions arising primarily within these structures or in secondary extension from adjacent disease processes. The cranial nerves are examined separately and in sequence (see Chapter 61). Some cranial nerve deficits can be detected by observing the patient’s face, eye movements, speech, and swallowing. EMG is used to investigate motor and sensory dysfunction. An MRI scan is used to obtain images of the cranial nerves and brain stem. An overview of disorders that may affect each of the cranial nerves, including clinical manifestations and nursing interventions, is presented in Table 65-1. The following discussion centres on the most common disorders of the cranial nerves: trigeminal neuralgia, a condition affecting the fifth cranial nerve; and Bell’s palsy, caused by involvement of the seventh cranial nerve.

Trigeminal Neuralgia (Tic Douloureux) Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated by any of the three branches, but most commonly the second and third branches of the trigeminal nerve (Fig. 65-6) (Hannon et al., 2010). The pain ends as abruptly as it starts and is described as a unilateral shooting and stabbing sensation. The unilateral nature of the pain is an important feature. Associated involuntary contraction of the facial muscles can cause sudden closing of the eye or twitching of the mouth, hence the former name tic douloureux (painful twitch). Although the cause is not certain, vascular compression and pressure are suggested causes. As the brain ages, a loop of a cerebral artery or vein may compress the nerve root entry point, which can be identified on MRI scan (Gronseth, Cruccu, Alksne, et al., 2008). Trigeminal neuralgia is most likely to occur after age 40 and is more common in women and in people with MS compared to the general population (Bennetto, Patel, & Fuller, 2007). Pain-free intervals may be measured in

FIGURE 65-6. Distribution of trigeminal nerve branches.

terms of minutes, hours, days, or longer. With advancing years, the painful episodes tend to become more frequent and agonizing. The patient lives in constant fear of attacks. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking. A draft of cold air or direct pressure against the nerve trunk may also cause pain. Certain areas are called trigger points because the slightest touch immediately starts a paroxysm or episode. To avoid stimulating these areas, patients with trigeminal neuralgia try not to touch or wash their faces, shave, chew, or do anything else that might cause an attack. These behaviours are a clue to the diagnosis.

Medical Management Pharmacologic Therapy Antiseizure agents, such as carbamazepine (Tegretol), relieve pain in most patients with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Carbamazepine is taken with meals. Serum levels must be monitored to avoid toxicity in patients who require high doses to control the pain. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. The patient is monitored for bone marrow depression during long-term therapy. Gabapentin (Neurontin) and baclofen (Lioresal) are also used for pain control. If pain control is still not achieved, phenytoin (Dilantin) may be used as adjunctive therapy.

Surgical Management If pharmacologic management fails to relieve pain, a number of surgical options are available. Although these procedures may relieve facial pain for a few years, recurrence and complication rates are high (Hickey, 2009). The choice of procedure depends on the patient’s preference and health status. MICROVASCULAR DECOMPRESSION OF THE TRIGEMINAL NERVE. An intracranial approach is used to relieve

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Disorders of Cranial Nerves

Disorder

Clinical Manifestations

Nursing Interventions

Olfactory Nerve—I Head trauma Intracranial tumour Intracranial surgery

Unilateral or bilateral anosmia (temporary or persistent) Diminished taste for food

Assess sense of smell. Assess for cerebrospinal fluid rhinorrhea if patient has sustained head trauma.

Lesions of optic tract producing homonymous hemianopsia

Assess visual acuity. Restructure environment to prevent injuries. Teach patient to accommodate for visual loss.

Dilation of pupil with loss of light reflex on one side Impairment of ocular movement Diplopia Gaze palsies Ptosis of eyelid

Assess extraocular movement and for nonreactive pupil.

Pain in face Diminished or loss of corneal reflex Chewing dysfunction

Assess for pain and triggering mechanisms for pain. Assess for difficulty in chewing. Discuss trigger zones and pain precipitants with patient. Protect cornea from abrasion. Ensure good oral hygiene. Educate patient about medication regimen.

Facial dysfunction; weakness and paralysis Hemifacial spasm Diminished or absent taste Pain

Recognize facial paralysis as emergency; refer for treatment as soon as possible. Teach protective care for eyes. Select easily chewed foods; patient should eat and drink from unaffected side of mouth. Emphasize importance of oral hygiene. Provide emotional support for changed appearance of face.

Tinnitus Vertigo Hearing difficulties

Assess pattern of vertigo. Provide for safety measures to prevent falls. Ensure that patient can maintain balance before ambulating. Caution patient to change positions slowly. Assist with ambulation. Encourage use of assistive devices.

Pain at base of tongue Difficulty in swallowing Loss of gag reflex Palatal, pharyngeal, and laryngeal paralysis

Assess for paroxysmal pain in throat, decreased or absent swallowing, and gag and cough reflexes. Monitor for dysphagia, aspiration, and nasal dysarthric speech. Position patient upright for eating or tube feeding.

Voice changes (temporary or permanent hoarseness) Vocal paralysis Dysphagia

Assess for airway obstruction/provide airway management. Prevent aspiration. Support patient having voice reconstruction procedures.

Drooping of affected shoulder with limited shoulder movement Weakness or paralysis of head rotation, flexion, extension; shoulder elevation

Support patient undergoing diagnostic tests.

Optic Nerve—II Optic neuritis Increased intracranial pressure Pituitary tumour Oculomotor Nerve—III Trochlear Nerve—IV Abducens Nerve—VI Vascular Brain stem ischemia Hemorrhage and infarction Neoplasm Trauma Infection Trigeminal Nerve—V Trigeminal neuralgia Head trauma Cerebellopontine lesion Sinus tract tumour and metastatic disease Compression of trigeminal root by tumour

Facial Nerve—VII Bell’s palsy Facial nerve tumour Intracranial lesion Herpes zoster

Vestibulocochlear Nerve—VIII Tumours and acoustic neuroma Vascular compression of nerve Ménière’s syndrome

Glossopharyngeal Nerve—IX Glossopharyngeal neuralgia from neurovascular compression of cranial nerves IX and X Trauma Inflammatory conditions Tumour Vertebral artery aneurysms Vagus Nerve—X Spastic palsy of larynx; bulbar paralysis; high vagal paralysis Guillain–Barré syndrome Vagal body tumours Nerve paralysis from malignancy, surgical trauma such as carotid endarterectomy Spinal Accessory Nerve—XI Spinal cord disorder Amyotrophic lateral sclerosis Trauma Guillain–Barré syndrome

continued >

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Disorders of Cranial Nerves (Continued)

Disorder

Clinical Manifestations

Nursing Interventions

Hypoglossal Nerve—XII Medullary lesions Amyotrophic lateral sclerosis Polio and motor system disease, which may destroy hypoglossal nuclei Multiple sclerosis Trauma

Abnormal movements of tongue Weakness or paralysis of tongue muscles Difficulty in talking, chewing, and swallowing

Observe swallowing ability. Observe speech pattern. Be aware of swallowing or vocal difficulties. Prepare for alternate feeding methods (tube feeding) to maintain nutrition.

the contact between the cerebral vessel and the trigeminal nerve root entry. With the aid of an operating microscope, the artery loop is lifted from the nerve to relieve the pressure, and a small prosthetic device is inserted to prevent recurrence of impingement on the nerve. The postoperative management is the same as for other intracranial surgeries (see Chapter 62). RADIOFREQUENCY THERMAL COAGULATION. Percutaneous radiofrequency produces a thermal lesion on the trigeminal nerve. Although immediate pain relief is experienced, dysesthesia of the face and loss of the corneal reflex may occur. Use of stereotactic MRI for identification of the trigeminal nerve followed by gamma knife radiosurgery is being used at some medical centres. PERCUTANEOUS BALLOON MICROCOMPRESSION. Percutaneous balloon microcompression disrupts large myelinated fibres in all three branches of the trigeminal nerve. After its placement, the balloon is filled with a contrast material for fluoroscopic identification. The balloon compresses the nerve root for 1 minute and provides microvascular decompression.

Nursing Management Preventing Pain

the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub the eye because the pain of a resulting injury will not be detected. The eye is assessed for irritation or redness. Artificial tears may be prescribed to prevent dryness in the affected eye. The patient is cautioned not to chew on the affected side until numbness has diminished. The patient is observed carefully for any difficulty in eating or swallowing foods of different consistencies.

Bell’s Palsy Bell’s palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side (Fig. 65-7). Although the cause is unknown, theories about causes include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination of all of these factors. Most adults with Bell’s

Facial nerve

Preoperative management of a patient with trigeminal neuralgia occurs mostly on an outpatient basis and includes recognizing factors that may aggravate excruciating facial pain, such as food that is too hot or too cold or jarring of the patient’s bed or chair. Even washing the face, combing the hair, or brushing the teeth may produce acute pain. The nurse can assist the patient in preventing or reducing this pain by providing instructions about preventive strategies. Providing cotton pads and room temperature water for washing the face, instructing the patient to rinse with mouthwash after eating if tooth brushing causes pain, and performing personal hygiene during pain-free intervals are all effective strategies. The patient is instructed to take food and fluids at room temperature, to chew on the unaffected side, and to ingest soft foods. The nurse recognizes that anxiety, depression, and insomnia often accompany chronic painful conditions and uses appropriate interventions and referrals. See Chapter 14 for management of patients with chronic pain.

Providing Postoperative Care Postoperative neurologic assessments are conducted to evaluate the patient for facial motor and sensory deficits in each of the three branches of the trigeminal nerve. If

FIGURE 65-7. Distribution of the facial nerve.

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palsy are younger than 45 years of age (Greco, Gallo, Fusconi, et al., 2012). Bell’s palsy may be a type of pressure paralysis. The inflamed, edematous nerve becomes compressed to the point of damage, or its blood supply is occluded, producing ischemic necrosis of the nerve. The face is distorted from paralysis of the facial muscles; increased lacrimation (tearing); and painful sensations in the face, behind the ear, and in the eye. The patient may experience speech difficulties and may be unable to eat on the affected side because of weakness or paralysis of the facial muscles. Most patients recover completely, and Bell’s palsy rarely recurs (Greco et al., 2012).

Medical Management The objectives of treatment are to maintain the muscle tone of the face and to prevent or minimize denervation. The patient should be reassured that no stroke has occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Corticosteroid therapy (prednisone) may be prescribed to reduce inflammation and edema; this reduces vascular compression and permits restoration of blood circulation to the nerve. Early administration of corticosteroid therapy appears to diminish the severity of the disease, relieve the pain, and prevent or minimize denervation (Greco et al., 2012). Facial pain is controlled with analgesic agents. Heat may be applied to the involved side of the face to promote comfort and blood flow through the muscles. Electrical stimulation may be applied to the face to prevent muscle atrophy. Although most patients recover with conservative treatment, surgical exploration of the facial nerve may be indicated if a tumor is suspected, for surgical decompression of the facial nerve, or for surgical treatment of a paralyzed face.

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DISORDERS OF THE PERIPHERAL NERVOUS SYSTEM Peripheral Neuropathies A peripheral neuropathy (disorder of the nervous system) is a disorder affecting the peripheral motor and sensory nerves. Peripheral nerves connect the spinal cord and brain to all other organs. They transmit motor impulses from the brain and relay sensory impulses to the brain. Peripheral neuropathies are characterized by bilateral and symmetric disturbance of function, usually beginning in the feet and hands. The most common cause of peripheral neuropathy is diabetes with poor glycemic control (Tesfaye, Chaturvedi, Simon, et al., 2005). The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness, diminished reflexes, pain, and paresthesia (numbness, tingling) of the extremities. Peripheral nerve disorders are diagnosed by history, physical examination, and electrodiagnostic studies such as electroencephalography. The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process (Miller, 2009). No specific treatment exists for peripheral neuropathy. Elimination or control of the cause may slow progression. Patients with peripheral neuropathy are at risk for falls, thermal injuries, and skin breakdown. The plan of care includes inspection of the lower extremities for skin breakdown. Assistive devices such as a walker or cane may decrease the risk of falls. Bath water temperature is checked to avoid thermal injury. Footwear should be accurately sized. Driving may be limited or eliminated, thereby disrupting the patient’s sense of independence.

Nursing Management

Mononeuropathy

While the paralysis lasts, nursing care involves protection of the eye from injury. Frequently, the eye does not close completely and the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and ulceration may occur. Distortion of the lower lid alters the proper drainage of tears. To prevent injury, the eye should be covered with a protective shield at night. The eye patch may abrade the cornea, however, because there is some difficulty in keeping the partially paralyzed eyelids closed. Moisturizing eye drops during the day and eye ointment at bedtime may help prevent injury (Carlson & Pfadt, 2005). The patient can be taught to close the paralyzed eyelid manually before going to sleep. Wrap-around sunglasses or goggles may be worn during the day to decrease normal evaporation from the eye. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.

Mononeuropathy is limited to a single peripheral nerve and its branches. It arises when the trunk of the nerve is compressed or entrapped (as in carpal tunnel syndrome), traumatized (as when bruised by a blow), overstretched (as in joint dislocation), punctured by a needle used to inject a drug or damaged by the drugs thus injected, or inflamed because an adjacent infectious process extends to the nerve trunk. Mononeuropathy is frequently seen in patients with diabetes. Pain is seldom a major symptom of mononeuropathy when the condition is due to trauma, but in patients with complicating inflammatory conditions such as arthritis, pain is prominent. Pain is increased with all body movements that tend to stretch, strain, or cause pressure on the injured nerve and sudden jarring of the body (e.g., from coughing or sneezing). The skin in the areas supplied by nerves that are injured or diseased may become reddened and glossy, the subcutaneous tissue may become edematous, and the nails and hair in this area are altered. Chemical injuries to a nerve trunk, such as those caused by drugs injected into or near it, are often permanent. The objective of treatment of mononeuropathy is to remove the cause, if possible (e.g., freeing the compressed nerve). Local corticosteroid injections may reduce

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inflammation and the pressure on the nerve. Aspirin or codeine may be used to relieve pain. Nursing care involves protection of the affected limb or area from injury, as well as appropriate patient teaching about mononeuropathy and its treatment.

Critical Thinking Exercises 1 A 19-year-old college student is admitted with suspected meningitis. Identify two assessment parameters that indicate meningitis. What interventions would be included in your plan of care to protect the patient from injury? The patient’s family has many questions about the disease and their risk of contracting meningitis. Develop a teaching plan that would describe meningitis and prophylactic therapy for the patient’s family and close contacts. 2 Your patient has been prescribed a new medication for the treatment of MS that requires self-injection. She reports that she has a fear of self-injection. Identify additional assessment parameters that need to be used. Develop a teaching plan for self-injection. What resources may be needed to enable her to be successful? 3

Your 40-year-old patient is being investigated for trigeminal neuralgia. What is the current evidence base for diagnostic evaluation and treatment of trigeminal neuralgia? Identify the criteria used to evaluate the strength of the evidence for diagnostic evaluation and treatment of trigeminal neuralgia. How would you use this information in developing a nursing plan of care for this patient?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisk indicates classic reference.

BOOKS Goetz, C. (2007). Textbook of clinical neurology (3rd ed.). Philadelphia, PA: Saunders. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hickey, J. V. (2009). The clinical practice of neurological & neurosurgical nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Iggulden, H. (2006). Care of the neurological patient. Oxford: Blackwell Publishing. Karch, A. (2014). Lippincott’s nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins. Karpoff, S., & Labus, D. M. (2008). Portable diagnostic tests. Philadelphia, PA: Lippincott Williams & Wilkins. Lemon, C. A., & Clarke, R. (2014). Nursing management: Chronic neurological problems. In S. L. Lewis, S. R. Derksen, M. M. Heitkemper, et al. (Eds.). Medical surgical nursing in Canada (3rd Can. ed.) Toronto, ON: Elsevier Canada. Mazzoni, P., Pearson, T. S., & Rowland, L. P. (2006). Merritt’s neurology handbook. Philadelphia, PA: Lippincott Williams & Wilkins. Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Hughes, R. G. (Ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses. (AHRQ Publication No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality. www.ahrq.gov/qual/ nurseshdbk/ van de Beek, D., de Gans, J., Tunkel, A. R., et al. (2006). Community-acquired bacterial meningitis. New England Journal of Medicine, 354(1), 44–53. CNS Infections National Advisory Committee on Communicable Diseases. (2013). Update on the use of quadrivalent conjugate meningococcal vaccines. Canada Communicable Disease Report CCDR 39, ACS-1, 1-40. Public Health Agency of Canada. Retrieved from http://www.phac-aspc.gc.ca/ publicat/ccdr-rmtc/13vol39/acs-dcc-1/index-eng.php National Institute of Allergies and Infectious Diseases (NIAID). (2008). NIAID research on West Nile Virus. Retrieved from http://www.niaid. nih.gov/topics/westnile/Pages/default.aspx Tunkel, A. R., Glaser, C. A., Block, K. C., et al. (2008). The management of encephalitis: Clinical practice guidelines by the infectious diseases society of America. Clinical Infectious Diseases, 47(1), 303–327. Creutzfeldt–Jakob Disease Glatzel, M., Stoeck, K., Seeger, H., et al. (2005). Human prion diseases: Molecular and clinical aspects. Archives of Neurology, 62(4), 545–552. Public Health Agency of Canada. (2012). Creutzfeldt-Jacob disease. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/hcaiiamss/cjd-mcj/cjd-eng.php Public Health Agency of Canada. (2014). Creutzfeldt-Jacob disease, CJD Surveillance System. Ottawa: Author, Retrieved from http://www.phacaspc.gc.ca/hcai-iamss/cjd-mcj/cjdss-ssmcj/stats-eng.php Ward, H., Everington, D., Cousens, S. N., et al. (2007). Risk factors for sporadic Creutzfeldt-Jakob disease. Annals of Neurology, 63(3), 347–354. Multiple Sclerosis Barbero, P., Verdun, E., Bergui, M., et al. (2004). High dose, frequently administered interferon beta therapy for relapsing remitting multiple sclerosis must be maintained over the long term: The Interferon Beta Dose Reduction Study. Journal of the Neurological Sciences, 222(1–2), 13–19. Holland, N., & Madonna, M. (2005). Nursing grand rounds: Multiple sclerosis. Journal of Neuroscience Nursing, 37(1), 15–19. Johnson, S. L. (2008). The concept of fatigue in multiple sclerosis. Journal of Neuroscience Nursing, 40(2), 72–77. **Lublin, F. D., & Reingold, S. C. (1996). Defining the clinical course of multiple sclerosis: Results of an international study. Neurology, 46(4), 907–911. *Miller, C. E., & Jezewski, M. A. (2006). Relapsing MS patient’s experiences with glatiramer acetate treatment: A phenomenological study. Journal of Neuroscience Nursing, 38(1), 37–41. Moore, L. A. (2007). Intimacy and multiple sclerosis. Nursing Clinics of North America, 42(4), 606–620. *Motl, R. W., Snook, E. M., & Schapiro, R. T. (2007). Symptoms and physical activity behavior in individuals with multiple sclerosis. Research in Nursing and Health, 31(5), 466–475. Nazarko, L. (2013). Multiple sclerosis: Offering care tailored to the person’s needs. British Journal of Health Care Assistants, 67(12), 594–599. *Newland, P. (2008). Pain in women with relapsing-remitting multiple sclerosis and in healthy women: A comparative study. Journal of Neuroscience Nursing, 40(5), 262–268. Phillips, L. J., & Stuifbergen, A. K. (2009). Structural equation modeling of disability in women with fibromyalgia or Multiple Sclerosis. Western Journal of Nursing Research, 31(1), 89–109. Ross, A. P., Hackbarth, N., Rohl, C., et al. (2008). Effective multiple sclerosis management through improved patient assessment. Journal of Neuroscience Nursing, 40(3), 150–157. Stern, M. (2005). Aging with multiple sclerosis. Physical Medicine and Rehabilitation Clinics of North America, 16(1), 219–234. Ward-Abel, N., Vernon, K., & Warner, R. (2014). An exciting era of treatments for relapsing-remitting multiple sclerosis. British Journal of Neuroscience Nursing, 10(1), 21–28. Myasthenia Gravis and Guillain–Barré Syndrome Allen, S. (2006). Management of myasthenia gravis. Pharmaceutical Journal, 277(19), 703–706.

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Ho, D., Thakur, K., Gorson, K. C., et al. (2008). Influence of critical illness on axonal loss in Guillain-Barré syndrome. Muscle and Nerve, 39(1), 10–15. Randell, D. J., Byars, A., Williams, F., et al. (2008). Glyconutrient supplementation in patients with myasthenia gravis. Journal of Alternative and Complementary Medicine, 14(9), 1–8. Winer, J. B. (2014). An Update in Guillain-Barré syndrome. Autoimmune Diseases, 2014, 793024, 6 pages. Trigeminal Neuralgia and Neuropathies Bennetto, L., Patel, J. K., & Fuller, G. (2007). Trigemminal neuralgia and its management. British Medical Journal, 334, 201–205. doi:10.1136/ bmj.39085.614792 Carlson, D. S., & Pfadt, E. (2005). When your patient has acute facial paralysis. Nursing, 35(4), 54–56. Greco, A. Gallo, A. Fusconi, M., et al. (2012). Bell’s palsy and autoimmunity. Autoimmunity Reviews, 12, 323–328.

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Gronseth, G., Cruccu, G., Alksne, J., et al. (2008). Practice parameter: The diagnostic evaluation and treatment of trigeminal neuralgia. Neurology, 71(8), 1183–1190. Tesfaye, S., Chaturvedi, N., Simon, E. M., et al. (2005). Vascular risk factors and diabetic neuropathy. New England Journal of Medicine, 352(4), 341–350.

RESOURCES Guillain-Barré Syndrome Foundation International, http://gbs-cidp. org/ Multiple Sclerosis Society of Canada, http://mssociety.ca/en/ Myasthenia Gravis Foundation of America, www.myasthenia.org The Neuropathy Association, Inc., www.neuropathy.org

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66 Management of Patients With Oncologic or Degenerative Neurologic Disorders Adapted by Ann Ranson Ratusz

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify the pathophysiologic processes responsible for oncologic disorders. 2. Describe brain and spinal cord tumours: their classification, clinical manifestations, diagnosis, and medical and nursing management. 3. Use the nursing process as a framework for care of patients with cerebral metastases or inoperable brain tumours. 4. Identify the pathophysiologic processes responsible for various degenerative neurologic disorders. 5. Use the nursing process as a framework for care of patients with Parkinson’s disease. 6. Identify resources for patients and families with oncologic and degenerative neurologic disorders. 7. Use the nursing process as a framework for care of patients following a cervical discectomy.

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The occurrence of oncologic or degenerative disease processes in the neurologic system produces a unique set of nursing challenges. Oncologic disorders include brain and spinal cord tumours. Degenerative neurologic disorders include Parkinson’s disease, Huntington disease, Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), muscular dystrophies, and degenerative disc disease. Postpolio syndrome is thought to be degenerative in nature and is included in this chapter.

ONCOLOGIC DISORDERS OF THE BRAIN AND SPINAL CORD Oncologic disorders of the brain and spinal cord include several types of neoplasms, each with its own biology, prognosis, and treatment options. Because of the unique anatomy and physiology of the central nervous system (CNS), this collection of neoplasms is challenging to diagnose and treat.

Primary Brain Tumours A brain tumour is a localized intracranial lesion that occupies space within the skull. A tumour usually grows as a spherical mass, but it also can grow diffusely and infiltrate tissue. The effects of neoplasms are caused by the compression and infiltration of tissue. A variety of physiologic changes result, causing any or all of the following pathophysiologic events: • Increased intracranial pressure (ICP) and cerebral edema • Seizure activity and focal neurologic signs • Hydrocephalus • Altered pituitary function Primary brain tumours originate from cells and structures within the brain. Secondary, or metastatic, brain tumours develop from structures outside the brain and occur in 10% to 20% of patients with cancer (Bader & Littlejohns, 2010). Brain tumours rarely metastasize outside the CNS. Metastatic lesions to the brain can occur

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from the lung, breast, lower gastrointestinal tract, pancreas, kidney, and skin (melanomas). The cause of primary brain tumours is unknown. The only known risk factor is exposure to ionizing radiation. Both glial and meningeal neoplasms have been linked to irradiation of the cranium. The risk is 1% to 3% with a latency period of 10 to 20 years after exposure (Niranjan, Kondziolka, & Lundsford, 2009; Rowe, 2006). Environmental risk factors, such as cell phone use, have been investigated, but results suggest that they are not associated with primary brain tumours (Vanchieri, 2011). A history of any allergy has also been investigated and preliminary results suggest a decreased incidence of glioma, meningioma, and acoustic neuroma (Turner, Krewski, Armstrong, et al., 2013). The incidence of brain tumours appears to have increased in the past few decades. Epidemiologic data, however, suggest that this is due more to aggressive and accurate diagnosis rather than to an actual rise in incidence. In Canada, it is estimated that 1,650 men and 1,200 women will develop brain cancer in 2013 (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2013). Secondary tumours or metastases to the brain from a systemic primary cancer are even more common than new cases of malignant brain and other nervous system tumours. The highest incidence of brain tumours in adults occurs in the fifth, sixth, and seventh decades. In adults, most brain tumours originate from glial cells (cells that make up the structure and support system of the brain and spinal cord) and are supratentorial (located above the covering of the cerebellum). Neoplastic lesions in the brain ultimately cause death by impairing vital functions, such as respiration, or by increasing ICP.

Types of Primary Brain Tumours Brain tumours may be classified into several groups: those arising from the coverings of the brain (e.g., dural meningioma), those developing in or on the cranial nerves (e.g., acoustic neuroma), those originating within brain tissue (e.g., glioma), and metastatic lesions originating elsewhere in the body. Tumours of the pituitary and pineal glands and of cerebral blood vessels are also types of brain

Glossary akathisia: restlessness, urgent need to move around, and agitation bradykinesia: very slow voluntary movements and speech chorea: rapid, jerky, involuntary, purposeless movements of the extremities or facial muscles, including facial grimacing dementia: a progressive organic mental disorder characterized by personality changes, confusion, disorientation, and deterioration of intellect associated with impaired memory and judgment dyskinesia: impaired ability to execute voluntary movements dysphonia: abnormal voice quality caused by weakness and incoordination of muscles responsible for speech

micrographia: small and often illegible handwriting neurodegenerative: a disease, process, or condition that leads to deterioration of normal cells or function of the nervous system papilledema: edema of the optic nerve paresthesia: a sensation of numbness, tingling, or a “pins and needles” sensation radiculopathy: disease of a spinal nerve root, often resulting in pain and extreme sensitivity to touch sciatica: inflammation of the sciatic nerve, resulting in pain and tenderness along the nerve through the thigh and leg spondylosis: ankylosis or stiffening of the cervical or lumbar vertebrae

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CHART 66-1

Classification of Brain Tumours in Adults I. Intracerebral Tumours A. Gliomas—infiltrate any portion of the brain; most common type of brain tumour 1. Astrocytomas (grades I and II) 2. Glioblastoma multiforme (astrocytoma grades III and IV) 3. Oligodendrocytoma (low and high grades) 4. Ependymoma (grades I to IV) 5. Medulloblastoma II. Tumours Arising From Supporting Structures A. Meningiomas B. Neuromas (acoustic neuroma, schwannoma) C. Pituitary adenomas III. Developmental Tumours A. Angiomas B. Dermoid, epidermoid, teroma, craniopharyngioma IV. Metastatic Lesions

tumours. Relevant clinical considerations include the location and the histologic character of the tumour. Tumours may be benign or malignant. A benign tumour, such as a colloid cyst, can occur in a vital area and can grow large enough to have serious effects (Richards & Ballard, 2008). See Chart 66-1 for the classification of brain tumours.

Gliomas Glial tumours, the most common type of intracerebral brain neoplasm, account for approximately half of brain tumours, and are divided into many categories (Lawler & Chiocca, 2013). Astrocytomas, which are the most common type of glioma, are graded from I to IV to indicate the degree of malignancy (Diepenbrock, 2007). The grade is based on cellular density, cell mitosis, and appearance. Usually, these tumours spread by infiltrating into the surrounding neural connective tissue and therefore cannot be totally removed without causing considerable damage to vital structures. Oligodendroglial tumours represent 20% of gliomas and are categorized as low grade or high grade (anaplastic) (American Brain Tumour Association [ABTA], 2012a). The histologic distinction between astrocytomas and oligodendrogliomas is difficult to make, but important, because oligodendrogliomas are more sensitive than astrocytomas to chemotherapy (Lawler & Chiocca, 2013).

Meningiomas Meningiomas, which represent 15% to 20% of all primary brain tumours, are common benign encapsulated tumours of arachnoid cells on the meninges (Diepenbrock, 2007). They are slow growing and occur most often in middleaged adults (more often in women). Meningiomas most often occur in areas proximal to the venous sinuses. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue. Standard treatment is surgery with complete removal or partial dissection.

Acoustic Neuromas An acoustic neuroma is a tumour of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. It usually arises just within the internal auditory meatus, where it frequently expands before filling the cerebellopontine recess. An acoustic neuroma may grow slowly and attain considerable size before it is correctly diagnosed. The patient usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. As the tumour becomes larger, painful sensations of the face may occur on the same side, as a result of the tumour’s compression of the fifth cranial nerve. Many acoustic neuromas are benign and can be managed conservatively. Many that continue to grow can be surgically removed and have a good prognosis (see Chapter 60) (Diepenbrock, 2007). Some acoustic neuromas may be suitable for stereotactic radiotherapy rather than open craniotomy (Theodosopoulos & Pensak, 2011). Stereotactic radiotherapy is discussed later in this chapter.

Pituitary Adenomas Pituitary tumours represent about 9% to 12% of all brain tumours, making them the third most common brain tumour (ABTA, 2012b). They cause symptoms as a result of pressure on adjacent structures or hormonal changes (hyperfunction or hypofunction of the pituitary). The pituitary gland, also called the hypophysis, is a relatively small gland located in the sella turcica. It is attached to the hypothalamus by a short stalk (hypophyseal stalk) and is divided into two lobes: the anterior (adenohypophysis) and the posterior (neurohypophysis). PRESSURE EFFECTS OF PITUITARY ADENOMAS. Pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm, or optic tracts or on the hypothalamus or the third ventricle if the tumour invades the cavernous sinuses or expands into the sphenoid bone. These pressure effects produce headache, visual dysfunction, hypothalamic disorders (disorders of sleep, appetite, temperature, and emotions), increased ICP, and enlargement and erosion of the sella turcica. HORMONAL EFFECTS OF PITUITARY ADENOMAS.

Functioning pituitary tumours can produce one or more hormones normally produced by the anterior pituitary. There are prolactin-secreting pituitary adenomas (prolactinomas), growth hormone–secreting pituitary adenomas that produce acromegaly in adults, and adrenocorticotropic hormone (ACTH)–producing pituitary adenomas that result in Cushing’s disease (Gordon, 2007). Adenomas that secrete thyroid-stimulating hormone or follicle-stimulating hormone and luteinizing hormone occur infrequently, whereas adenomas that produce both growth hormone and prolactin are relatively common. The female patient whose pituitary gland is secreting excessive quantities of prolactin presents with amenorrhea or galactorrhea (excessive or spontaneous flow of milk). Male patients with prolactinomas may present with impotence and hypogonadism. Acromegaly, caused by excess growth hormone, produces enlargement of the hands and feet, distortion of the facial features, and pressure on peripheral nerves (entrapment syndromes). The clinical features of Cushing’s disease, a condition associated with

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prolonged overproduction of cortisol, occur with excessive production of ACTH. Manifestations include a form of obesity with redistribution of fat to the facial, supraclavicular, and abdominal areas; hypertension; purple striae and ecchymoses; osteoporosis; elevated blood glucose levels; and emotional disorders. Endocrine disorders resulting from these tumours are discussed in Chapter 43.

Angiomas Brain angiomas (masses composed largely of abnormal blood vessels) are found either in or on the surface of the brain. They occur in the cerebellum in 83% of cases (Barker, 2008). Some persist throughout life without causing symptoms; others cause symptoms of a brain tumour. Occasionally, the diagnosis is suggested by the presence of another angioma somewhere in the head or by a bruit (an abnormal sound) that is audible over the skull. Because the walls of the blood vessels in angiomas are thin, these patients are at risk for hemorrhagic stroke. In fact, cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma.

Gerontologic Considerations The most frequent tumour types in the elderly are anaplastic astrocytoma, glioblastoma multiforme, and cerebral metastases from other sites. The incidence of primary brain tumours and the likelihood of malignancy increase with age. Intracranial tumours can produce personality changes, confusion, speech dysfunction, or dis-

turbances of gait. In elderly patients, early signs and symptoms of intracranial tumours can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Neurologic signs and symptoms in the elderly must be carefully evaluated, because 10% of brain metastases occur in patients with a history of prior cancer. Researchers are investigating patterns of care and clinical outcomes of elderly patients with primary brain tumours (Barnholtz-Sloan, Williams, Maldonado, et al., 2008).

Clinical Manifestations Brain tumours can produce both focal or generalized neurologic signs and symptoms. Generalized symptoms reflect increased ICP, and the most common focal or specific signs and symptoms result from tumours that interfere with functions in specific brain regions. Figure 66-1 indicates common tumour sites in the brain.

Increased Intracranial Pressure As discussed in Chapter 62, the skull is a rigid compartment containing essential noncompressible contents: brain matter, intravascular blood, and cerebrospinal fluid (CSF). According to the modified Monro–Kellie hypothesis, if any one of these skull components increases in volume, ICP increases unless one of the other components decreases in volume. Consequently, any change in volume occupied by the brain (as occurs with disorders such as brain tumour or cerebral edema) produces signs and symptoms of increased ICP.

Lateral ventricle ependymoma glioblastoma multiforme

Corpus callosum astrocytoma oligodendroglioma lipoma

Cerebrum astrocytoma oligodendroglioma lymphoma metastatic tumours Pineal area pineocytoma pineoblastoma

3rd ventricle area ependymoma

Optic chiasm astrocytoma Pituitary area craniopharyngioma pituitary adenoma epidermoid cyst Acoustic nerve neuroma

FIGURE 66-1. Common brain tumour sites.

Brain stem astrocytoma glioblastoma multiforme metastatic tumours

4th ventricle ependymoma

Cerebellum medulloblastoma astrocytoma hemangioblastoma metastatic tumours

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Symptoms of increased ICP result from a gradual compression of the brain by the enlarging tumour. The effect is a disruption of the equilibrium that exists between the brain, the CSF, and the cerebral blood. As the tumour grows, compensatory adjustments may occur through compression of intracranial veins, reduction of CSF volume (by increased absorption or decreased production), a modest decrease in cerebral blood flow, or reduction of intracellular and extracellular brain tissue mass. When these compensatory mechanisms fail, the patient develops signs and symptoms of increased ICP, most often including headache, nausea with or without vomiting, and papilledema (edema of the optic disc) (Lee & Armstrong, 2008; Rowland & Pedley, 2010). Personality changes and a variety of focal deficits, including motor, sensory, and cranial nerve dysfunction, are common. HEADACHE. Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumour’s invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumour. Headaches are usually described as deep or expanding or as dull but unrelenting. Frontal tumours usually produce a bilateral frontal headache; pituitary gland tumours produce pain radiating between the two temples (bitemporal); in cerebellar tumours, the headache may be located in the suboccipital region at the back of the head. VOMITING. Vomiting, seldom related to food intake, is usually the result of irritation of the vagal centres in the medulla. Forceful vomiting is described as projectile vomiting. VISUAL DISTURBANCES. Papilledema is present in 70% to 75% of patients and is associated with visual disturbances such as decreased visual acuity, diplopia (double vision), and visual field deficits (Rowland & Pedely, 2010).

Localized Symptoms Common focal or localized symptoms are hemiparesis, seizures, and mental status changes. When specific regions of the brain are affected, additional local signs and symptoms occur, such as sensory and motor abnormalities, visual alterations, alterations in cognition, and language disturbances (e.g., aphasia) (Fox, Mitchell, & BoothJones, 2006). The progression of the signs and symptoms is important, because it indicates tumour growth and expansion. For example, a rapidly developing hemiparesis is more typical of a highly malignant glioma than of a lowgrade tumour. Although some tumours are not easily localized because they lie in so-called silent areas of the brain (i.e., areas in which functions are not definitely determined), many tumours can be localized by correlating the signs and symptoms to specific areas in the brain, as follows: • A motor cortex tumour produces seizurelike movements localized on one side of the body, called Jacksonian seizures. • An occipital lobe tumour produces visual manifestations: Contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumour) and visual hallucinations.

• A cerebellar tumour causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction. • A frontal lobe tumour frequently produces personality disorders, changes in emotional state and behaviour, and an apathetic mental attitude. The patient often becomes extremely untidy and careless and may use obscene language. • A cerebellopontine angle tumour usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms. Tinnitus and vertigo appear first, soon followed by progressive nerve deafness (eighth cranial nerve dysfunction). Numbness and tingling of the face and tongue occur (due to involvement of the fifth cranial nerve). Later, weakness or paralysis of the face develops (seventh cranial nerve involvement). Finally, because the enlarging tumour presses on the cerebellum, abnormalities in motor function may be present.

Assessment and Diagnostic Findings The history of the illness and the manner and time frame in which the symptoms evolved are key components in the diagnosis of brain tumours. A neurologic examination indicates the areas of the CNS that are involved. To assist in the precise localization of the lesion, a battery of tests is performed. Computed tomography (CT) scans, enhanced by a contrast agent, can give specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema. CT scans can provide information about the ventricular system. A magnetic resonance imaging (MRI) scan is the most helpful diagnostic tool for detecting brain tumours, particularly smaller lesions, and tumours in the brain stem and pituitary regions, where bone is thick (Fig. 66-2). In a few instances, the appearance of a brain tumour on an MRI scan is so characteristic that a biopsy is unnecessary, especially when the tumour is located in a part of the brain that is difficult to biopsy (Barker, 2008). Positron emission tomography (PET) is used to supplement MRI or CT scanning in centres where it is increasingly available. Newer PET scans are being used concurrently with CT scans (hybrid scans) to produce a fused image of the PET and CT scan. On PET scans, lowgrade tumours are associated with hypometabolism and high-grade tumours show hypermetabolism. This information can be useful in making treatment decisions (ABTA, 2012). Computer-assisted stereotactic (threedimensional) biopsy is used to diagnose deep-seated brain tumours and to provide a basis for treatment and prognosis. Cerebral angiography allows for the visualization of cerebral blood vessels and measurement of blood flow into the brain, thus provides the location of most cerebral tumours (ABTA, 2012). An electroencephalogram (EEG) can detect an abnormal brain wave in regions occupied by tumour; it is used to evaluate temporal lobe seizures and to assist in ruling out other disorders. Cytologic studies of the CSF may be

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• Targeting molecules and pathways in the replication of tumour cells • Improving drug therapy (Lawler & Chiocca, 2013).

Surgical Management

FIGURE 66-2. Low-grade glioma. Magnetic resonance image of the brain shows an abnormal density in the right temporal lobe. (Courtesy of the Hospital of the University of Pennsylvania, Nuclear Medicine Section, Philadelphia, PA.)

performed to detect malignant cells, because CNS tumours can shed cells into the CSF.

Medical Management A variety of medical treatment modalities, including chemotherapy and external-beam radiation therapy, are used alone or in combination with surgical resection (Lawler & Chiocca, 2013). Radiation therapy, the cornerstone of treatment for many brain tumours, decreases the incidence of recurrence of incompletely resected tumours. Brachytherapy (the surgical implantation of radiation sources to deliver high doses at a short distance) has had promising results for primary malignancies. It is usually used as an adjunct to conventional radiation therapy and surgical resection or as a rescue measure for recurrent disease (Schwarz, Thon, Nikolajek, et al., 2012). Intravenous (IV) autologous bone marrow transplantation is used in some patients who will receive chemotherapy or radiation therapy, because it can “rescue” the patient from the bone marrow toxicity associated with high doses of chemotherapy and radiation. A fraction of the patient’s bone marrow is aspirated, usually from the iliac crest, and stored. The patient receives large doses of chemotherapy or radiation therapy to destroy large numbers of malignant cells. The marrow is then reinfused by IV after treatment is completed. A number of therapies are either in clinical trials or being tested experimentally on animals. Such strategies are: • Creation of vaccines to enhance immune functioning and recognition of tumour cells • Engineering viruses to replicate in tumour cell

The objective of surgical management is to remove or destroy the entire tumour without increasing the neurologic deficit (paralysis, blindness) or to relieve symptoms by partial removal (decompression). A variety of treatment modalities may be used; the specific approach depends on the type of tumour, its location, and its accessibility. In many patients, combinations of these modalities are used. Most pituitary adenomas are treated by transsphenoidal microsurgical removal (see Chapter 62), and the remainder of tumours that cannot be removed completely are treated by radiation (Patel, Yu, & Piepmeier, 2012). An untreated brain tumour ultimately leads to death, either from increasing ICP or from the damage the tumour causes to brain tissue. Conventional surgical approaches require a craniotomy (incision into the skull). See Chapter 63 for a discussion of care of the patient who has undergone a craniotomy. This approach is used in patients with meningiomas, acoustic neuromas, cystic astrocytomas of the cerebellum, colloid cysts of the third ventricle, congenital tumours such as dermoid cyst, and some of the granulomas. With improved imaging techniques and the availability of the operating microscope and microsurgical instrumentation, even large tumours can be removed through a relatively small craniotomy. For patients with malignant glioma, complete removal of the tumour and cure are not possible, but the rationale for resection includes relief of ICP, removal of any necrotic tissue, and reduction in the bulk of the tumour, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. Stereotactic approaches involve the use of a threedimensional frame that allows very precise localization of the tumour; a stereotactic frame and multiple imaging studies (x-rays, CT scans) are used to localize the tumour and verify its position (Fig. 66-3). New brain-mapping technology helps determine how close diseased areas of the brain are to structures essential for normal brain function. Lasers or radiation can be delivered with stereotactic approaches. Radioisotopes such as iodine 131 (131I) can also be implanted directly into the tumour to deliver high doses of radiation to the tumour (brachytherapy) while minimizing effects on surrounding brain tissue. Stereotactic procedures may be performed using a linear accelerator or gamma knife to perform radiosurgery. These procedures allow treatment of deep, inaccessible tumours, often in a single session. Precise localization of the tumour is accomplished by the stereotactic approach and by minute measurements and precise positioning of the patient. Multiple narrow beams then deliver a very high dose of radiation. An advantage of this method is that no surgical incision is needed; a disadvantage is the lag time between treatment and the desired result (Pollock, 2006; Swinson & Friedman, 2008).

Nursing Management The patient with a brain tumour may be at increased risk for aspiration as a result of cranial nerve dysfunction.

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A

B

FIGURE 66-3. (A) Using stereotactic or “brain-mapping” guided approach, a three-dimensional computer image fuses the computed tomography image and magnetic resonance image to pinpoint the exact location of the brain tumour. This low-grade astrocytoma is localized adjacent to the brain stem, is nonoperable, and is treated with radiation. Note the optic chiasm and optic nerves. (B) Computerized image of the prescribed radiation dose.

Preoperatively, the gag reflex and ability to swallow are evaluated. In patients with diminished gag response, care includes teaching the patient to direct food and fluids toward the unaffected side, having the patient sit upright to eat, offering a semisoft diet, and having suction readily available. The effects of increased ICP caused by the tumour mass are reviewed in Chapter 62. The nurse performs neurologic checks, monitors vital signs, maintains a neurologic flow chart, spaces nursing interventions to prevent rapid increase in ICP, and reorients the patient when necessary to person, time, and place. Patients with changes in cognition caused by their lesion require frequent reorientation and the use of orienting devices (e.g., personal possessions, photographs, lists, clock), supervision of and assistance with self-care, and ongoing monitoring and intervention for prevention of injury. Patients with seizures are carefully monitored and protected from injury. Motor function is checked at intervals, because specific motor deficits may occur, depending on the tumour’s location. Sensory disturbances are assessed. Speech is evaluated. Eye movement and pupillary size and reaction may be affected by cranial nerve involvement. The psychosocial effects on family caregivers of a family member who has a primary malignant brain tumour may be significant (Schmer, Ward-Smith, Latham, et al., 2008) (Chart 66-2). The nursing process for patients undergoing neurosurgery is discussed in Chapter 61. The patient’s functional abilities should be reassessed postoperatively, because changes can occur.

mon intracerebral tumour, their exact incidence is unknown (Fox, Cheung, Patel, et al., 2011, Raizer & Abrey, 2007). This high rate of occurrence is clinically important as more patients with all forms of cancer live longer because of improved therapies. Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis, aphasia, and seizures. These signs and symptoms can be devastating to both patient and family.

Medical Management The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both patient and family. Patients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods. The median survival time for patients with no treatment for brain metastases is 1 month; with corticosteroid treatment alone it is 2 months; radiation therapy extends the median survival time to 3 to 6 months. The therapeutic approach includes radiation therapy (the foundation of treatment), surgery (usually for a single intracranial metastasis), and chemotherapy; more often, some combination of these treatments is the optimal method. Gamma knife radiosurgery is considered if three or fewer lesions are present.

Cerebral Metastases

Pharmacologic Therapy

A significant number of patients with cancer experience neurologic deficits caused by metastasis to the brain. Although metastatic lesions to the brain are the most com-

Corticosteroids are useful in relieving headache and alterations in level of consciousness. Corticosteroids such as dexamethasone (Decadron) and prednisone are thought

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NURSING RESEARCH PROFILE

Chart 66-2. The Caregiver Perspective When a Family Member has a Malignant Brain Tumour Schmer, C., Ward-Smith, P., Latham, S., et al. (2008). When a family member has a malignant brain tumour: The caregiver perspective. Journal of Neuroscience Nursing, 40(2), 78–84. Purpose There have been no significant advances in the treatment of malignant brain tumours over the past 25 years, and care is performed primarily by family members. The purpose of this study was to explore the perspective of the caregiver for a patient receiving chemotherapy for initial treatment of a malignant brain tumour. Design This was a phenomenologic study that used interviews to explore caregiver perspectives. Ten family members (seven spouses, two daughters, and one son-in-law) provided data. Semi structured interviews took place with the caregiver while the patient was receiving chemotherapy within the first 6 months of treatment for a primary malignant brain tumour. Data analysis was conducted using Colaizzi’s method, a qualitative data analysis technique, to identify themes.

to reduce inflammation and edema around tumours (Karch, 2014). Other medications used include osmotic diuretics (e.g., mannitol [Osmitrol]) to decrease the fluid content of the brain, which leads to a decrease in ICP. Antiseizure agents (e.g., phenytoin [Dilantin]) are used to prevent and treat seizures (Rowland & Pedley, 2010). The pharmacologic management of pituitary tumours is complex and usually carried out on an outpatient basis (Gordon, 2007). Venous thromboembolic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE), develops in 19% to 29% of patients and is associated with significant morbidity. Anticoagulants are not usually prescribed because of the risk of CNS hemorrhage; however, prophylactic therapy with low–molecularweight heparin is under investigation (Gerber, Grossman, & Streiff, 2006). Chemotherapy plays a small role in managing brain metastasis because of poor penetration across the blood– brain barrier. Drug penetration and sensitivity of brain cells are two factors that determine the responsiveness of metastatic brain tumours to chemotherapy. Research is being directed at multidrug regimens and drug resistance (ABTA, 2012). Encouraging results have been seen with chemotherapeutic agents such as carmustine (BCNU), lomustine (CCNU), and PCV (a triple-drug combination of procarbazine hydrochloride, lomustine, and vincristine). Promising results have been seen with the use of topotecan (Hycamtin), another chemotherapy agent. Pain is managed by means of a stepped progression in the doses and type of analgesic agents needed for relief. If the patient has severe pain, morphine can be infused into the epidural or subarachnoid space through a spinal needle

Findings Data analysis uncovered three main themes. The first was that the diagnosis of a brain tumour is a shock; all participants used the work shock when explaining their feelings on hearing the diagnosis. The second was that immediate family role changes occur; diagnosis of a primary malignant brain tumour and subsequent treatment resulted in immediate family role changes for both the patient and caregiver. The final theme was that there are psychosocial effects for the caregiver, his or her family, and the person with the brain tumour. Participants did not perceive caring for the family member as a burden. Nursing Implications Little research has focused on the experience and changing roles of family members immediately after diagnosis or during the initial treatment phase of a terminal illness. This research provides beginning knowledge for health care professionals about the experience of a family caregiver of a patient with a primary brain tumour. During the first 6 months of treatment, there was a low physical need burden but significant psychosocial effects. Nurses working with patients and families should be prepared to address these psychosocial effects (e.g., family role changes).

and a catheter placed as near as possible to the spinal segment where the pain is projected. Small doses of morphine are administered at prescribed intervals (see Chapter 14). !!"##

Nursing Process

The Patient With Cerebral Metastases or Incurable Brain Tumour Assessment The nursing assessment includes a baseline neurologic examination and focuses on how the patient is functioning, moving, and walking; adapting to weakness or paralysis and to loss of vision and speech; and dealing with seizures. Assessment addresses symptoms that cause distress to the patient and affect the quality of life, including pain, respiratory problems, bowel and bladder disorders, sleep disturbances, and impairment of skin integrity, fluid balance, and temperature regulation (Arzbaecher, 2007). Tumour invasion, compression, or obstruction may cause these disorders. Nutritional status is assessed, because cachexia (weak and emaciated condition) is common in patients with metastases. The nurse explores changes associated with poor nutritional status (anorexia, pain,

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weight loss, altered metabolism, muscle weakness, malabsorption, and diarrhea) and asks the patient about altered taste sensations that may be secondary to dysphagia, weakness, and depression and about distortions and impaired sense of smell (anosmia). The nurse takes a dietary history to assess food intake, intolerance, and preferences. Calculation of body mass index can confirm the loss of subcutaneous fat and lean body mass (see Chapter 5). Biochemical measurements are reviewed to assess the degree of malnutrition, impaired cellular immunity, and electrolyte balance (see Appendix A for normal laboratory values). A dietitian assists in determining the caloric needs of the patient. The nurse works with other members of the health care team to assess the impact of the illness on the family in terms of home care, altered relationships, financial problems, time pressures, and family problems. This information is important in helping family members cope with the diagnosis and the changes associated with it.

Interventions

Diagnosis

Patients with nausea, vomiting, diarrhea, breathlessness, and pain are rarely interested in eating. These symptoms are managed or controlled through assessment, planning, and care. The nurse teaches the family how to position the patient for comfort during meals. Meals are planned for times when the patient is rested and in less distress from pain or the effects of treatment. The patient needs to be clean, comfortable, and free of pain for meals, in an environment that is as attractive as possible. Oral hygiene before meals helps to improve appetite. Offensive sights, sounds, and odours are eliminated. Creative strategies may be required to make food more palatable, provide enough fluids, and increase opportunities for socialization during meals. The family may be asked to keep a daily weight chart and to record the quantity of food eaten to determine the daily calorie count. Dietary supplements, if acceptable to the patient, can be provided to meet increased caloric needs. If the patient is not interested in most usual foods, those foods preferred by the patient should be offered. When the patient shows marked deterioration as a result of tumour growth and effects, some other form of nutritional support (e.g., tube feeding, parenteral nutrition) may be indicated if consistent with the patient’s end-of-life preferences (Dudek, 2010). Nursing interventions include assessing the patency of the central and IV lines or feeding tube, monitoring the insertion site for infection, checking the infusion rate, monitoring intake and output, and changing the IV tubing and dressing. Family members are instructed in these techniques if they will be providing care at home. Parenteral nutrition can be provided at home if indicated. The patient’s quality of life may guide the selection, initiation, maintenance, and discontinuation of nutritional support. The nurse and family should not place too much emphasis on eating or on discussions about food, because the patient may not desire aggressive nutritional intervention. The subsequent

Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Self-care deficit (feeding, bathing, and toileting) related to loss or impairment of motor and sensory function and decreased cognitive abilities • Imbalanced nutrition, less than body requirements, related to cachexia due to treatment and tumour effects, decreased nutritional intake, and malabsorption • Anxiety related to fear of dying, uncertainty, change in appearance, or altered lifestyle • Interrupted family processes related to anticipatory grief and the burdens imposed by the care of the person with a terminal illness Other nursing diagnoses of the patient with cerebral metastases may include acute pain related to tumour compression; impaired gas exchange related to dyspnea; constipation related to decreased fluid and dietary intake and medications; impaired urinary elimination related to reduced fluid intake, vomiting, and side effects of medications; sleep pattern disturbances related to discomfort and fear of dying; impairment of skin integrity related to cachexia, poor tissue perfusion, and decreased mobility; deficient fluid volume related to fever, vomiting, and low fluid intake; and ineffective thermoregulation related to hypothalamic involvement, fever, and chills. See Chapter 16 for assessment and nursing interventions for the patient with cancer.

Planning and Goals The goals for the patient may include compensating for self-care deficits, improving nutrition, reducing anxiety, enhancing family coping skills, and absence of complications.

Compensating for Self-Care Deficits The patient may have difficulty participating in goal setting as the tumour metastasizes and affects cognitive function. The nurse should encourage the family to keep the patient as independent as possible for as long as possible. Increasing assistance with self-care activities is required. Because the patient with cerebral metastasis and the family live with uncertainty, they are encouraged to plan for each day and to make the most of each day. The tasks and challenges are to assist the patient to find useful coping mechanisms, adaptations, and compensations for solving problems that arise. This helps patients maintain some sense of control. An individualized exercise program helps maintain strength, endurance, and range of motion. Eventually, referral for home or hospice care may be necessary (see Chapter 18).

Improving Nutrition

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course of action must be congruent with the wishes and choices of the patient and family.

Relieving Anxiety Patients with cerebral metastases may be restless, with changing moods that may include intense depression, euphoria, paranoia, and severe anxiety. The response of patients to terminal illness reflects their pattern of reaction to other crisis situations. Serious illness imposes additional strains that often bring other unresolved problems to light. The patient’s own coping strategies can help deal with anxious and depressed feelings. Health care providers need to be sensitive to the patient’s concerns and fears. Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. The presence of family, friends, a spiritual advisor, and health professionals may be supportive. Support groups such as the Brain Tumour Support Group may provide a feeling of support and strength. Spending time with patients allows them time to talk and to communicate their fears and concerns. Open communication and acknowledgment of fears are often therapeutic. Touch is also a form of communication. These patients need reassurance that continuing care will be provided and that they will not be abandoned. The situation becomes more endurable when others share in the experience of dying. If a patient’s emotional reactions are very intense or prolonged, additional help from a spiritual advisor, social worker, or mental health professional may be indicated.

Enhancing Family Processes The family needs to be reassured that their loved one is receiving optimal care and that attention will be paid to the patient’s changing symptoms and concerns. When the patient can no longer carry out selfcare, the family and additional support systems (social worker, home health aide, home care nurse, hospice nurse) may be needed. End-of-life care is provided with respect, and reassurance is provided by communicating the plan of care to the family (Fields, 2007).

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient and family often have major responsibility for care at home. Therefore, teaching includes pain management strategies, prevention of complications related to treatment strategies, and methods to ensure adequate fluid and food intake (Chart 66-3). Teaching needs of the patient and family regarding care priorities are likely to change as the disease progresses. The nurse should assess the changing needs of the patient and the family and inform them about resources and services early, to assist them in dealing with changes in the patient’s condition. CONTINUING CARE. Home care nursing and hospice services are valuable resources that should be made available to the patient and the family early in the course of a terminal illness. Anticipating needs before they occur can assist in smooth initiation of services. Home care needs and interventions focus on four major areas: palliation of symptoms and pain control, assistance in self-care, control of treatment complications, and administration of specific forms

CHART 66-3

HOME CARE CHECKLIST •

The Patient With Cerebral Metastases Patient

Caregiver

• State effects of the tumour according to its type and location in the brain.

✔

✔

• Describe side effects of treatment.

✔

✔

• Identify community resources, including: • Home health services • Hospices • Support groups • American Brain Tumour Association

✔ ✔ ✔ ✔

✔ ✔ ✔ ✔

✔ ✔ ✔

✔ ✔ ✔ ✔

✔ ✔ ✔

✔ ✔ ✔

At the completion of the home care instruction, the patient or caregiver will be able to:

• Identify coping strategies, such as: • Taking control, setting daily goals, and staying positive • Rehabilitation to improve self-care • Relaxation techniques • Family support • Verbalize an understanding of the treatment plan for: • Medications and pain control • Nutritional needs • Contacting the health care provider

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of treatment, such as parenteral nutrition. The home care nurse assesses pain management, respiratory status, complications of the disorder and its treatment, and the patient’s cognitive and emotional status. Additionally, the nurse assesses the family’s ability to perform necessary care and notifies the physician about changing needs or complications if indicated (Warnoch & Tod, 2013). The patient and family who elect to care for the patient at home as the disease progresses benefit from the care and support provided through hospice and palliative care services (Fields, 2007). Steps to initiate hospice care, including discussion of hospice care as an option, should not be postponed until death is imminent. Exploration of hospice care as an option should be initiated at a time when hospice services can provide support and care to the patient and family consistent with their end-of-life decisions and can assist in allowing death with dignity. End-oflife care is further described in Chapter 18.

Evaluation

tumour level to progressive loss of motor function and paralysis. Usually, sharp pain occurs in the area innervated by the spinal roots that arise from the cord in the region of the tumour. In addition, increasing sensory deficits develop below the level of the lesion.

Assessment and Diagnostic Findings Neurologic examination and diagnostic studies are used to make the diagnosis. Neurologic examination includes assessment of pain, loss of reflexes, loss of sensation or motor function, and the presence of weakness and paralysis. Additional assessment findings usually include pain duration for longer than 1 month and an elevated erythrocyte sedimentation rate. Helpful diagnostic studies include x-rays, radionuclide bone scans, CT scans, MRI scans, and biopsy. The MRI scan is the most commonly used and the most sensitive diagnostic tool, and it is particularly helpful in detecting epidural spinal cord compression and metastases (Rowland & Pedley, 2010).

Expected Patient Outcomes

Medical Management

Expected patient outcomes may include the following:

Treatment of specific intraspinal tumours depends on the type and location of the tumour and the presenting symptoms and physical status of the patient. Surgical intervention is the primary treatment for most spinal cord tumours (Mechtler & Nandigam, 2013). Other treatment modalities include partial removal of the tumour, decompression of the spinal cord, chemotherapy, and radiation therapy, particularly for intramedullary tumours and metastatic lesions (Rowland & Pedley, 2010). Epidural spinal cord compression occurs in 5% to 10% of patients who die of cancer and is considered a neurologic emergency (Chaichana, Pendleton, Sciubba, et al., 2009). For the patient with epidural spinal cord compression resulting from metastatic cancer (most commonly from breast, prostate, or lung), high-dose dexamethasone (Decadron) combined with radiation therapy is effective in relieving pain (Dy, Asch, Naeim, et al., 2008). Surgical removal of metastatic tumours is being investigated to ascertain if survival time increases. Preliminary results demonstrate increased survival for select histological types of spinal cord metastasis (Chaichana et al., 2009). See Chapter 17 for a discussion of care of the patient with spinal cord compression. Palliative care may be an option for the medical management of some patients.

1. Engages in self-care activities as long as possible a. Uses assistive devices or accepts assistance as needed b. Schedules periodic rest periods to permit maximal participation in self-care 2. Maintains as optimal a nutritional status as possible a. Eats and accepts food within limits of condition and preferences b. Accepts alternative methods of providing nutrition if indicated 3. Reports being less anxious a. Is less restless and is sleeping better b. Verbalizes concerns and fears about death c. Participates in activities of personal importance as long as feasible 4. Family members seek help as needed a. Demonstrate ability to bathe, feed, and care for the patient and participate in pain management and prevention of complications b. Express feelings and concerns to appropriate health professionals c. Discuss and seek hospice care as an option

Spinal Cord Tumours Tumours within the spine are classified according to their anatomic relation to the spinal cord. They include intramedullary lesions (within the spinal cord), extramedullary– intradural lesions (within or under the spinal dura), and extramedullary–extradural lesions (outside the dural membrane). Tumours that occur within the spinal cord or exert pressure on it cause symptoms ranging from localized or shooting pains and weakness and loss of reflexes above the

Surgical Management Tumour removal is desirable but not always possible. The goal is to remove as much tumour as possible while sparing uninvolved portions of the spinal cord. Microsurgical techniques have improved the prognosis for patients with intramedullary tumours. Prognosis is related to the degree of neurologic impairment at the time of surgery, the speed with which symptoms occurred, and the origin of the tumour. Patients with extensive neurologic deficits before surgery usually do not make significant functional recovery even after successful tumour removal (Mechtler & Nandigam, 2013).

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Nursing Management Providing Preoperative Care The objectives of preoperative care include recognition of neurologic changes through ongoing assessments, pain control, and management of altered activities of daily living (ADLs) resulting from sensory and motor deficits and bowel and bladder dysfunction. The nurse assesses for weakness, muscle wasting, spasticity, sensory changes, bowel and bladder dysfunction, and potential respiratory problems, especially if a cervical tumour is present. The patient is also evaluated for coagulation deficiencies. A history of aspirin intake is obtained and reported, because the use of aspirin may impede hemostasis postoperatively. Breathing exercises are taught and demonstrated preoperatively. Postoperative pain management strategies are discussed with the patient before surgery.

Assessing the Patient after Surgery The patient is monitored for deterioration in neurologic status. A sudden onset of neurologic deficit is an ominous sign and may be due to vertebral collapse associated with spinal cord infarction. Frequent neurologic checks are carried out, with emphasis on movement, strength, and sensation of the upper and lower extremities. Assessment of sensory function involves pinching the skin of the arms, legs, and trunk to determine if there is loss of feeling and, if so, at what level. Vital signs are monitored at regular intervals.

Managing Pain The prescribed pain medication should be administered in adequate amounts and at appropriate intervals to relieve pain and prevent its recurrence. Pain is the hallmark of spinal metastasis. Patients with sensory root involvement or vertebral collapse may suffer excruciating pain, which requires effective pain management (Hickey, 2013). The bed is usually kept flat initially. The nurse turns the patient as a unit, keeping shoulders and hips aligned and the back straight. The side-lying position is usually the most comfortable, because this position imposes the least pressure on the surgical site. Placement of a pillow between the knees of the patient in a side-lying position helps to prevent extreme knee flexion.

Monitoring and Managing Potential Complications If the tumour was in the cervical area, respiratory compromise due to postoperative edema may occur. The nurse monitors the patient for asymmetric chest movement, abdominal breathing, and abnormal breath sounds. For a high cervical lesion, the endotracheal tube remains in place until adequate respiratory function is ensured. The patient is encouraged to perform deep-breathing and coughing exercises. The area over the bladder is palpated or a bladder scan is performed to assess for urinary retention. The nurse also monitors for incontinence, because urinary dysfunction usually implies significant decompensation of spinal cord function. An intake and output record is maintained. Additionally, the abdomen is auscultated for bowel sounds.

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Staining of the dressing may indicate leakage of CSF from the surgical site, which may lead to serious infection or to an inflammatory reaction in the surrounding tissues that can cause severe pain in the postoperative period.

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. In preparation for discharge, the patient is assessed for the ability to function independently in the home and for the availability of resources such as family members to assist in caregiving. Patients with residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be alerted to the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters). The patient is taught to check skin integrity daily. Patients with impaired motor function related to motor weakness or paralysis may require training in ADLs and safe use of assistive devices, such as a cane, walker, or wheelchair. The patient and family members are instructed about pain management strategies, bowel and bladder management, and assessment for signs and symptoms that should be reported promptly. CONTINUING CARE. Referral for inpatient or outpatient rehabilitation may be warranted to improve self-care abilities. A home care referral may be indicated and provides the home care nurse with the opportunity to assess the patient’s physical and psychological status and the patient’s and family’s ability to adhere to recommended management strategies. During the home visit, the nurse determines whether changes in neurologic function have occurred. The patient’s respiratory status and nutritional status are assessed. The adequacy of pain management is assessed, and modifications are made to ensure adequate pain relief. The need for hospice services or placement in an extended-care facility is discussed with the patient and family if warranted, and the patient is asked about preferences for end-of-life care. Additionally, social workers may be consulted to assist the patient and family members in identifying support groups and agencies that can provide help in coping with the disease process.

DEGENERATIVE DISORDERS Disorders of the central and peripheral nervous system that are neurodegenerative (leading to deterioration of normal cells or function of the nervous system) are characterized by the slow onset of signs and symptoms. Patients are managed at home for as long as possible and are admitted to the acute care setting for exacerbations, treatments, and surgical interventions as needed.

Parkinson’s Disease Parkinson’s disease is a slowly progressing neurologic movement disorder that eventually leads to disability. It is the second most common neurodegenerative disease, and an estimated 5,500 new cases are reported each year in Canada (Lix, Hobson, Azimaee, et al., 2010; Parkinson Society British Columbia, 2014). The disease affects men more often than women. Symptoms usually first appear

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in the fifth decade of life; however, cases have been diagnosed as early as 30 years of age. The degenerative or idiopathic form of Parkinson’s disease is the most common; there is also a secondary form with a known or suspected cause. Although the cause of most cases is unknown, research suggests several causative factors, including genetics, atherosclerosis, excessive accumulation of oxygen-free radicals, viral infections, head trauma, chronic use of antipsychotic medications, and some environmental exposures.

Pathophysiology Parkinson’s disease is associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia region of the brain (Fig. 66-4). Fibres or neuronal pathways project from the substantia nigra to the corpus striatum, where neurotransmitters are key to the control of complex body movements. Through the neurotransmitters acetylcholine (excitatory) and dopamine (inhibitory), striatal neurons relay messages to the higher motor centres that control and refine motor movements. The loss of dopamine stores in this area of the brain results in more excitatory neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement. Clinical symptoms do not appear until 60% of the pigmented neurons are lost and the striatal dopamine level is decreased by 80%. Cellular degeneration impairs the extrapyramidal tracts that control semiautomatic functions and coordinated movements; motor cells of the motor cortex and the pyramidal tracts are not affected. Researchers are working on uncovering the exact mechanism of neurodegeneration; current theories suggest that it results from oxidative stress in a portion of the neuron known as Lewy bodies, protein aggregation, or a combination of the two mechanisms (Barker & Barasi, 2008).

Clinical Manifestations Parkinson’s disease has a gradual onset, and symptoms progress slowly over a chronic, prolonged course. The cardinal signs are tremor, rigidity, bradykinesia (abnormally slow movements), and postural instability (Chen & Fernandez, 2007; Thomure, 2006).

Tremor Although symptoms are variable, a slow, unilateral resting tremor is present in the majority of patients at the time of diagnosis (Chen & Fernandez, 2007). Resting tremor characteristically disappears with purposeful movement but is evident when the extremities are motionless. The tremor may manifest as a rhythmic, slow turning motion (pronation–supination) of the forearm and the hand and a motion of the thumb against the fingers as if rolling a pill between the fingers. Tremor is present while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious.

Rigidity Resistance to passive limb movement characterizes muscle rigidity. Passive movement of an extremity may cause

the limb to move in jerky increments, referred to as leadpipe or cogwheel movements (Chen & Fernandez, 2007). Involuntary stiffness of the passive extremity increases when another extremity is engaged in voluntary active movement. Stiffness of the arms, legs, face, and posture are common. Early in the disease, the patient may complain of shoulder pain due to rigidity.

Bradykinesia One of the most common features of Parkinson’s disease is bradykinesia, which refers to the overall slowing of active movement (Chen & Fernandez, 2007; Thomure, 2006). Patients may also take longer to complete activities and have difficulty initiating movement, such as rising from a sitting position or turning in bed.

Postural Instability The patient commonly develops postural and gait problems. A loss of postural reflexes occurs, and the patient stands with the head bent forward and walks with a propulsive gait. The posture is caused by the forward flexion of the neck, hips, knees, and elbows. The patient may walk faster and faster, trying to move the feet forward under the body’s centres of gravity (shuffling gait). Difficulty in pivoting causes loss of balance (either forward or backward). Gait impairment and postural instability place the patient at increased risk for falls (Sadowski, Jones, Gordon, et al., 2007).

Other Manifestations The effect of Parkinson’s disease on the basal ganglia often produces autonomic symptoms that include excessive and uncontrolled sweating, paroxysmal flushing, orthostatic hypotension, gastric and urinary retention, constipation, and sexual dysfunction (Miller, 2009). Psychiatric changes include personality changes, depression, dementia (progressive mental deterioration), delirium, hallucinations, and anxiety (Quelhas, 2013). Depression is common; whether it is a reaction to the disorder or is related to a biochemical abnormality is uncertain. Mental changes may appear in the form of cognitive, perceptual, and memory deficits, although intellect is not usually affected. Dementia affects up to 75% of patients over the course of the disease (Weintraub & Hurtig, 2007). Auditory and visual hallucinations have been reported in up to 40% of people with Parkinson’s disease and may be associated with depression, dementia, lack of sleep, or adverse effects of medications. Additionally, sleep disturbances are common. Hypokinesia (abnormally diminished movement) is also common and may appear after the tremor. The freezing phenomenon refers to a transient inability to perform active movement and is thought to be an extreme form of bradykinesia. Additionally, the patient tends to shuffle and exhibits a decreased arm swing. As dexterity declines, micrographia (small handwriting) develops. The face becomes increasingly masklike and expressionless, and the frequency of blinking decreases. Dysphonia (soft, slurred, low-pitched, and less audible speech) may occur as a result of weakness and incoordination of the muscles responsible for speech. In many cases, the patient develops dysphagia, begins to drool, and is at risk for choking and aspiration.

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Physiology/Pathophysiology Corpus striatum

Substantia nigra

Destruction of dopaminergic neuronal cells in the substantia nigra in the basal ganglia

Depletion of dopamine stores

Degeneration of the dopaminergic nigrostriatal pathway

Imbalance of excitatory (acetylcholine) and inhibiting (dopamine) neurotransmitters in the corpus striatum

Impairment of extrapyramidal tracts controlling complex body movements

Tremors

Rigidity

Bradykinesia

Postural changes

FIGURE 66-4. Pathophysiology of Parkinson’s disease. The nuclei in the substantia nigra project fibres to the corpus striatum. The nerve fibres carry dopamine to the corpus striatum. The loss of dopamine nerve cells from the brain’s substantia nigra is thought to be responsible for the symptoms of Parkinsonism.

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Complications associated with Parkinson’s disease are common and are typically related to disorders of movement. As the disease progresses, patients are at risk for respiratory and urinary tract infection, skin breakdown, and injury from falls. The adverse effects of medications used to treat the symptoms are associated with numerous complications such as dyskinesia or orthostatic hypotension (Karch, 2014).

Assessment and Diagnostic Findings Although laboratory tests and imaging studies are not helpful to the clinician in diagnosing Parkinson’s disease, ongoing research with PET and single photon emission computed tomography (SPECT) scanning has been helpful in understanding the disease and advancing treatment. Currently, the disease is diagnosed clinically from the patient’s history and the presence of two of the four cardinal manifestations: tremor, rigidity, bradykinesia, and postural changes. Early diagnosis can be difficult because patients rarely are able to pinpoint when the symptoms started. Often, a family member notices a change such as stooped posture, a stiff arm, a slight limp, tremor, or slow, small handwriting. The medical history, presenting symptoms, neurologic examination, and response to pharmacologic management are carefully evaluated when making the diagnosis (Thomure, 2006). With advances in neuroimaging techniques investigators are seeking to identify early warning symptoms or a prodromal phase of Parkinson’s disease. For example, Parkinson’s disease not only affects the substantia nigra, but extends to regions such as the anterior olfactory site well before cardinal symptoms appear. Extensions to other regions are associated with a loss of smell, decreased contrast sensitivity to colours, and altered sleep cycles called REM behaviour disorder (Stern & Siderowf, 2010).

Medical Management Treatment is directed at controlling symptoms and maintaining functional independence, because no medical or surgical approaches in current use prevent disease progression. Care is individualized for each patient based on presenting symptoms and social, occupational, and emotional needs. Pharmacologic management is the mainstay of treatment, although advances in research have led to increased surgical options. Patients are usually cared for at home and are admitted to the hospital only for complications or to initiate new treatments.

Pharmacologic Therapy Antiparkinsonian medications act by (1) increasing striatal dopaminergic activity; (2) reducing the excessive influence of excitatory cholinergic neurons on the extrapyramidal tract, thereby restoring a balance between dopaminergic and cholinergic activities; or (3) acting on neurotransmitter pathways other than the dopaminergic pathway. Levodopa (Larodopa) is the most effective agent and the mainstay of treatment. Levodopa is converted to dopamine

in the basal ganglia, producing symptom relief. Levodopa is available in three forms: immediate-release, orally disintegrating, and sustained-release tablets (Halkias, Haq, Huang, et al., 2007). The beneficial effects of levodopa are most pronounced in the first few years of treatment. Benefits begin to wane and adverse effects become more severe over time. Confusion, hallucinations, depression, and sleep alterations are associated with prolonged use. Within 5 to 10 years, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements), including facial grimacing, rhythmic jerking movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities. The patient may experience an on–off syndrome in which sudden periods of near immobility (“off effect”) are followed by a sudden return of effectiveness of the medication (“on effect”). Various adjunctive therapies are used to minimize dyskinesias (Chen & Fernandez, 2007). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, which is characterized by severe rigidity, stupor, hyperthermia, and elevated creatine kinase levels (Musselman & Saely, 2013). Additional medications used to treat Parkinson’s disease are described in Table 66-1.

Surgical Management The limitations of levodopa therapy, improvements in stereotactic surgery, and new approaches in transplantation have renewed interest in the surgical treatment of Parkinson’s disease. In patients with disabling tremor, rigidity, or severe levodopa-induced dyskinesia, surgery may be considered. Although surgery provides symptom relief in selected patients, it has not been shown to alter the course of the disease or to produce permanent improvement. STEREOTACTIC PROCEDURES. Thalamotomy and pallidotomy are effective in relieving many of the symptoms of Parkinson’s disease (Rowland & Pedley, 2010). Patients eligible for these procedures are those who have had an inadequate response to medical therapy; they must meet strict criteria to be eligible. Candidates eligible for these procedures are patients with idiopathic Parkinson’s disease who are taking maximum doses of antiparkinsonian medications. Patients with dementia and atypical Parkinson’s disease are usually not considered for stereotactic procedures. Parkinson’s disease rating scales and specific neurologic tests are used to identify eligible patients. The intent of thalamotomy and pallidotomy is to interrupt the nerve pathways and thereby alleviate tremor or rigidity. During thalamotomy, a stereotactic electrical stimulator destroys part of the ventrolateral portion of the thalamus in an attempt to reduce tremor; the most common complications are ataxia and hemiparesis. Pallidotomy involves destruction of part of the ventral aspect of the medial globus pallidus through electrical stimulation in patients with advanced disease (Murdoch, 2010) The procedure is effective in reducing rigidity, bradykinesia, and dyskinesia, thus improving motor function and ADLs in the immediate postoperative course. Potential complications include hemiparesis and stroke, as well as cognitive, speech, swallowing, and visual changes.

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TABLE 66-1

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Summary of Medications Used to Treat Parkinson’s Disease

Medications

Indications and Therapeutic Effects

Common Side Effects

Control of tremor and rigidity Counteract the action of acetylcholine

Blurred vision, flushing, rash, constipation, urinary retention, and acute confusional states Contraindicated in patients with narrow-angle glaucoma

Reduce rigidity, tremor, bradykinesia, and postural changes in early Parkinson’s disease

Psychiatric disturbances (mood changes, confusion, depression, hallucinations), lower extremity edema, nausea, epigastric distress, urinary retention, headache, and visual impairment

Early Parkinson’s disease as well as secondary drug therapy after carbidopa or levodopa loses effectiveness Early stages of Parkinson’s disease

Nausea, vomiting, diarrhea, lightheadedness, hypotension, impotence, and psychiatric effects

Inhibit dopamine breakdown

Can cause hypertensive crisis

Anticholinergic Agents Trihexyphenidyl hydrochloride (Apo-Trihex) Benztropine mesylate (Cogentin) Antiviral Agents Amantadine hydrochloride (Symmetrel)

Dopamine Agonists Bromocriptine mesylate (Parlodel) Pergolide (Permax) Nonergot Derivatives Ropinirole hydrochloride (Requip) Pramipexole (Mirapex) Monoamine Oxidase Inhibitors Selegiline (Eldepryl) Rasagiline (Azilect)

May cause drowsiness or dizziness

Catechol-O-Methyltransferase Inhibitors Entacapone (Comtan) Tolcapone (Tasmar)

Antidepressants Tricyclic Antidepressants Amitriptyline hydrochloride (Elavil) Serotonin Reuptake Inhibitors Fluoxetine hydrochloride (Prozac) Bupropion hydrochloride (Wellbutrin) Antihistamines Diphenhydramine hydrochloride (Benadryl) Orphenadrine citrate (Banflex) Phenindamine hydrochloride (Neo-Synephrine)

Increase the duration of action of carbidopa or levodopa Reduce motor fluctuations in patients with advanced Parkinson’s disease Anticholinergic and antidepressant

Hypertension, insomnia, dry mouth

Antidepressant

Clinical worsening and suicide risk

May reduce tremors

Anticholinergic and sedative effects

A CT scan, x-ray, MRI scan, or angiogram is used to localize the appropriate surgical site in the brain. Then the patient’s head is positioned in a stereotactic frame (Fig. 66-5). After the surgeon makes an incision in the skin and a burr hole, an electrode is passed through to the target area in the thalamus or globus pallidum. The desired response of the patient to the electrical stimulation (i.e., a decrease in rigidity) is the basis for the selection of the area of the brain to be destroyed. Stereotactic procedures are completed on one side of the brain at a time. If rigidity or tremor is bilateral, a 6-month interval is suggested between procedures. NEURAL TRANSPLANTATION. Ongoing research is exploring transplantation of porcine neuronal cells, human fetal cells, and stem cells (Rowland & Pedley, 2010). Legal, ethical, and political concerns surrounding the use of fetal brain cells and stem cells have limited the implementation of these procedures.

FIGURE 66-5. A stereotactic frame is applied to a patient’s head in preparation for pallidotomy. The frame immobilizes the head.

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Pulse generator in clavicle area

FIGURE 66-6. Deep brain stimulation is provided by a pulse generator surgically implanted in a pouch beneath the clavicle. The generator sends high-frequency electrical impulses to the thalamus, thereby blocking the nerve pathways associated with tremors in Parkinson’s disease.

DEEP BRAIN STIMULATION. Pacemakerlike brain implants are used to relieve tremors (Rowland & Pedley, 2010). The stimulation can be bilateral or unilateral; bilateral stimulation of the subthalamic nucleus is thought to be of greater benefit to patients than results achieved with thalamotomy, pallidotomy, or fetal nigral transplantation. In deep brain stimulation, an electrode is placed in the thalamus and connected to a pulse generator that is implanted in a subcutaneous subclavicular or abdominal pouch. The battery-powered pulse generator sends high-frequency electrical impulses through a wire placed under the skin to a lead anchored to the skull (Fig. 66-6). The electrode blocks nerve pathways in the brain that cause tremors. These devices are not without complications that can result from both the surgical procedure needed for implantation and the device itself (e.g., lead leakage and accidental deactivation by electromagnetic fields from electrical items such as an electrical toothbrush) (Tousi & Wilson, 2013).

!!"##

Nursing Process

The Patient With Parkinson’s Disease Assessment Assessment focuses on how the disease has affected the patient’s ADLs and functional abilities. The patient is observed for degree of disability and func-

tional changes that occur throughout the day, such as responses to medication. Almost every patient with a movement disorder has some functional alteration and may have some type of behavioural dysfunction. The following questions may be useful to assess alterations: • Do you have leg or arm stiffness? • Have you experienced any irregular jerking of your arms or legs? • Have you ever been “frozen” or rooted to the spot and unable to move? • Does your mouth water excessively? Have you (or others) noticed yourself grimacing or making faces or chewing movements? • What specific activities do you have difficulty doing? During this assessment, the nurse observes the patient for quality of speech, loss of facial expression, swallowing deficits (drooling, poor head control, coughing), tremors, slowness of movement, weakness, forward posture, rigidity, evidence of mental slowness, and confusion. Parkinson’s disease symptoms, as well as side effects of medications, put these patients at high risk for falls; therefore, a fall risk assessment should be conducted (Sadowski et al., 2007).

Diagnosis Nursing Diagnoses Based on the assessment data, the patient’s major nursing diagnoses may include the following: • Impaired physical mobility related to muscle rigidity and motor weakness • Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance • Constipation related to medication and reduced activity • Imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing • Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move facial muscles • Ineffective coping related to depression and dysfunction due to disease progression Other nursing diagnoses may include sleep pattern disturbances, deficient knowledge, risk for injury, risk for activity intolerance, disturbed thought processes, and compromised family coping.

Planning and Goals The goals for the patient may include improving functional mobility, maintaining independence in ADLs, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, and developing positive coping mechanisms.

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Nursing Interventions Improving Mobility A progressive program of daily exercise will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that occur when muscles are not used. Walking, riding a stationary bicycle, swimming, and gardening are all exercises that help maintain joint mobility. Stretching (stretch–hold–relax) and rangeof-motion exercises promote joint flexibility. Postural exercises are important to counter the tendency of the head and neck to be drawn forward and down. A physical therapist may be helpful in developing an individualized exercise program and can provide instruction to the patient and caregiver on exercising safely. Faithful adherence to an exercise and walking program helps delay the progress of the disease. Warm baths and massage, in addition to passive and active exercises, help relax muscles and relieve painful muscle spasms that accompany rigidity. Balance may be adversely affected because of the rigidity of the arms (arm swinging is necessary in normal walking). Special walking techniques must be learned to offset the shuffling gait and the tendency to lean forward. The patient is taught to concentrate on walking erect, to watch the horizon, and to use a wide-based gait (i.e., walking with the feet separated). A conscious effort must be made to swing the arms, raise the feet while walking, and use a heel–toe placement of the feet with long strides. The patient is advised to practice walking to marching music or to the sound of a ticking metronome, because this provides sensory reinforcement. Performing breathing exercises while walking helps move the rib cage and aerate parts of the lungs. Frequent rest periods aid in preventing frustration and fatigue.

Enhancing Self-Care Activities Encouraging, teaching, and supporting the patient during ADLs promote self-care. See Chapter 12 for rehabilitation techniques. Environmental modifications are necessary to compensate for functional disabilities. Patients may have severe mobility problems that make normal activities impossible. Adaptive or assistive devices may be useful. A hospital bed at home with bedside rails, an overbed frame with a trapeze, or a rope tied to the foot of the bed can provide assistance in pulling up without help. An occupational therapist can evaluate the patient’s needs in the home, make recommendations regarding adaptive devices, and teach the patient and caregiver how to improvise.

Improving Bowel Elimination The patient may have severe problems with constipation. Among the factors causing constipation are weakness of the muscles used in defecation, lack of exercise, inadequate fluid intake, and decreased autonomic nervous system activity. The medications used

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for the treatment of the disease also inhibit normal intestinal secretions. A regular bowel routine may be established by encouraging the patient to follow a regular time pattern, consciously increase fluid intake, and eat foods with moderate fibre content. Laxatives should be avoided. Psyllium (Metamucil), for example, decreases constipation but carries the risk of bowel obstruction (Karch, 2014). A raised toilet seat is useful, because the patient has difficulty in moving from a standing to a sitting position.

Improving Nutrition Patients may have difficulty maintaining their weight. Eating becomes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing. These patients are at risk for aspiration because of impaired swallowing and the accumulation of saliva. They may be unaware that they are aspirating; subsequently, bronchopneumonia may develop. Monitoring weight on a weekly basis indicates whether caloric intake is adequate. Supplemental feedings increase caloric intake. As the disease progresses, a nasogastric tube or percutaneous endoscopic gastroscopy may be necessary to maintain adequate nutrition. A dietitian can be consulted regarding nutritional needs.

Enhancing Swallowing Swallowing difficulties and choking are common in Parkinson’s disease (Chen & Fernandez, 2007). These can lead to problems with poor head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and disturbances in pharyngeal motility. To offset these problems, the patient should sit in an upright position during mealtime. A semisolid diet with thick liquids is easier to swallow than solids; thin liquids should be avoided. Thinking through the swallowing sequence is helpful. The patient is taught to place the food on the tongue, close the lips and teeth, lift the tongue up and then back, and swallow. The patient is encouraged to chew first on one side of the mouth and then on the other. To control the buildup of saliva, the patient is reminded to hold the head upright and make a conscious effort to swallow. Massaging the facial and neck muscles before meals may be beneficial.

Encouraging the use of Assistive Devices An electric warming tray keeps food hot and allows the patient to rest during the prolonged time that it may take to eat. Special utensils also assist at mealtime. A plate that is stabilized, a nonspill cup, and eating utensils with built-up handles are useful selfhelp devices. The occupational therapist can assist in identifying appropriate adaptive devices.

Improving Communication Speech disorders are present in most patients with Parkinson’s disease. The low-pitched, monotonous,

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soft speech of patients requires that they make a conscious effort to speak slowly, with deliberate attention to what they are saying. The patient is reminded to face the listener, exaggerate the pronunciation of words, speak in short sentences, and take a few deep breaths before speaking. A speech therapist may be helpful in designing speech improvement exercises and assisting the family and health care personnel to develop and use a method of communication that meets the patient’s needs. A small electronic amplifier is helpful if the patient has difficulty being heard.

Supporting Coping Abilities Support can be given by encouraging the patient and pointing out that activities will be maintained through active participation. A combination of physiotherapy, psychotherapy, medication therapy, and support group participation may help reduce the depression that often occurs. Patients with Parkinson’s disease can become withdrawn. It is best if patients are active participants in their therapeutic program, including social and recreational events. A planned program of activity throughout the day prevents too much daytime sleeping as well as disinterest and apathy. Patients often feel embarrassed, apathetic, inadequate, bored, and lonely. In part, these feelings may result from physical slowness and the great effort that even small tasks require. The patient is assisted and encouraged to set achievable goals (e.g., improvement of mobility). Every effort should be made to encourage patients to carry out the tasks involved in meeting their own daily needs and to remain independent. Doing things for the patient merely to save time undermines the basic goal of improving coping abilities and promoting a positive self-concept.

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. Patient and family education is important in the management of Parkinson’s disease. Teaching needs depend on the severity of symptoms and the stage of the disease. Care must be taken not to overwhelm the patient and family with too much information early in the disease process. The patient’s and family’s need for information is ongoing as adaptations become necessary. The education plan should include a clear explanation of the disease and the goal of assisting the patient to remain functionally independent as long as possible. Every effort is made to explain the nature of the disease and its management to offset disabling anxieties and fears. The patient and family must be taught about the effects and side effects of medications and about the importance of reporting side effects to the physician (Chart 66-4). CONTINUING CARE. In the early stages, the patient can be managed well at home. Family members often serve as caregivers, with home care or community

services available to assist in meeting health care needs as the disease progresses. The family caregiver may be under considerable stress from living with and caring for a person with a significant disability. Providing information about treatment and care prevents many unnecessary problems. The caregiver is included in the plan and may be advised to learn stress reduction techniques, to include others in the caregiving process, to obtain periodic relief from responsibilities, and to have a yearly health assessment. Allowing family members to express feelings of frustration, anger, and guilt is often helpful to them. The patient should be evaluated in the home for adaptation and safety needs and compliance with the plan of care. In the advanced stages, patients usually enter long-term care facilities if family support is absent. Periodically, admission to an acute care facility may be necessary for changes in medical management or treatment of complications. Nurses provide support, education, and monitoring of patients over the course of the illness. The nurse involved in home and continuing care needs to remind the patient and family members of the importance of addressing health promotion needs such as screening for hypertension and stroke risk assessments in this predominantly elderly population. Patients are taught about the importance of these activities and are referred to appropriate health care providers. Informational booklets and a newsletter for patient education are published by the Parkinson’s Society of Canada and the National Parkinson’s Foundation (see Resources).

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Strives toward improved mobility a. Participates in exercise program daily b. Walks with wide base of support; exaggerates arm swinging when walking c. Takes medications as prescribed 2. Progresses toward self-care a. Allows time for self-care activities b. Uses self-help devices 3. Maintains bowel function a. Consumes adequate fluid b. Increases dietary intake of fibre c. Reports regular pattern of bowel function 4. Attains improved nutritional status a. Swallows without aspiration b. Takes time while eating 5. Achieves a method of communication a. Communicates needs b. Practices speech exercises 6. Copes with effects of Parkinson’s disease a. Sets realistic goals b. Demonstrates persistence in meaningful activities c. Verbalizes feelings to appropriate person

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CHART 66-4

HOME CARE CHECKLIST •

The Patient With Parkinson’s Disease Patient

Caregiver

• Define Parkinson’s disease and discuss its long-term effects.

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• Identify the medication regimen and name adverse effects, and precautions.

✔

✔

• Discuss the risk for injury; prevent falls; implement adaptive measures in the home.

✔

✔

• Describe nutritional needs, dietary restrictions, dysphagia management, and ways to

✔

✔

• Manage constipation: fluid intake, bowel routine.

✔

✔

• Manage urinary problems: functional incontinence, retention (indwelling urinary catheter

✔

✔

• Explain effects of immobility and define preventive care: skin breakdown (frequent turning,

✔

✔

• Define benefits of daily exercise program.

✔

✔

• Walk and balance safely.

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• Demonstrate speech and communication skills: speech exercises, communication

✔

• Name signs and symptoms of infection (urinary and respiratory) and state when health care

✔

✔

• Describe strategies to promote self-care activities and independence.

✔

✔

• Identify resources: American Parkinson’s Disease Association, National Parkinson’s Disease

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

prevent aspiration.

care, suprapubic catheter care).

pressure release, skin care), pneumonia (deep breathing, movement), contractures (rangeof-motion exercises).

techniques, breathing exercises. provider should be notified.

Foundation, and local support groups.

Huntington Disease Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. The disease affects approximately 1 in 10,000 men or women of all races at midlife. It is transmitted as an autosomal dominant genetic disorder; therefore, each child of a parent with Huntington disease has a 50% risk of inheriting the disorder (Bordelon, 2013). A genetic marker for Huntington disease has been identified. Researchers can identify people who will develop this disease. However, genetic testing offers no hope of cure or even specific prediction of the timing of disease onset. Even though the gene was mapped in 1983 and presymptomatic testing has been offered since 1986, many patients choose not to be tested. For most people, the benefits of testing are unclear because of ethical issues and concerns about confidentiality. Genetic counselling is crucial after testing, and patients and their families may require long-term psychological counselling and emotional, financial, and legal support. People of childbearing age with a family history of Huntington disease often seek information about their risk of disease transmission.

Pathophysiology The basic pathology involves premature death of cells in the striatum (caudate and putamen) of the basal ganglia, the region deep within the brain that is involved in the control of movement. Cells also are lost in the cortex, the region of the brain associated with thinking, memory, perception, and judgment, and in the cerebellum, the area that coordinates voluntary muscle activity. Cell loss is associated with a mutant variety of the protein called huntingtin. Huntingtin normally concentrates in neurons and is involved in vital cellular processes. The mutant huntingtin protein disrupts neuronal cellular functioning in areas such as the mitochondria, transport of axon critical factors, calcium signaling, and transcription of various genes (Bordelon, 2013; Ha & Fung, 2012).

Clinical Manifestations The most prominent clinical features of the disease are chorea (abnormal involuntary movements), intellectual decline, and, often, emotional disturbance (Stephen, Skillen, Day, et al. 2010). As the disease progresses, a constant writhing, twisting, uncontrollable movement may involve the entire body. These motions are devoid of purpose or

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rhythm, although patients may try to turn them into purposeful movement. All of the body musculature is involved. Facial movements produce tics and grimaces. Speech becomes slurred, hesitant, often explosive, and eventually unintelligible. Chewing and swallowing are difficult, and there is a constant danger of choking and aspiration. Choreiform movements persist during sleep but are diminished. As with speech, the gait becomes disorganized to the point that ambulation eventually is impossible. Although independent ambulation should be encouraged for as long as possible, a wheelchair usually becomes necessary. Eventually, the patient is confined to bed when the chorea interferes with walking, sitting, and all other activities. Bladder and bowel control is lost. Cognitive function is usually affected, with dementia usually occurring. Initially, the patient is aware that the disease is responsible for the myriad dysfunctions that are occurring. The mental and emotional changes that occur may be more devastating to the patient and family than the abnormal movements. Personality changes may result in nervous, irritable, or impatient behaviours. In the early stages, patients are particularly subject to uncontrollable fits of anger; profound, often suicidal depression; apathy; anxiety; psychosis; or euphoria. Judgment and memory are impaired, and dementia eventually ensues. Hallucinations, delusions, and paranoid thinking may precede the appearance of disjointed movements. Emotional and cognitive symptoms often become less acute as the disease progresses (Walker, 2007). Onset usually occurs between 35 and 45 years of age, although about 10% of patients are children. The disease progresses slowly. Despite a ravenous appetite, patients usually become emaciated and exhausted. Patients succumb in 10 to 20 years to heart failure, pneumonia, or infection, or as a result of a fall or choking.

Assessment and Diagnostic Findings The diagnosis is made based on the clinical presentation of characteristic symptoms, a positive family history, the known presence of a genetic marker, and exclusion of other causes. The use of a genetic test has been available since 1993 and genetic counselling is recommended prior to and following the genetic test (Andersson, Juth, Petersen, et al., 2012; Etchegary, 2011).

Management Although no treatment halts or reverses the underlying process, medications may reduce chorea. Typical antispsychotic drugs such as thiothixene hydrochloride (Navane) and haloperidol (Haldol), which predominantly block dopamine receptors, improve the chorea in many patients, but the side effects such as apathy and akathisia are problematic. Atypical antispsychotic drugs such as aripiprazole have shown promising results in reducing chorea. The drug tetrabenazine, which depletes dopamine, has also demonstrated convincing reduction in chorea movements and is now approved by the US Food and Drug Administration for treatment of Huntington disease

(Bordelon, 2013; Frank & Jankovic, 2010). Motor signs must be assessed and evaluated on an ongoing basis so that optimal therapeutic drug levels can be reached. Akathisia (motor restlessness) in the overmedicated patient is dangerous because it may be mistaken for the restless fidgeting of the illness and consequently may be overlooked. In certain types of the disease, hypokinetic motor impairment resembles Parkinson’s disease. In patients who present with rigidity, some temporary benefit may be obtained from antiparkinson medications, such as levodopa (Dopar). Patients who have emotional disturbances, particularly depression, may be helped by antidepressant medications. The threat of suicide is present particularly early in the course of the disease (Walker, 2007). Psychotic symptoms usually respond to antipsychotic medications. Psychotherapy aimed at allaying anxiety and reducing stress may be beneficial. Nurses must look beyond the disease to focus on the patient’s needs and capabilities. Chart 66-5 explores an ethical issue related to end-of-life care for a patient with Huntington disease. Several new treatments, such as stem cell transplantation and gene therapy are under investigation (Bordelon, 2013).

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. The needs of the patient and family for education depend on the nature and severity of the physical, cognitive, and psychological changes experienced by the patient. The patient and family members are taught about the medications prescribed and about signs indicating a need for change in medication or dosage. The teaching plan addresses strategies to manage symptoms such as chorea, swallowing problems, limitations in ambulation, and loss of bowel and bladder function. Consultation with a speech therapist may be indicated to assist in identifying alternative communication strategies if speech is affected. CONTINUING CARE. A program combining medical, nursing, psychological, social, occupational, speech, and physical rehabilitation services and palliative care is needed to help the patient and family cope with this severely disabling illness. Huntington disease exacts enormous emotional, physical, social, and financial tolls on every member of the patient’s family. The family needs supportive care as they adjust to the impact of the illness (Etchegary, 2011). Regular follow-up visits help allay the fear of abandonment. Home care assistance, day care centres, respite care, and eventually skilled long-term care can assist the patient and family in coping with the constant strain of the illness. Although the relentless progression of the disease cannot be halted, families can benefit from the supportive care of knowledgeable health care workers who endeavour to provide excellence in care during all phases of the disease (Dellefield & Ferrini, 2011; Harding, Stewart, & Knight, 2012). Voluntary organizations can be major aids to families and have been largely responsible for bringing the illness to national attention. The Huntington’s Society of Canada helps patients and families by providing information, referrals, family and public education, and support for research.

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CHART 66-5

Care of the Patient With Huntington Disease Nursing Diagnosis: Risk for injury from falls and possible skin breakdown (pressure ulcers, abrasions), resulting from constant movement Nursing Interventions Pad the sides and head of the bed; ensure that the patient can see over the sides of bed. Use padded heel and elbow protectors. Keep the skin meticulously clean. Apply emollient cleansing agent and skin lotion as needed. Use soft sheets and bedding. Have patient wear football padding or other forms of padding. Encourage ambulation with assistance to maintain muscle tone. Secure the patient (only if necessary) in bed or chair with padded protective devices, making sure that they are loosened frequently.

Nursing Diagnosis: Imbalanced nutrition, less than body

requirements, due to inadequate intake and dehydration resulting from swallowing or chewing disorders and danger of choking or aspirating food

Nursing Interventions Administer phenothiazines as prescribed before meals (appears to calm some patients). Talk to the patient before mealtime to promote relaxation; use mealtime for social interaction. Provide undivided attention and help the patient enjoy the mealtime experience. Use a warming tray to keep food warm. Learn the position that is best for this patient. Keep patient as close to upright as possible while feeding. Stabilize patient’s head gently with one hand while feeding. Show the food and explain what the foods are (e.g., whether hot or cold). Encircle the patient with one arm and get as close as possible to provide stability and support while feeding. Use pillows and wedges for additional support. Do not interpret stiffness, turning away, or sudden turning of the head as rejection; these are uncontrollable choreiform movements. For feeding, use a long-handled spoon (iced-tea spoon). Place spoon on middle of tongue and exert slight pressure. Place bite-sized food between patient’s teeth. Serve stews, casseroles, and thick liquids. Disregard messiness and treat the person with dignity.

Alzheimer’s Disease Alzheimer’s disease, or senile dementia of the Alzheimer’s type, is a chronic, progressive, and degenerative brain disorder that is accompanied by profound effects on memory, cognition, and ability for self-care. Approximately 8% of the Canadian population aged 65 years and older have some type of dementia (Lindsay, Sykes, McDowell, et al., 2004). Alzheimer’s represents approximately two thirds of all dementia subtypes among those who are 65 years and over (Lindsay et al., 2004; World Health Organization & Alzheimer’s Disease International, 2012). Approximately 747,000 Canadians are living with Alzheimer’s or a related dementia (Alzheimer Society of

Wait for the patient to chew and swallow before introducing another spoonful. Make sure that bite-sized food is small. Give between-meal feedings. Constant movement expends more calories. Patients often have voracious appetites, particularly for sweets. Use blenderized meals if patient cannot chew; do not repeatedly give the same strained baby foods; gradually introduce increased textures and consistencies to the diet. For swallowing difficulties: Apply gentle deep pressure around the patient’s mouth. Rub fingers in circles on the patient’s cheeks and then down each side of the patient’s throat. Develop skill in Heimlich manoeuvre (to be used in the event of choking). Nursing Diagnosis: Anxiety and impaired communication from excessive grimacing and unintelligible speech

Nursing Interventions Read to the patient. Employ biofeedback and relaxation therapy to reduce stress. Consult with speech therapist to help maintain and prolong communication abilities. Try to devise a communication system, perhaps using cards with words or pictures of familiar objects, before verbal communication becomes too difficult. Patients can indicate correct card by hitting it with hand, grunting, or blinking the eyes. Learn how this particular patient expresses needs and wants— particularly nonverbal messages (widening of eyes, responses). Patients can understand even if unable to speak. Do not isolate patients by ceasing to communicate with them. Nursing Diagnosis: Disturbed thought processes and impaired social interaction

Nursing Interventions

Reorient the patient after awakening. Have clock, calendar, and wall posters in view to assist in orientation. Use every opportunity for one-to-one contact. Use music for relaxation. Have the patient wear a medical identification bracelet. Keep the patient in the social mainstream. Recruit and train volunteers for social interaction. Role-model appropriate and creative interactions. Do not abandon a patient because the disease is eventually terminal. Patients are living until the end.

Canada, 2012). Alzheimer’s disease is one of the most feared disorders of modern times because of its catastrophic consequences for the patient, family, and caregivers, who are faced with many crucial end-of-life decisions. Chapter 13 discusses the manifestations, management, and nursing care of the patient with Alzheimer’s disease.

Amyotrophic Lateral Sclerosis Amyotrophic lateral sclerosis (ALS) is a disease where there is a loss of motor neurons (nerve cells controlling muscles) in the anterior horns of the spinal cord and the

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motor nuclei of the lower brain stem. It is often referred to as Lou Gehrig’s disease after the famous baseball player who suffered from the disease. As motor neuron cells die, the muscle fibres that they supply undergo atrophic changes. Neuronal degeneration may occur in both the upper and lower motor neuron systems (see Chapter 61). Amyotrophic lateral sclerosis is theorized to be a complex genetic disorder that interacts with environmental factors, but definitive causative factors are not fully known. In approximately 5% to 10% of cases the cause is an autosomal dominant inheritance, commonly known as familial ALS (Harms & Baloh, 2013). Among the 90% of cases that are classified as sporadic ALS, genetic mutation is thought to play a causative role (Harms & Baloh, 2013). Approximately 2,500–3,000 Canadians live with ALS (ALS Society of Canada, 2014). ALS affects more men than women, with onset occurring usually in the fifth or sixth decade of life. Several risk factors have been identified, such as cigarette smoking and aluminum, but the exact cause is still unknown (Ahmed & Wicklund, 2011; Antao & Horton, 2012; de Jong, Huisman, Sutedja, et al., 2012; Fitzgerald, O’Reilly, Fondell, et al., 2013). Whatever the cause, once ALS is initiated, numerous cellular events such as, oxidative stress, overexcitation of nerve cells by the neurotransmitter glutamate, mitochondrial dysfunction, and growth factor deficiency, occur (Gordon, 2011). Eventually the affected motor neuron cells die.

Clinical Manifestations Clinical manifestations depend on the location of the affected motor neurons, because specific neurons activate specific muscle fibres. The chief symptoms are fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and incoordination. Loss of motor neurons in the anterior horns of the spinal cord results in progressive weakness and atrophy of the muscles of the arms, trunk, or legs. Spasticity usually is present, and the deep tendon stretch reflexes become brisk and overactive. Usually, the function of the anal and bladder sphincters remains intact, because the spinal nerves that control muscles of the rectum and urinary bladder are not affected. In about 25% of patients, weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking, swallowing, and ultimately breathing occurs. When the patient ingests liquids, soft palate and upper esophageal weakness causes the liquid to be regurgitated through the nose. Weakness of the posterior tongue and palate impairs the ability to laugh, cough, or even blow the nose. If bulbar muscles are impaired, speaking and swallowing are progressively difficult, and aspiration becomes a risk. The voice assumes a nasal sound, and articulation becomes so disrupted that speech is unintelligible. Some emotional liability may be present. It was traditionally believed that ALS spared cognitive function, but it is now recognized that some patients experience cognitive impairment. The prognosis generally is based on the area of CNS involvement and the speed with which the disease progresses. Eventually, respiratory function is compromised. Death usually occurs as a result of infection, respiratory failure, or aspiration.

Assessment and Diagnostic Findings ALS is diagnosed on the basis of the signs and symptoms, because no clinical or laboratory tests are specific for this disease. Electromyography and muscle biopsy studies of the affected muscles indicate reduction in the number of functioning motor units. A MRI scan may show high signal intensity in the corticospinal tracts; this differentiates ALS from a multifocal motor neuropathy. Neuropsychological testing can assist in assessment and diagnosis (Phukan, Pender, & Hardiman, 2007).

Management No specific therapy exists for ALS. The main focus of medical and nursing management is on interventions to maintain or improve function, well-being, and quality of life. The average survival time is 3 to 5 years with death due, most commonly, to respiratory insufficiency (Gordon, 2011). The medication riluzole (Rilutek), which is a glutamate antagonist, and Nuedexta, which is used to treat emotional lability, are both approved by the Food and Drug Administration for treatment of ALS (ALS Society of Canada, 2014). The action of riluzole is not clear, but its use has prolonged survival by 2 months (Gordon, 2011). Symptomatic treatment and rehabilitative measures are used to support the patient and improve the quality of life. Baclofen (Lioresal), dantrolene sodium (Dantrium), or diazepam (Valium) may be useful for patients troubled by spasticity, which causes pain and interferes with self-care. Research continues to test new drugs, such as tirasemtiv (ALS Society of Canada, 2014) and novel therapies such as stem cell transplants in an effort to treat ALS (Prabhakar, Marwaha, Lal, et al., 2012). Most patients with ALS are managed at home and in the community, with hospitalization for acute problems. The most common reasons for hospitalization are dehydration and malnutrition, pneumonia, and respiratory failure; recognizing these problems at an early stage in the illness allows for the development of preventive strategies. Endof-life issues include pain, dyspnea, and delirium (Davis & Lou, 2011). Mechanical ventilation (using negativepressure ventilators) is an option if alveolar hypoventilation develops. Noninvasive positive-pressure ventilation is also an option. The use of noninvasive positive-pressure ventilation is particularly helpful at night and postpones the decision about whether to undergo a tracheotomy for long-term mechanical ventilation. A patient experiencing aspiration and swallowing may require enteral feeding. A percutaneous endoscopic gastrostomy tube is inserted before the forced vital capacity drops below 50% of the predicted value. The tube can be safely placed in patients who are using noninvasive positivepressure ventilation for ventilatory support (Hickey, 2013). Decisions about life support measures are made by the patient and family and should be based on a thorough understanding of the disease, the prognosis, and the implications of initiating such therapy. Patients are encouraged to complete an advance directive or “living will” to preserve their autonomy in decision making. See Chapter 18 for additional discussion of end-of-life care.

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The ALS Society of Canada provides information and support to patients and their families. In partnership with other organizations and agencies, the ALS Society also supports research activities.

Muscular Dystrophies Muscular dystrophies are a group of genetic, incurable muscle disorders characterized by progressive weakening and wasting of the skeletal or voluntary muscles (Shieh, 2013). They have been classified according to their clinical presentation and affected muscle regions. For example, Duchenne muscular dystrophy, the most common type, which occurs in 1 of every 4,700 male births (Dooley, Gordon, Dodds, et al., 2010), delays motor development, enlargens calf muscles, weakens proximal muscles, and causes cardiomyopathy (Allen, Thrush, Hoffman, et al., 2012). Another type, limb girdle muscular dystrophy, which refers to a large group of genetics subtypes, causes proximal muscle weakness while sparing facial and distal muscles. Recent genetic advances have increased the identification of specific genetic syndromes for limb girdle muscular dystrophy. Similarly, knowledge of cellular dysfunctioning has expanded (Shieh, 2013). Concomitantly, there has been development of novel therapies such as viral gene therapy, stem cell transplants, and new pharmaceuticals that seek to interrupt the altered cellular pathways (Leung & Wagner, 2013). The therapeutic safety and efficacy of novel therapies are being researched through clinical trials (Nigro, Aurino, & Piluso, 2011). The pathologic features of all muscular dystrophies include degeneration and loss of muscle fibres, variation in muscle fibre size, phagocytosis and regeneration, and replacement of muscle tissue by connective tissue. The common characteristics of these diseases include varying degrees of muscle wasting and weakness and abnormal elevation in serum levels of muscle enzymes (Barker & Barasi, 2008). Differences among these diseases centre on the genetic pattern of inheritance, the muscles involved, the age at onset, and the rate of disease progression. The unique needs of these patients, who in the past did not live to adulthood, must be addressed as they live longer as a result of better supportive care.

Medical Management Treatment of the muscular dystrophies at this time focuses on supportive care and prevention of complications in the absence of a cure or specific pharmacologic interventions (Rowland & Pedley, 2010). The goal of supportive management is to keep the patient active and functioning as normally as possible and to minimize functional deterioration. An individualized therapeutic exercise program is prescribed to prevent muscle tightness, contractures, and disuse atrophy. Night splints and stretching exercises are used to delay contractures of the joints, especially the ankles, knees, and hips. Braces may compensate for muscle weakness. Spinal deformity is a severe problem. Weakness of trunk muscles and spinal collapse occur almost routinely in patients with severe neuromuscular disease. To help prevent spinal deformity, the patient is fitted with an orthotic jacket to improve sitting stability and reduce trunk deformity. This measure also supports cardiovascular status. In time, spinal

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fusion is performed to maintain spinal stability. Other procedures may be carried out to correct deformities. Compromised pulmonary function may result either from progression of the disease or from deformity of the thorax secondary to severe scoliosis. Upper respiratory infections and fractures from falls must be vigorously treated in a way that minimizes immobilization because joint contractures become worse when the patient’s activities are more restricted than usual. Other difficulties may be manifested in relation to the underlying disease. Weakness of the facial muscles makes it difficult to attend to dental hygiene and to speak clearly. Gastrointestinal tract problems may include gastric dilation, rectal prolapse, and fecal impaction. Finally, cardiomyopathy appears to be a common complication in all forms of muscular dystrophy (Rowland & Pedley, 2010). Genetic counselling is advised for parents and siblings of the patient because of the genetic nature of this disease. The Muscular Dystrophy Association works to combat neuromuscular disease through research, programs of patient services and clinical care, and professional and public education (see Resources).

Nursing Management The goals of the patient and the nurse are to maintain function at optimal levels and to enhance the quality of life. Therefore, the patient’s physical requirements, which are considerable, are addressed without losing sight of emotional and developmental needs. The patient and family are actively involved in decision making, including end-of-life decisions. During hospitalization for treatment of complications, the knowledge and expertise of the patient and family members responsible for caregiving in the home are assessed. Because the patient and family caregivers often have developed caregiving strategies that work effectively for them, these strategies need to be acknowledged and accepted, and provisions must be made to ensure that they are maintained during hospitalization. Families of adolescents and young adults with muscular dystrophy need assistance to shift the focus of care from pediatric to adult care and to understand the usual disease course. Nursing goals include assisting the adolescent to make the transition to adult values and expectations while providing age-appropriate ongoing care. The nurse may need to help build the confidence of an older adolescent or adult patient by encouraging him or her to pursue job training to become economically independent. Other nursing interventions might include guidance in accessing adult health care and finding appropriate programs in sex education.

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. The management goals are addressed in special rehabilitation programs or in the patient’s home and community. Therefore, the patient and family require information and instruction about the disorder, its anticipated course, and care and management strategies that will optimize the patient’s growth and development and physical and psychological status. Members of a variety of health-related disciplines are involved in patient and family teaching; recommendations are communicated to all members of the health care

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team so that they may work toward common goals (Rowland & Pedley, 2010). CONTINUING CARE. Both the neuromuscular disease and the associated deformities may progress in adolescence and adulthood. Self-help and assistive devices can aid in maintaining maximum independence. These devices, recommended by physical and occupational therapists, often become necessary as more muscle groups are affected. The family is taught to monitor the patient for respiratory problems, because respiratory infection and cardiac failure are the most common causes of death (Rowland & Pedley, 2010). As respiratory difficulties develop, patients and their families need information regarding respiratory support. Options currently exist that can provide ventilatory support (e.g., negative-pressure devices, positive-pressure ventilators) while allowing mobility. Patients can remain relatively independent in a wheelchair, for example, while being maintained on a ventilator at home for many years. The patient is encouraged to continue with range-ofmotion exercises to prevent contractures, which are particularly disabling. Practical adaptations must be made, however, to cope with the effects of chronic neuromuscular disability. The patient at various stages of the disease may require a manual or an electric wheelchair, gait aids, upper and lower extremity and spinal orthoses, seating systems, bathroom equipment, lifts, ramps, and additional assistive devices, all of which require a team approach. The home care nurse assesses how the patient and family are managing, makes referrals, and coordinates the activities of the physical therapist, occupational therapist, and social services. The patient is greatly concerned about issues surrounding the threat of increasing disability and dependence on others, accompanied by a significant deterioration in health-related quality of life. The patient is faced with a progressive loss of function, leading eventually to death. Feelings of helplessness and powerlessness are common. Each functional loss is accompanied by grief and mourning. The patient and family are assessed for depression, anger, or denial. The patient and family are assisted and encouraged to address decisions about end-of-life options before their need arises. A psychiatric nurse clinician or other mental health professional may assist the patient to cope and adapt to the disease. By understanding and addressing the physical Cauda equina (from Latin meaning tail of the horse)

Spinal nerve root

and psychological needs of the patient and family, the nurse provides a hopeful, supportive, and nurturing environment.

Degenerative Disc Disease In Canada, low back pain is a significant public health disorder. It is estimated that 80% of Canadians will develop back pain during their lifetime (Back Pain Canada, 2014). This results in significant economic and social costs. Acute low back pain lasts less than 3 months; chronic or degenerative disease has a duration of 3 months or longer. Most back problems are related to disc disease.

Pathophysiology The intervertebral disc is a cartilaginous plate that forms a cushion between the vertebral bodies (Fig. 66-7A). This tough, fibrous material is incorporated in a capsule. A ball-like cushion in the centre of the disc is called the nucleus pulposus. In herniation of the intervertebral disc (ruptured disc), the nucleus of the disc protrudes into the annulus (the fibrous ring around the disc), with subsequent nerve compression. Protrusion or rupture of the nucleus pulposus usually is preceded by degenerative changes that occur with aging. Loss of protein polysaccharides in the disc decreases the water content of the nucleus pulposus. The development of radiating cracks in the annulus weakens resistance to nucleus herniation. After trauma (falls and repeated minor stresses such as lifting incorrectly), the cartilage may be injured. For most patients, the immediate symptoms of trauma are short lived, and those resulting from injury to the disc do not appear for months or years. Then, with degeneration in the disc, the capsule pushes back into the spinal canal, or it may rupture and allow the nucleus pulposus to be pushed back against the dural sac or against a spinal nerve as it emerges from the spinal column (see Fig. 66-7B). This sequence produces pain due to radiculopathy (pressure in the area of distribution of the involved nerve endings). Continued pressure may produce degenerative changes in the involved nerve, such as changes in sensation and deep tendon reflexes. Herniated nucleus pulposus compresses nerve root

Spinal nerve root

Intervertebral disc Vertebral body Lamina

A

B

Spinous process

FIGURE 66-7. (A) Normal lumbar

spine vertebrae, intervertebral discs, and spinal nerve root. (B) Ruptured vertebral disc.

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Clinical Manifestations A herniated disc with accompanying pain may occur in any portion of the spine: cervical, thoracic (rare), or lumbar. The clinical manifestations depend on the location, the rate of development (acute or chronic), and the effect on the surrounding structures.

Assessment and Diagnostic Findings A thorough health history and physical examination are important to rule out potentially serious conditions that may manifest as low back pain, including fracture, tumour, infection, or cauda equina syndrome (Hickey, 2013). The MRI scan has become the diagnostic tool of choice for localizing even small disc protrusions, particularly for lumbar spine disease. If the clinical symptoms are not consistent with the pathology seen on MRI, CT scanning and myelography are performed. A neurologic examination is carried out to determine whether reflex, sensory, or motor impairment from root compression is present and to provide a baseline for future assessment. Electromyography may be used to localize the specific spinal nerve roots involved.

Medical Management Herniations of the cervical and the lumbar discs occur most commonly and are usually managed conservatively with bed rest and medication (Hickey, 2013). Surgery is sometimes necessary.

Surgical Management Surgical excision of a herniated disc is performed if there is evidence of a progressing neurologic deficit (muscle weakness and atrophy, loss of sensory and motor function, loss of sphincter control) and continuing pain or sciatica (leg pain resulting from sciatic nerve involvement) that are unresponsive to conservative management (Jacobs, Tulder, Arts, et al., 2011). The goal of surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse neurologic deficits (Hickey, 2013). Microsurgical techniques make it possible to remove only the amount of tissue that is necessary, which preserves the integrity of normal tissue better and imposes less trauma on the body. During these procedures, spinal cord function can be monitored electrophysiologically. To achieve the goal of pain relief, several surgical techniques are used, depending on the type and location of disc herniation, surgical morbidity, and results of previous surgery. Some of the surgical techniques available include: • Microdiscectomy: removal of herniated or extruded fragments of intervertebral disc material • Laminectomy: removal of the bone between the spinal process and facet–pedicle junction to expose the neural elements in the spinal canal (Hickey, 2013); this allows the surgeon to inspect the spinal canal, identify and remove pathologic tissue, and relieve compression of the cord and roots • Hemilaminectomy: removal of part of the lamina and part of the posterior arch of the vertebra

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• Partial laminectomy or laminotomy: creation of a hole in the lamina of a vertebra • Discectomy with fusion: fusion of the vertebral spinous process with a bone graft (from iliac crest or bone bank); the object of spinal fusion is to bridge over the defective disc to stabilize the spine and reduce the rate of recurrence • Foraminotomy: removal of the intervertebral foramen to increase the space for exit of a spinal nerve, resulting in reduced pain, compression, and edema

Herniation of a Cervical Intervertebral Disc The cervical spine is subjected to stresses that result from disc degeneration (due to aging, occupational stresses) and spondylosis (degenerative changes occurring in a disc and adjacent vertebral bodies). Cervical disc degeneration may lead to lesions that can cause damage to the spinal cord and its roots.

Clinical Manifestations A cervical disc herniation usually occurs at the C5–C6 or C6–C7 interspaces. Pain and stiffness may occur in the neck, the top of the shoulders, and the region of the scapulae. Sometimes patients interpret these signs as symptoms of heart trouble or bursitis. Pain may also occur in the upper extremities and head, accompanied by paresthesia (tingling or a “pins and needles” sensation) and numbness of the upper extremities. Cervical MRI usually confirms the diagnosis.

Medical Management The goals of treatment are to rest and immobilize the cervical spine to give the soft tissues time to heal and to reduce inflammation in the supporting tissues and the affected nerve roots in the cervical spine. Bed rest (usually 1 to 2 days) is important because it eliminates the stress of gravity and relieves the cervical spine of the need to support the head. It also reduces inflammation and edema in soft tissues around the disc, relieving pressure on the nerve roots. Proper positioning on a firm mattress may bring dramatic relief from pain. The cervical spine may be rested and immobilized by a cervical collar, cervical traction, or a brace. A collar allows maximal opening of the intervertebral foramina and holds the head in a neutral or slightly flexed position. The patient may have to wear the collar 24 hours a day during the acute phase. The skin under the collar is inspected for irritation. After the patient is free of pain, cervical isometric exercises are started to strengthen the neck muscles.

Pharmacologic Therapy Analgesic agents (nonsteroidal anti-inflammatory agents [NSAIDs], propoxyphene [Darvon], oxycodone [Tylox], or hydrocodone [Vicodin]) are prescribed during the acute phase to relieve pain, and sedatives may be administered to

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control the anxiety that is often associated with cervical disc disease. Muscle relaxants (cyclobenzaprine [Flexeril], methocarbamol [Robaxin], metaxalone [Skelaxin]) are administered to interrupt muscle spasm and to promote comfort. NSAIDs (aspirin, ibuprofen [Motrin, Advil], naproxen [Naprosyn, Anaprox]) or corticosteroids are prescribed to treat the inflammation that usually occurs in the affected nerve roots and supporting tissues. Occasionally, a corticosteroid is injected into the epidural space for relief of radicular (spinal nerve root) pain. NSAIDs are administered with food and antacids to prevent gastrointestinal irritation (Karch, 2014). Hot, moist compresses (for 10 to 20 minutes) applied to the back of the neck several times daily increase blood flow to the muscles and help relax the patient and reduce muscle spasm.

area around the cervical spine is palpated to assess muscle tone and tenderness. Range of motion in the neck and shoulders is evaluated. The patient is asked about any health issues that may influence the postoperative course and quality of life (Fowler, Anthony-Phillips, Mehta, et al., 2005). It is also important to assess mood and stress levels (Starkweather, Witek-Janusek, Nockels, et al., 2006). The nurse determines the patient’s need for information about the surgical procedure and reinforces what the physician has explained. Strategies for pain management are discussed with the patient.

Surgical Management

Nursing Diagnoses

Surgical excision of the herniated disc may be necessary if there is a significant neurologic deficit, progression of the deficit, evidence of cord compression, or pain that either worsens or fails to improve. A cervical discectomy, with or without fusion, may be performed to alleviate symptoms (Gebremariam, Koes, Puel, et al., 2012). An anterior surgical approach may be used through a transverse incision to remove disc material that has herniated into the spinal canal and foramina, or a posterior approach may be used at the appropriate level of the cervical spine. Potential complications with the anterior approach include carotid or vertebral artery injury, recurrent laryngeal nerve dysfunction, esophageal perforation, and airway obstruction. Complications of the posterior approach include damage to the nerve root or the spinal cord due to retraction or contusion of either of these structures, resulting in weakness of muscles supplied by the nerve root or cord. Microsurgery, such as endoscopic microdiscectomy, may be performed in selected patients through a small incision, using magnification techniques. This usually results in less tissue trauma and pain, and patients consequently have a shorter hospital stay compared with those who have conventional surgery.

Based on the assessment data, the patient’s major nursing diagnoses may include the following:

!!"##

Nursing Process

The Patient Undergoing a Cervical Discectomy Assessment The patient is asked about past injuries to the neck (whiplash), because unresolved trauma can cause persistent discomfort, pain and tenderness, and symptoms of arthritis in the injured joint of the cervical spine. Assessment includes determining the onset, location, and radiation of pain and assessing for paresthesias, limited movement, and diminished function of the neck, shoulders, and upper extremities. It is important to determine whether the symptoms are bilateral; with large herniations, bilateral symptoms may be caused by cord compression. The

Diagnosis

• Acute pain related to the surgical procedure • Impaired physical mobility related to the postoperative surgical regimen • Deficient knowledge about the postoperative course and home care management Other nursing diagnoses may include preoperative anxiety, postoperative constipation, urinary retention related to the surgical procedure, self-care deficits related to use of a neck orthosis, and sleep pattern disturbance related to disruption in lifestyle.

Collaborative Problems/ Potential Complications Based on all the assessment data, the potential complications may include the following: • Hematoma at the surgical site, resulting in cord compression and neurologic deficit • Recurrent or persistent pain after surgery

Planning and Goals The goals for the patient may include relief of pain, improved mobility, increased knowledge and self-care ability, and prevention of complications.

Nursing Interventions Relieving Pain The patient may be kept flat in bed for 12 to 24 hours. If the patient has had a bone fusion with bone removed from the iliac crest, considerable pain may be experienced at the donor site. Interventions consist of monitoring the donor site for hematoma formation, administering the prescribed postoperative analgesic agent, positioning for comfort, and reassuring the patient that the pain can be relieved. If the patient experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon.

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The patient may experience a sore throat, hoarseness, and dysphagia due to temporary edema. These symptoms are relieved by throat lozenges, voice rest, and humidification. A puréed diet may be given if the patient has dysphagia.

Improving Mobility Postoperatively, a cervical collar (neck orthosis) is usually worn, which contributes to limited neck motion and altered mobility. The patient is instructed to turn the body instead of the neck when looking from side to side. The neck should be kept in a neutral (midline) position. The patient is assisted during position changes, to make sure that head, shoulders, and thorax are kept aligned. When assisting the patient to a sitting position, the nurse supports the patient’s neck and shoulders. To increase stability, the patient should wear shoes when ambulating.

Monitoring and Managing Potential Complications The patient is evaluated for bleeding and hematoma formation by assessing for excessive pressure in the neck or severe pain in the incision area. The dressing is inspected for serosanguineous drainage, which suggests a dural leak. If this occurs, meningitis is a threat. A complaint of headache requires careful evaluation. Neurologic checks are made for swallowing deficits and upper and lower extremity weakness, because cord compression may produce rapid or delayed onset of paralysis. The patient who has had an anterior cervical discectomy is also assessed for a sudden return of radicular (spinal nerve root) pain, which may indicate instability of the spine. Throughout the postoperative course, the patient is monitored frequently to detect any signs of respiratory difficulty, because retractors used during surgery may injure the recurrent laryngeal nerve, resulting in hoarseness and the inability to cough effectively and clear pulmonary secretions. In addition, the blood pressure and pulse are monitored to evaluate cardiovascular status. Bleeding at the surgical site and subsequent hematoma formation may occur. Severe localized pain not relieved by analgesic agents should be reported to the surgeon. A change in neurologic status (motor or sensory function) should be reported promptly, because it suggests hematoma formation that may necessitate surgery to prevent irreversible motor and sensory deficits.

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient’s hospital stay is likely to be short; therefore, the patient and family should understand the care that is important for a smooth recovery. A cervical collar is usually worn for about 6 weeks. The patient is instructed in use and care of the cervical collar. The patient is instructed to alternate tasks that involve minimal body movement (e.g., reading) with tasks that require greater body movement.

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The patient is instructed about strategies for pain management and about signs and symptoms that may indicate complications that should be reported to the physician. The nurse assesses the patient’s understanding of these management strategies, limitations, and recommendations. Additionally, the nurse assists the patient in identifying strategies to cope with ADLs (e.g., self-care, childcare) and minimize risks to the surgical site (Chart 66-6). A discharge teaching plan is developed collaboratively by members of the health care team to decrease the risk of recurrent disc herniation. Topics include those previously discussed as well as proper body mechanics, maintenance of optimal weight, proper exercise techniques, and modifications in activity. CONTINUING CARE. The patient is instructed to see the physician at prescribed intervals so that the physician can document the disappearance of old symptoms and assess the range of motion of the neck. Recurrent or persistent pain may occur despite removal of the offending disc or disc fragments. Patients who undergo discectomy usually have consented to surgery after prolonged pain; they have often undergone repeated courses of ineffective conservative management and previous surgeries to relieve the pain. Therefore, the recurrence or persistence of symptoms postoperatively, including pain and sensory deficits, is often discouraging for the patient and family. The patient who experiences recurrence of symptoms requires emotional support and understanding. Additionally, the patient is assisted in modifying activities and in considering options for subsequent treatment. The nurse reminds the patient and family members of the need to participate in health promotion and health screening practices.

Evaluation Expected Patient Outcomes Expected patient outcomes may include the following: 1. Reports decreasing frequency and severity of pain 2. Demonstrates improved mobility a. Demonstrates progressive participation in selfcare activities b. Identifies prescribed activity limitations and restrictions c. Demonstrates proper body mechanics 3. Is knowledgeable about postoperative course, medications, and home care management a. Lists the signs and symptoms to be reported postoperatively b. Identifies dose, action, and potential side effects of medications c. Identifies appropriate home care management activities and any restrictions 4. Has absence of complications a. Reports no increase in incision pain or sensory symptoms b. Demonstrates normal findings on neurologic assessment

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CHART 66-6

HOME CARE CHECKLIST •

The Patient With Cervical Discectomy and Cervical Collar Patient

Caregiver

• Care for the surgical incision site. • Keep staples or sutures clean and dry and cover with dry dressing. • Notify physician if any signs or symptoms of infection occur, such as fever, redness or

✔

✔ ✔

• Demonstrate proper body mechanics and prescribed exercise techniques.

✔

• Modify activity: • Avoid sitting or standing for more than 30 minutes. • Avoid twisting, flexing, extending, or rotating the neck. • Avoid long automobile rides. • Avoid sleeping in a prone position or use of pillows, to minimize neck flexion in bed;

✔ ✔ ✔ ✔

At the completion of the home care instruction, the patient or caregiver will be able to:

irritation, drainage, increased pain.

keep head in a neutral position.

• Use adequate mattress and chair support. • Wear low-heeled shoes.

✔ ✔

• Follow physician’s instructions regarding lifting, climbing stairs, driving a car, sexual activity,

✔

• Practice stress reduction and relaxation techniques.

✔

• Care of the cervical collar: • Wear the collar at all times until directed otherwise by the physician. • Wash the neck twice a day with mild soap. • Keep the neck still while the collar is open.

✔ ✔ ✔

sports, exercise, and return to work.

• With the assistance of a helper, wash the neck in steps: • Lie flat and supine. • Open the Velcro tabs on each side of the collar and remove its front portion. • Gently wash and dry the neck. • Replace the front part of the collar and refasten the tabs. • Turn to one side with a thin pillow under the head. • Open one tab. • Gently wash and dry the back of the neck. Refasten the tab. • Turn to the other side and wash and dry this side. Refasten the tab.

✔

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

• Place a wrinkle-free silk scarf under the collar to increase comfort.

✔

✔

• For men: Shave without twisting or moving the neck. This may be done with help while lying

✔

✔

flat or sitting. Remove only the front part of the collar for shaving.

Herniation of a Lumbar Disc Approximately 90% to 95% of lumbar disc herniations occur at the L5–S1 region (Hickey, 2013). A herniated lumbar disc produces low back pain accompanied by varying degrees of sensory and motor impairment.

Clinical Manifestations The patient complains of low back pain with muscle spasms, followed by radiation of the pain into one hip and down into the leg (sciatica). Pain is aggravated by actions that increase intraspinal fluid pressure, such as bending, lifting, or straining (as in sneezing or coughing), and usually is relieved by bed rest. Usually there is some type of postural deformity, because pain causes an alteration of the normal spinal mechanics. If the patient lies on the back

and attempts to raise a leg in a straight position, pain radiates into the leg; this manoeuvre, called the straight legraising test, stretches the sciatic nerve. Additional signs include muscle weakness, alterations in tendon reflexes, and sensory loss (Chou, Qaseem, Snow, et al., 2007).

Assessment and Diagnostic Findings The diagnosis of lumbar disc disease is based on the history and physical findings and the use of imaging techniques such as MRI, CT, and myelography (Chou et al., 2007).

Medical Management The objectives of treatment are to relieve pain, slow disease progression, and increase the patient’s functional

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ability. Bed rest, previously a standard in treatment of back pain, is no longer recommended. The American College of Physicians recommends patients remain active (Chou et al., 2007). Because muscle spasm is prominent during the acute phase, muscle relaxants are used. Evidence supports the use of NSAIDs, which may be administered to counter the inflammation that usually occurs in the supporting tissues and the affected nerve roots. Contrarily, recent evidence suggests the use of systemic corticosteroids is ineffective for pain relief (Chou, 2010). Short term epidural injections of steroids have some beneficial effect (Chou, Atlas, Stanos, et al., 2009). Moist heat and massage help relax muscles. Strategies for increasing the patient’s functional ability include weight reduction, physical therapy, and biofeedback. Exercises, prescribed by physical therapists, can help strengthen back muscles and decrease pain (Hickey, 2013). Chapter 14 describes nursing interventions for the patient with pain.

Surgical Management In the lumbar region, surgical treatment includes lumbar disc excision through a posterolateral laminotomy and the newer techniques of microdiscectomy and percutaneous discectomy. In microdiscectomy, an operating microscope is used to visualize the offending disk and compressed nerve roots; it permits a small incision (2.5 cm [1 inch]) and minimal blood loss and takes about 30 minutes of operating time. Generally, the hospital stay is short, and the patient makes a rapid recovery. Several minimally invasive techniques in spinal surgery have led to improved patient outcomes and lower hospital costs, and research on these techniques is ongoing (Starkweather, Witek-Janusek, Nockels, et al., 2008). Research suggests that intraoperative wound infiltration with bupivacaine hydrochloride solution decreases pain and the need for opioids postoperatively (Ersayli, Gurget, Bekar, et al., 2006). COMPLICATIONS OF DISC SURGERY. A patient undergoing a disc procedure at one level of the vertebral column may have a degenerative process at other levels. A herniation relapse may occur at the same level or elsewhere, so the patient may become a candidate for another disc procedure. Arachnoiditis (inflammation of the arachnoid membrane) may occur after surgery (and after myelography); it involves an insidious onset of diffuse, frequently burning pain in the lower back, radiating into the buttocks. Disc excision can leave adhesions and scarring around the spinal nerves and dura, which then produce inflammatory changes that create chronic neuritis and neurofibrosis. Disc surgery may relieve pressure on the spinal nerves, but it does not reverse the effects of neural injury and scarring and the pain that results. Failed disc syndrome (recurrence of sciatica after lumbar discectomy) remains a cause of disability (Hickey, 2013).

Nursing Management Providing Preoperative Care Most patients fear surgery on any part of the spine and therefore need explanations about the surgery and

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FIGURE 66-8. Before the patient undergoes laminectomy surgery, the logrolling technique that will be used for turning the patient should be demonstrated. The patient’s arms will be crossed and the spine aligned. To avoid twisting the spine, the head, shoulders, knees, and hips are turned at the same time so that the patient rolls over like a log. When in a side-lying position, the patient’s back, buttocks, and legs are supported with pillows.

reassurance that it will not weaken the back. When data are being collected for the health history, any reports of pain, paresthesia, or muscle spasm are recorded to provide a baseline for comparison after surgery. Health issues that may influence the postoperative course and quality of life (e.g., fatigue, mood, stress, patient expectations) are important to assess (Saban & Penckofer, 2007; Starkweather et al., 2008). Preoperative assessment also includes an evaluation of movement of the extremities as well as bladder and bowel function. To facilitate the postoperative turning procedure, the patient is taught to turn as a unit (called logrolling) as part of the preoperative preparation (see Fig. 66-8). Before surgery, the patient is also encouraged to take deep breaths, cough, and perform muscle-setting exercises to maintain muscle tone.

Assessing the Patient After Surgery After lumbar disc excision, vital signs are checked frequently and the wound is inspected for hemorrhage, because vascular injury is a complication of disk surgery. Because postoperative neurologic deficits may occur from nerve root injury, the sensation and motor strength of the lower extremities are evaluated at specified intervals, along with the colour and temperature of the legs and sensation of the toes. It is important to assess for urinary retention, another sign of neurologic deterioration. In discectomy with fusion, the patient has an additional surgical incision if bone fragments were taken from the iliac crest or fibula to serve as wedges in the spine. The recovery period is longer than for those patients who underwent discectomy without spinal fusion, because bony union must take place.

Positioning the Patient To position the patient, a pillow is placed under the head, and the knee rest is elevated slightly to relax the back muscles. When the patient is lying on one side, however, extreme

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knee flexion must be avoided. The patient is encouraged to move from side to side to relieve pressure and is reassured that no injury will result from moving. When the patient is ready to turn, the bed is placed in a flat position and a pillow is placed between the patient’s legs. The patient turns as a unit (logrolls) without twisting the back. To get out of bed, the patient lies on one side while pushing up to a sitting position. At the same time, the nurse or family member eases the patient’s legs over the side of the bed. Coming to a sitting or standing posture is accomplished in one long, smooth motion. Most patients walk to the bathroom on the same day as the surgery. Sitting is discouraged except for defecation.

Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient is advised to increase activity gradually, as tolerated, because it takes up to 6 weeks for the ligaments to heal. Excessive activity may result in spasm of the paraspinal muscles. Activities that produce flexion strain on the spine (e.g., driving a car) should be avoided until healing has taken place. Heat may be applied to the back to relax muscle spasms. Scheduled rest periods are important, and the patient is advised to avoid heavy work for 2 to 3 months after surgery. Exercises are prescribed to strengthen the abdominal and erector spinal muscles. A back brace or corset may be necessary if back pain persists. CONTINUING CARE. Referral for inpatient or outpatient rehabilitation may be warranted to improve selfcare abilities after medical or surgical treatment for herniation of a lumbar disc. A home care referral may be indicated and provides the home care nurse with the opportunity to assess the patient’s physical and psychological status, as well as his or her ability to adhere to recommended management strategies. During the home visit, the nurse determines whether changes in neurologic function have occurred. The adequacy of pain management is assessed, and modifications are made to ensure adequate pain relief.

Postpolio Syndrome People who survived the polio epidemic of the 1950s, many of whom are now elderly, are developing new symptoms of weakness, fatigue, and musculoskeletal pain. Researchers estimate that between 40% and 60% (Nollet, 2011) of the 1,000,000 polio survivors are experiencing the phenomenon known as postpolio syndrome. Women and greater severity of acute paralytic poliomyelitis are associated with an increased risk of developing postpolio syndrome (Bertolasi, Acler, dall’Ora, et al., 2012).

Pathophysiology The exact cause of postpolio syndrome is not known, but researchers have proposed three main hypotheses. These include, overstress/overuse-induced degeneration of remaining neurons, the persistence of the polio virus, and

neuroinflammation or immune-related damage (Bertolasi et al., 2012; Borg, 2011).

Assessment and Diagnostic Findings No specific diagnostic test exists for postpolio syndrome. Clinical diagnosis is made on the basis of the history and physical examination and exclusion of other medical conditions that could be causing the new symptoms. Patients report a history of paralytic poliomyelitis followed by partial or complete recovery of function, with a plateau of function and then the recurrence of symptoms. Signs and symptoms may occur decades after the original onset of poliomyelitis (Nollet, 2011).

Management No specific medical or surgical treatment is available for this syndrome, and therefore nurses play a pivotal role in the team approach to assisting patients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Other health care professionals who may assist in patient care include physical, occupational, speech, and respiratory therapists. Nursing interventions are aimed at maintaining the patient’s strength as well as physical, psychological, and social well-being (LaRocca, 2011). The patient needs to plan and coordinate activities to conserve energy and reduce fatigue. Rest periods should be planned and assistive devices used to reduce weakness and fatigue. Lifestyle changes and pacing are also used to cope with fatigue (Davidson, Auyeung, Luff, et al., 2009). Pain in muscles and joints may be a problem. Nonpharmacologic techniques such as the application of heat and cold are most appropriate, because older patients may not tolerate or may have strong reactions to medications. Maintaining a balance between adequate nutritional intake and avoiding excess calories that can lead to obesity in this sedentary group of patients is a challenge. Pulmonary hygiene and adequate fluid intake can help with airway management. Several interventions can improve sleep, including limiting caffeine intake before bedtime and assessing for nocturia. If nocturia is an issue, the patient needs to be evaluated for obstructive sleep apnea. Supportive ventilation may be appropriate, with continuous positive airway pressure if sleep apnea is a problem. Bone density testing in patients with unilateral low limb involvement postpolio syndrome has revealed low bone mass and osteoporosis of the hips (Oncu, Atamaz, Durmas, et al., 2013). Therefore, the importance of identifying risks, preventing falls, and treating osteoporosis must be discussed with patients and families. Families also need to be made aware of the possibility of changes in individual and family relationships due to the many symptoms of postpolio syndrome (Ward, 2008). The nurse also needs to remind patients and family members of the need for health promotion activities and health screening.

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Critical Thinking Exercises 1 A 48-year-old man is married with two young children and has been newly diagnosed with a metastatic spinal cord tumour. Assess and prioritize the patient’s physiologic and psychosocial needs. Identify appropriate nursing interventions to alleviate the patient’s and family’s physiologic and emotional stressors. Address the patient’s need for emotional support from both the nursing staff and the family. 2 A 75-year-old woman newly diagnosed with Parkinson’s disease asks what type of medication she will be given. What are the possible medication regimens that may be used to treat her disease and the common side effects of each? How would your discharge teaching targeted toward medications be modified if the patient lives alone and is hearing impaired? 3

A 45-year-old patient with Huntington disease has been referred for end-of-life care. What resources would you use to identify the current guidelines for end-of-life care? What is the current evidence base for end-of-life nursing care? Identify the criteria used to evaluate the strength of the evidence for end-oflife nursing care.

4 A 60-year-old patient with low back pain is seen in the clinic. What nursing interventions and actions would you suggest to assist in the management of low back pain? What strategies would you advise the patient to avoid? What is the rationale for your suggestions? State the types of health promotion activities you would recommend to this patient and the rationale for your recommendations.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Back Pain Canada (2014). Health professional. Toronto: Author. Retrieved from http://www.backcarecanada.ca/site.php?sec_id=439&msid=3 Bader, M. K., & Littlejohns, L. R. (2010). AANN core curriculum for neuroscience nursing (5th ed.). Glenview, IL: Amercian Association of Neuroscience Nurses. Barker, E. (2008). Neuroscience nursing: A spectrum of care (3rd ed.). St. Louis, MO: Mosby. Barker, R. A., & Barasi, S. (2008). Neuroscience at a glance (3rd ed.). Oxford: Blackwell Publishing. Diepenbrock, N. H. (2007). Quick reference to critical care (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Dudek, S. G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hickey, J. V. (2013). The clinical practice of neurological & neurosurgical nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Karch, A. M. (2014). Lippincott’s nursing drug guide (12 ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Lawler, S., & Chiocca, E. (2013). Brain tumours and gliomas, In S. Geoffrey, Ginsburg, F. Huntington, et al. (Eds.), Genomic and Personalized Medicine (2nd ed.) (pp. 749–769). San Diego, CA: Elsevier. Miller, C. A. (2009). Nursing for wellness in older adults (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Pollock, B. E. (2006). Guiding neurosurgery by evidence. Basal: Karger.

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Raizer, J. J., & Abrey, L. E. (Eds.). (2007). Brain metastases. New York, NY: Springer. Rowland, L. P., & Pedley T. A. (2010). Merritt’s neurology (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS Alzheimer’s Disease Alzheimer Society of Canada. (2012). A new way of looking at the impact of dementia in Canada. Retrieved March 8, 2014, from http://www. alzheimer.ca/∼/media/Files/national/Media-releases/asc_factsheet_ new_data_09272012_en.ashx Lindsay, J., Sykes, E., McDowell, I., et al. (2004). More than the epidemiology of Alzheimer’s disease: Contributions of the Canadian study of health and aging. Canadian Journal of Psychiatry, 49 (2), 83–91. World Health Organization & Alzheimer’s Disease International. (2012). Dementia: A public health priority. Geneva: Publications of the World Health Organization. Retrieved March 7, 2014, from http://www.who. int/mental_health/publications/dementia_report_2012/en/ Amyotrophic Lateral Sclerosis ALS Society of Canada. (2014). ALS Quick Facts. Retrieved March 8, 2014, from http://www.als.ca/sites/default/files/files/Fact%20 Sheets/2011Research_Facts%20Sheet_Apr%2017.pdf Ahmed, A., & Wicklund, M. (2011). Amyotrophic lateral sclerosis: What role does environment play? Neurological Clinics, 29 (3), 689–711. Antao, V. C., & Horton, D. K. (2012). The National Amyotrophic Lateral Sclerosis Registry. Journal of Environmental Health, 75 (1), 28–30. Davis, M., & Lou, J. (2011). Management of amyotrophic lateral sclerosis (ALS) by the family nurse practitioner: A timeline for anticipated referrals. Journal of the American Academy of Nurse Practitioners, 23, 464–472. de Jong, S. W., Huisman, M., Sutedja, N., et al. (2012). Smoking, alcohol consumption, and the risk of amyotrophic lateral sclerosis: A population-based study. American Journal of Epidemiology, 176(3), 233–239. Fitzgerald, K., O’Reilly, E., Fondell, E., et al. (2103). Intakes of vitamin C and caroteniods and risk of amyotrophic lateral sclerosis: Pooled results from 5 cohort studies. Annuals of Neurology, 73(2), 236–245. Gordon, P. H. (2011). Amyotrophic lateral sclerosis: Pathophysiology, diagnosis and management. CNS Drugs, 25 (1), 1–15. Harms, M., & Baloh, R. (2013). Clinical neurogenetics. Neurologic Clinics, 31(4), 929–950. Phukan, J., Pender, N., & Hardiman, O. (2007). Cognitive impairment in amyotrophic lateral sclerosis. The Lancet Neurology, 6(11), 994– 1003. Prabhakar, S., Marwaha, N., Lal, V., et al. (2012). Autologous bone-marrow-derived stem cells in amyotrophic lateral sclerosis: A pilot study. Neurology India, 60(5), 465–469. Degenerative Disc Disease Chou, R. (2010). Pharmacological management of low back pain. Drugs, 70(4), 387–402. Chou, R., Atlas, S., Stanos, S., et al. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society clinical practice guideline. Spine, 34 (10), 1078–1093. Chou, R., Qaseem, A., Snow, V., et al. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annuals of Internal Medicine, 147, 478–491. Ersayli, D. T., Gurget, A., Bekar, A., et al. (2006). Effects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar discectomy. Spine, 31(19), 2221–2226. *Fowler, S., Anthony-Phillips, P., Mehta, D., et al. (2005). Health-related quality of life in patients undergoing anterior cervical discectomy. Journal of Neuroscience Nursing, 37(2), 97–100. Gebremariam, L., Koes, B. W., Peul, W. C., et al. (2012). Evaluation of treatment effectiveness for the herniated cervical review. Spine, 37(2), E109–E118. Jacobs, W. C., Tudler, M., Arts, M., et al. (2011). Surgery versus conservative management of sciatica due to a lumbar herniated disc: A systematic review. European Spine Journal, 20(4), 513.

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Neurologic Function

*Saban, K. L., & Penckofer, S. M. (2007). Patient expectations of quality of life following lumbar spinal surgery. Journal of Neuroscience Nursing, 39 (3), 180–189. *Starkweather, A. R., Witek-Janusek, L., Nockels, R. P., et al. (2006). The impact of psychological and immune factors in sciatic pain: A randomized controlled trial among herniated disc patients. SCI Nursing, 23(3), 1–11. *Starkweather, A. R., Witek-Janusek, L., Nockels, R. P., et al. (2008). The multiple benefits of minimally invasive spinal surgery: Results comparing transforaminal lumbar interbody fusion and posterior lumbar fusion. Journal of Neuroscience Nursing, 40(1), 32–39. Huntington Disease Andersson, P., Juth, N., Petersen, A., et al. (2012). Ethical aspects of undergoing a predictive genetic testing for Huntington’s disease. Nursing Ethics, 20(2), 189–199. Bordelon, Y. (2013). Clinical neurogenetics. Neurologic Clinics, 31(4), 1085–1094. Dellefield, M., & Ferrini, R. (2011). Promoting excellence in end-of-life care: Lessons learned from a cohort of nursing home residents with advanced Huntington disease. Journal of Neuroscience, 43(4), 186–192. Etchegary, H. (2011). Healthcare experiences of families affected by Huntington’s disease: Need for improved care. Chronic Illness, 7(3), 225–238. Frank, S., & Jankovic, J. (2010). Advances in the pharmacological management of Huntington’s disease. Drugs, 70(5), 561–571. Ha, A., & Fung, V. (2012). Huntington’s disease. Current Opinion in Neurology, 25 (4), 491–498. Harding, V., Stewart, I., & Knight, C. (2012). Health-care workers’ perceptions of contributors to quality of life for people with Huntington’s disease. British Journal of Neuroscience Nursing, 8 (4), 191–197. Walker, F. (2007). Huntington’s disease. Seminars in Neurology, 27(2), 143–150. Muscular Dystrophies Allen, H. D., Thrush, P. T., Hoffman, T. M., et al. (2012). Cardiac management in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(4), 855–868. Dooley, J., Gordon, K. E., Dodds, L., et al. (2010). Duchenne muscular dystrophy: A 30-year population-based incidence study. Clinical Pediatrics, 49 , 177–179. Leung, D. G., & Wagner, K. R. (2013). Therapeutic advances in muscular dystrophy. Annals of Neurology, 74, 404–411. Nigro, V., Aurino, S., & Piluso, G. (2011). Limb girdle muscular dystrophies: Update on genetic diagnosis and therapeutic approaches. Current Opinion in Neurology, 24, 429–436. Shieh, P. B. (2013). Muscular dystrophies and other genetic myopathies. Neurology Clinics, 31, 1009–1029. Oncologic Disorders American Brain Tumour Association (ABTA). (2012a). About brain tumours: A primer for patients and caregivers: 2012. Retrieved February 28, 2014, from http://www.abta.org/secure/about-brain-tumours-a-primer.pdf American Brain Tumour Association (ABTA). (2012b). Pituitary tumour: 2012. Retrieved February 27, 2014, from http://www.abta.org/secure/ pituitary-tumours-brochure.pdf Arzbaecher, J. (2007). Spinal metastasis in glioblastoma multiforme: A case study. Journal of Neuroscience Nursing, 39 (1), 21–25. Barnholtz-Sloan, J. S., Williams, V. L., Maldonado, J. L., et al. (2008). Patterns of care and outcomes among elderly individuals with primary malignant astrocytoma. Journal of Neurosurgery, 108 (4), 642–648. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. (2013). Canadian Cancer Statistics 2013. Toronto, ON: Canadian Cancer Society. Chaichana, K., Pendleton, C., Sciubba, D., et al. (2009). Outcome following decompressive surgery for different histological types of metastatic tumours causing epidural spinal cord compression. Journal of Neurosurgery. Spine, 11, 56–63. Dy, S., Asch, S., Naeim, A., et al. (2008). Evidence-based standards for cancer pain management. Clinical Oncology, 26(23), 3879–3885. Fields, L. (2007). DNR does not mean no care. Journal of Neuroscience Nursing, 39 (5), 294–296. Fox, B., Cheung, V., Patel, A., et al. (2011). Epidemiology of metastatic brain tumours. Neurosurgery Clinics of North America, 22(1), 1–6. Fox, S., Mitchell, S., & Booth-Jones, M. (2006). Cognitive impairment in patients with brain tumours: Assessment and intervention in the clinic setting. Clinical Journal of Oncology Nursing, 10(2), 169–176.

Gerber, D., Grossman, S., & Streiff, M. (2006). Management of venous thromboembolism in patients with primary and metastatic brain tumours. Journal of Clinical Oncology, 24(8), 1310–1318. Gordon, B. M. (2007). Pharmacological management of secreting pituitary tumours. Journal of Neuroscience Nursing, 39 (1), 52–57. Lee, E., & Armstrong, T. (2008). Increased intracranial pressure. Clinical Journal of Oncology Nursing, 12(1), 37–41. Mechtler, L., & Nandigam, K. (2013). Spinal cord tumours. Neurologic Clinics, (31)1, 241–268. Niranjan, A., Kondziolka, D., & Lundsford, D. (2009). Neoplastic transformation after radiosurgery or radiotherapy: Risks and realities. Otolaryngologic Clinics of North America, 42(4), 717–729. Patel, T., Yu, J., & Piepmeier, J. (2012). Role of neurosurgery and radiation therapy in the management of brain tumours. Hematology/Oncology Clinics of North America, 26(4), 757–777. Richards, J., & Ballard, N. (2008). Colloid cyst: A case study. Journal of Neuroscience Nursing, 40(2), 103–105. Rowe, J. (2006). Late neoplastic complications after radiation treatments for benign intracranial tumours. Neurosurgery Clinics of North America, 17(2), 181–185. *Schmer, C., Ward-Smith, P., Latham, S., et al. (2008). When a family member has a malignant brain tumour: The caregiver perspective. Journal of Neuroscience Nursing, 40(2), 78–84. Schwarz, S., Thon, N., Nikolajek, K., et al. (2012). Iodine-125 brachytherapy for brain tumours – a review. Radiation Oncology, 7, 1–30. Swinson, B., & Friedman, W. (2008). Linear accelerator stereotactic radiosurgery for metastatic brain tumours: Years of experience at the University of Florida. Neurosurgery, 62(5), 1018–1032. Theodosopoulos, P., & Pensak, M. (2011). Contemporary management of acoustic neuromas. The Laryngoscope, 121(6), 1133–1137. Turner, M., Krewski, D., Armstrong, B., et al. (2013). Allergy and brain tumors in the INTERPHONE study: Pooled results from Australia, Canada, France, Israel, and New Zealand. Cancer Causes and Control: An International Journal of Studies of Cancer in Human populations, 24(5), 949–960. Vanchieri, C. (2011). New data on nonmalignant brain tumours could spur research efforts. Journal of the National Cancer Institute, 103(9), 706–707, 713. Warnoch, C., & Tod, A. (2013). A descriptive exploration of the experiences of patients with significant functional impairment following a recent diagnosis of metastatic spinal cord compression. Journal of Advanced Nursing, 70(3), 564–574. Parkinson’s Disease. Chen, J. J., & Fernandez, H. H. (2007). Community and long-term care management of Parkinson’s disease in the elderly. Drugs and Aging, 24(8), 663–680. Halkias, I. A. C., Haq, I., Huang, Z., et al. (2007). When should Levodopa therapy be initiated in patients with Parkinson’s disease? Drugs and Aging, 24(4), 261–273. Lix, L., Hobson, D., Azimaee, M. et al. (2010). Socioeconomic variations in the prevalence and incidence of Parkinson’s disease: A population-based analysis. Journal of Epidemiology Community Health, 64, 335–340. Murdoch, B. E. (2010). Surgical approaches to treatment of Parkinson’s disease: Implications for speech function. International Journal of Speech-Language Pathology, 12(5), 375–384. Musselman, M., & Suprat, S. (2013). Diagnosis and treatment of druginduced hyperthermia. American Journal of Health-System Pharmacy, 70(1), 34–42. Parkinson Society British Columbia. (2014). Parkinson’s disease Fact Sheet. Retrieved March 2, 2014, from http://www.parkinson.bc.ca/ Parkinsons-Disease-Fact-Sheet Quelhas, R. (2013). Psychiatric care in Parkinson’s disease. Journal of Psychiatric Practice, 19 (2), 119–141. *Sadowski, C. A., Jones, C. A., Gordon, B., et al. (2007). Knowledge of risk factors for falling reported by patients with Parkinson disease. Journal of Neuroscience Nursing, 39 (6), 336–341. Stern, M., & Siderowf, A. (2010). Parkinson’s at risk syndrome: Can Parkinson’s disease be predicted. Movement Disorders, 25 (1), S89– S93. Thomure, A. (2006). Helping your patient manage Parkinson’s disease. Nursing, 36(8), 20. Tousi, B., & Wilson, K. (2013). Falls related to accidental deactivation of deep brain stimulators in patients with Parkinson’s disease living in long term care facilities. Journal of the American Medical Directors Association, 14, 58–59.

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Management of Patients With Oncologic or Degenerative Neurologic Disorders

Weintraub, D., & Hurtig, H. I. (2007). Presentation and management of psychosis in Parkinson’s disease and dementia with Lewy bodies. American Journal of Psychiatry, 164(10), 1491–1498. Postpolio Syndrome Bertolasi, L., Acler, M., dall’Ora, E., et al. (2012). Risk factors for postpolio syndrome among an Italian population: A case-control study. Neurological Sciences, 33, 1271–1275. Borg, K. (2011). Post-polio syndrome- immune modulation and a potential biomarker. Journal of Rehabilitation Medicine, Supplement 4, 14. Davidson, C. A., Auyeung, V., Luff, R., et al. (2009). Prolonged benefit in post-polio syndrome from comprehensive rehabilitation: A pilot study. Disability and Rehabilitation, 31(4), 309–317. LaRocca, S. A. (2011). Post-polio syndrome unraveling. Nursing, 26–39. Nollet, F. (2011). Post-polio syndrome, overview of current knowledge. Journal of Rehabilitation Medicine, Supplement 4, 10. Oncu, J., Atamaz, F, Durmas, B., et al. (2013). Psychometric properties of fatigue severity and fatigue impact scales in postpolio patients. International Journal of Rehabilitation Research, 36(4), 339–345. Ward, S. (2008). Does anyone see me? Playing host to the uninvited guest of post-polio syndrome. Qualitative Inquiry, 14(3), 360–383.

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RESOURCES ALS Society of Canada/Société canadienne de la SLA: http://www.als.ca. Alzheimer Society of Canada/Société canadienne de l’Alzheimer: http:// www.alzheimer.ca. Brain Tumour Foundation of Canada: http://www.braintumour.ca. British Columbia Cancer Agency: http://www.bccancer.bc.ca. Canadian Cancer Society: http://www.cancer.ca. Canadian Chiropractic Association: http://www.ccachiro.org. Huntington Society of Canada/Société Huntington du Canada: http:// www.huntingtonsociety.ca. Michael J. Fox Foundation for Parkinson’s Research: http://www. michaeljfox.org/index.cfm. Muscular Dystrophy Canada: http://www.muscle.ca. Parkinson Society Canada/Société Parkinson Canada: http://www.parkinson.ca. Polio Canada: http://www.marchofdimes.ca/EN/programs/PolioCanada/ Pages/default.aspx.

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Case Study Applying Concepts From NANDA, NIC, and NOC A Patient With Musculoskeletal Limitations Complicated by a Medical Illness Mrs. Letourneau is a 72-year-old woman with severe osteoarthritis of the spine and a recent history of left total hip replacement. She has been attending outpatient physical therapy sessions three times a week and uses a wheeled walker at home. Today, she was admitted to the hospital with a partial small bowel obstruction. The health care team anticipates that the obstruction will resolve without surgical intervention, and her expected length of stay is 5 to 7 days. Currently, she is allowed nothing by mouth, has a Salem sump tube in place, and is receiving peripheral parenteral nutrition until a central line is started. The nurse is concerned that Mrs. Letourneau’s already impaired physical mobility will decline further, secondary to her illness and to the medical treatments that make independent ambulation difficult. Visit to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems.

Musculoskeletal Function

A patient with musculoskeletal limitations complicated by a medical illness receives the nursing diagnoses Impaired Physical Mobility

may respond to

requires nursing interventions Exercise Promotion

and

and

may require

Exercise Promotion Strength Training

outcomes should show improvement in may lead to improved

Mobility Level

may lead to improved

reduces the risk for or develop

which support

Risk for Disuse Syndrome

which requires preventive care and ongoing monitoring

Embolus Precautions

and

reduces risk for

reduces risk for

Pressure Ulcer Prevention

and

Surveillance

leads to early detection of

Immobility Consequences: Physiological

Nursing Classifications and Languages NANDA Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes Return to functional baseline status, stabilization of, or improvement in:

Impaired Physical Mobility— Limitation in independent, purposeful physical movement of the body or of one or more extremities

Exercise Promotion—Facilitation of regular physical activity to maintain or advance to a higher level of fitness and health

Mobility Level—Ability to move purposefully in own environment independently with or without assistive device

Risk For Disuse Syndrome—At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity

Exercise Promotion: Strength Training—Facilitating regular resistive muscle training to maintain or increase muscle strength

Immobility Consequences: Physiological—Severity of compromise in physiological functioning due to impaired physical mobility

Embolus Precautions—Reduction of the risk of an embolus in a patient with thrombi or at risk for developing thrombus formation Pressure Ulcer Prevention— Prevention of pressure ulcers for an individual at high risk for developing them Surveillance—Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making From Bulechek, G. M., Butcher, H. K., Dochterman, J. M. et al. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier; Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions & classification 2012–2014 . Oxford, UK: WileyBlackwell; Johnson, M., Moorhead, S., Bulechek, G.M., et al. (Eds.). (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care (3rd ed.). St. Louis, MO: Mosby; Moorhead, S., Johnson, M., Mass, M. L., et al. (Eds.). (2013). Nursing outcomes classification (5th ed.). St. Louis, MO: Elsevier.

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67 Assessment of Musculoskeletal Function Adapted by D. Lynn Skillen

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the anatomy and physiology of the musculoskeletal system. 2. Relate the significance of the health history to the assessment of musculoskeletal health. 3. Describe the physical examination of the musculoskeletal system. 4. Discuss the significance of assessment for the nursing diagnosis of musculoskeletal dysfunction. 5. Demonstrate knowledge of the diagnostic tests used for assessment of musculoskeletal function.

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The musculoskeletal system comprises the bones, joints, muscles, tendons, ligaments, menisci, and bursae of the body. Their functions are highly integrated. Disease and/ or injury of one component adversely affects others. For instance, an infection in a joint (septic arthritis) causes degeneration of the articular surfaces of the bones within the joint and local muscle atrophy. Diseases and injuries involving the musculoskeletal system are commonly implicated in disability and death. Across the Canadian lifespan, these are broadly grouped into five categories: genetic, traumatic, infectious, neoplastic, and rheumatologic (Gunta, 2010a,b). Musculoskeletal disorders can significantly affect overall productivity, independence, and quality of life. Nurses in all practice areas encounter patients with disturbances in the musculoskeletal system. Among those are the many types of arthritis (Miles, Hannon, & Rizzo, 2010). In Canada, more than 4.6 million individuals aged 15 years or older report having arthritis. Two out of three are women, and for them arthritis is the leading cause of disability; in men, it

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is the third cause (The Arthritis Society, 2014). To complicate disability, arthritis has a significant impact on mental health (O’Donnell, Lagacé, McRae, et al., 2011). Another condition, osteoporosis, is associated with risk for fractures among Canadians who are 40 years of age or more. A common complication of osteoporosis is the fracture of a hip, pelvis, spine, upper arm, or wrist. Many Canadians are at risk, especially because they are not being screened for the condition, do not report regular physical activity, and/or are not taking calcium or vitamin D supplements (PHAC, 2010a). In 2005 to 2006, 132,000 hospitalizations were associated with arthritis (PHAC, 2010b).

ANATOMIC AND PHYSIOLOGIC OVERVIEW The musculoskeletal system protects vital organs, including the brain, heart, lungs, and spinal cord; provides a

Glossary atonic: without tone; denervated muscle that atrophies atrophy: wasting; decrease in the size of a muscle bursa: fluid-filled sac found in connective tissue, commonly but not always in the area of joints callus: osseous material at a fracture site; replaced by bone during healing cancellous bone: latticelike bone structure; network of osseous material cartilage: dense, tough, avascular connective tissue in joints, at ends of bone clonus: rapid, rhythmic muscular contractions associated with a significant hyperactive deep tendon reflex contracture: fibrosis of connective tissue found in fascia, joint, muscle, or skin; a shortening cortical bone: dense rigid layer of a bone; also called compact bone crepitus: grating or crackling sounds or sensations; may occur when bone fragments move against each other, cartilage erodes and joint surfaces grind on each other, inflamed tendons move, or air is trapped in subcutaneous tissues diaphysis: shaft (middle section) of a long bone effusion: excess fluid in joint or other body structure endosteum: a thin, vascular membrane covering the marrow cavity of long bones and the network of osseous tissue (trabeculae) in cancellous bone epiphysis: end of a long bone fascia (epimysium): a fibrous membrane that covers, supports, and separates muscles; superficially, connects skin to muscle fasciculation: involuntary twitching of muscle fibres flaccid: limp; without muscle tone hypertrophy: enlargement; increase in size or bulk of muscle isometric contraction: increased muscle tension, muscle length unchanged, no joint motion isotonic contraction: muscle tension unchanged, muscle length shortened, joint motion

joint: articulation between two bones; type of joint determines amount of movement joint capsule: fibrous connective tissue that encloses joints kyphosis: exaggeration of the convex curvature of the thoracic spine lamella: a thin layer, membrane, plate, or scale; may be bone, cellular, or tissue ligament: band of fibrous connective tissue connecting bones, cartilages, or organs lordosis: exaggeration of the concave curvature of the lumbar spine ossification: formation of bone matrix osteoblast: bone-forming cell of mesodermal origin osteoclast: bone resorption cell; absorbs calcium salts osteocyte: mesodermal bone-forming cell; maintains bone as living structure osteogenesis: bone formation osteon: microscopic functional unit of compact bone paresthesia: unpleasant numb, tingling, stinging, burning, or prickly sensation periosteum: dense fibrous membrane covering bone, but not articular surfaces; serves as attachment for tendons and ligaments remodelling: process that ensures bone maintenance through simultaneous bone resorption and formation resorption: removal/destruction of tissue, such as bone scoliosis: lateral curvature of the spine; congenital, functional, idiopathic, or disease-related spastic: increased muscle tone synovium: membrane in joint that secretes lubricating fluid tendon: band of fibrous connective tissue connecting muscle to bone tone (tonus): residual tension in relaxed muscle trabeculae: latticelike bone structure; network of osseous tissue in cancellous bone

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Musculoskeletal Function

sturdy framework to support body structures; and makes mobility possible. Muscles and tendons hold the bones together; tendons attach muscles to bones. They also move to produce heat that helps maintain body temperature. Joints permit body movement. Movement facilitates the return of deoxygenated blood to the right side of the heart by massaging the venous vasculature. The musculoskeletal system serves as a reservoir for immature blood cells and essential minerals, including calcium, phosphorus, magnesium, and fluoride. Over 98% of total body calcium is present in bone (Martini, Timmons, & Tallitsch, 2012).

Anatomy and Physiology of the Skeletal System The human body has 206 bones divided into four categories: long bones (e.g., femur), short bones (e.g., metacarpals), flat bones (e.g., sternum), and irregular bones (e.g., vertebrae). The function and forces exerted on a specific bone determine its construction and shape. Bones are constructed of cancellous (trabecular) or cortical (compact) bone tissue. Long bones are shaped like rods or shafts with rounded ends (Fig. 67-1). The shaft (diaphysis) is primarily cortical bone. The ends of the long bones (epiphyses) are primarily cancellous bone. The epiphyseal plate separates the epiphyses from the diaphysis and is the centre for longitudinal growth in children. It is calcified in adults. The ends of long bones are covered at the joints by articular cartilage (dense, tough, avascular tissue). Long bones are designed for weight bearing and movement.

Cartilage Proximal epiphysis

Growth lines Spongy bone (containing red marrow) Medullary (marrow) cavity Endosteum Yellow marrow Periosteum

Diaphysis Artery

Compact bone Periosteum Osteocytes

Blood vessels

Distal epiphysis

Volkmann’s canal

FIGURE 67-1. Structure of a long bone; composition of compact bone.

Short bones consist of cancellous bone covered by a layer of compact bone. Flat bones (cancellous bone layered between compact bone) are important sites of hematopoiesis and protect several vital organs (e.g., the heart). Irregular bones have unique shapes related to their function, but generally their structure is similar to that of flat bones. Bone is composed of cells, protein matrix, and mineral deposits. Three basic types of cells exist: osteoblasts, osteocytes, and osteoclasts. Osteoblasts secrete bone matrix for bone formation. Matrix consists of collagen and ground substances (glycoproteins and proteoglycans) that provide a framework for deposit of inorganic mineral salts (primarily calcium and phosphorus). Osteocytes (mature bone cells) support bone maintenance and lie in lacunae (bone matrix units). Osteoclasts, located in shallow Howship’s lacunae (small pits in bones), are multinuclear cells active in bone resorption. The microscopic and fundamental functional unit of mature cortical bone is the osteon (haversian system). The centre of the osteon, the haversian canal, contains a capillary. Around the capillary are circles of mineralized bone matrix called lamellae. Within the lamellae are osteocyte-containing lacunae. Tiny canaliculi (canals) communicate with adjacent blood vessels in the haversian system to nourish the lacunae. Layers of lacunae in cancellous bone form an irregular lattice network (trabeculae) that is filled with red bone marrow. Capillaries nourish the osteocytes located in the lacunae (Porth, 2010). A dense, fibrous membrane known as the periosteum covers the bone, but not the articular ends. This membranous structure nourishes bone and facilitates its growth. The periosteum contains nerves, blood vessels, and lymphatics, and makes possible the attachment of tendons and ligaments (Porth, 2010). The endosteum is a thin, vascular membrane that lines the marrow cavity of long bones and the trabeculae in cancellous bone. Located near the endosteum in Howship’s lacunae are osteoclasts that dissolve bone matrix to maintain the marrow cavity (Porth, 2010). Vascular bone marrow is located in flat bones and the medullary (shaft) cavity of long bones. In adults, red bone marrow, found mainly in the sternum, ilium, vertebrae, and ribs, produces red blood cells, white blood cells, and platelets in a process called hematopoiesis. Adult long bones are filled with fatty yellow marrow (Porth, 2010). Bone tissue is highly vascular. Cancellous bone receives a rich blood supply from epiphyseal vessels. Periosteal vessels carry blood to compact bone through minute Volkmann’s canals. In addition, nutrient arteries penetrate the periosteum and enter the medullary cavity through foramina (small openings). Arteries supply blood to the marrow and bone. Veins may accompany arteries or exit separately (Porth, 2010).

Bone Formation Osteogenesis (bone formation) begins long before birth. Bone matrix is formed during ossification and hard mineral crystals composed of calcium and phosphorus (e.g., hydroxyapatite) are bound to the collagen fibres. The minerals give bone its characteristic strength and the proteinaceous collagen gives bone its resilience (Porth, 2010).

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Bone Maintenance Bone is a dynamic tissue in a constant state of turnover. During childhood, bones grow and form by a process called modelling. By the early 20s, remodelling is the primary process. Remodelling maintains bone structure and function through simultaneous resorption and osteogenesis (Gunta, 2010a). Each year almost 20% of the adult skeleton is replaced (Martini et al., 2012). Every 10 years, the adult skeleton is totally replaced (Coates, 2013). At the same time, bone turnover rates are affected by many diseases and conditions. Bone turnover markers assist in the management of osteoporosis and fracture prediction (Dreyer & Vieira, 2010; Naylor & Eastell, 2012). In healthy individuals, several factors influence the balance between bone resorption and formation: physical activity; dietary intake of certain nutrients, especially calcium; and various hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, estrogen, and testosterone (Gunta, 2010a). Physical activity, particularly weight-bearing activity, stimulates bone formation and remodelling. Bones subjected to frequent weight bearing tend to be thick and strong. Conversely, bones become osteopenic and weak in individuals who are unable to engage in regular weightbearing activities, are on prolonged bed rest, or have some physical disabilities. They have increased bone resorption from calcium loss and their weakened bones may fracture easily. Dietary habits are important for bone health. The body requires calcium for building bone mass and obtains it from dairy products (e.g., milk, yogurt, cheese, custards) and nondairy alternatives (e.g., soy, almonds, calciumenriched orange juice, canned salmon, or sardines). Vitamin D is essential to ensure strong bones, in part by promoting the absorption of the mineral calcium. It also protects against fractures by improving muscle function which helps to maintain balance and prevent falls. Canadians do not produce enough vitamin D from exposure to the sun because of Canada’s northern geographical location, the use of sunscreen, and the decreasing ability to synthesize vitamin D with age. Osteoporosis Canada recommends that all Canadian adults use vitamin D supplements every day throughout the year (Osteoporosis Canada, 2014a). Several hormones are vital for ensuring that calcium is properly absorbed and available for bone mineralization and matrix formation. Calcitriol increases the amount of calcium in the blood by promoting absorption of calcium from the gastrointestinal tract. It also facilitates mineralization of osteoid tissue. A deficiency of vitamin D results in bone mineralization deficit, deformity, and fracture (Osteoporosis Canada, 2014b; Porth, 2010). Calcitonin and PTH are the major hormonal regulators of calcium homeostasis. Secreted by the thyroid gland in response to elevated blood calcium levels, calcitonin inhibits bone resorption and increases the deposit of calcium in bone (Porth, 2010). Partly by promoting movement of calcium from the bone, PTH regulates the concentration of calcium in the blood. Responding to low blood calcium levels, increased levels of PTH prompt the mobilization of calcium, demineralization of bone, and formation of bone cysts.

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Both thyroid hormone and cortisol have multiple systemic effects with specific effects on bones. Excessive thyroid hormone production in adults (e.g., Graves disease) can increase bone resorption and decrease bone formation. Increased levels of cortisol have the same effects. Individuals receiving long-term synthetic cortisol or corticosteroids (e.g., prednisone) are at increased risk for steroid-induced osteopenia and fractures. Growth hormone has direct and indirect effects on skeletal growth and remodelling. It stimulates the liver and to a lesser degree the bones to produce insulin-like growth factor-1 (IGF-I) that accelerates bone modelling in children and adolescents. Growth hormone also directly stimulates skeletal growth in children and adolescents. Likely the low levels of both growth hormone and IGF-I that occur with aging are partly responsible for decreased bone formation and resultant osteopenia (Matfin, 2010). Estrogen and testosterone have important effects on bone remodelling (Gunta, 2010a). Estrogen stimulates osteoblasts and inhibits osteoclasts, enhancing bone formation and inhibiting resorption. Testosterone has both direct and indirect effects on bone growth and formation. Directly, it causes skeletal growth in adolescence and has continued effects on skeletal muscle growth throughout the lifespan. Increased muscle mass creates greater weightbearing stress on bones, resulting in increased bone formation. Indirectly, testosterone converts to estrogen in adipose tissue, providing an additional source of bonepreserving estrogen for aging men. During bone remodelling, osteoblasts produce a receptor for activated nuclear factor-kappa B ligand (RANKL) that binds to the receptor for activated nuclear factorkappa B (RANK) present on the cell membranes of osteoclast precursors. This causes them to differentiate and mature into osteoclasts, which trigger bone resorption. Conversely, osteoblasts may produce osteoprotegerin (OPG) that blocks the action of RANKL, stopping the process of bone resorption. As a result of the inflammatory process, T cells may become activated and also produce RANKL, overriding the effects of OPG and causing continued bone resorption during times of stress and injury. This can lead to loss of bone matrix and fractures (Gunta, 2010a). The bone blood supply also affects bone formation. With diminished blood supply or hyperemia (congestion), osteogenesis and bone density decrease. Bone necrosis occurs when the bone is deprived of blood.

Bone Healing Most fractures heal with a combination of intramembranous and endochondral ossification processes. When a bone is fractured, it regenerates itself without scarring, but a thickened area on the bone surface could indicate a healed fracture (Gunta, 2010b). Fracture healing occurs in the bone marrow, bone cortex, periosteum, and adjacent soft tissue. In the marrow, endothelial cells rapidly differentiate into osteoblasts. In bone cortex, new osteons are formed. In periosteum, a hard callus (fibrous tissue) forms during intramembranous ossification peripheral to the fracture and cartilage forms during endochondral ossification close to the fracture site. In adjacent soft tissue, a bridging callus forms that provides stability to the fractured bones.

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The process of fracture healing may be structured over three phases: Phase I: Reactive phase: When the fracture occurs, the body responds with bleeding into the injured tissue and formation of a hematoma at the fracture site. The release of cytokines initiates the fracture healing processes by causing proliferation of fibroblasts and angiogenesis to ensue (i.e., the growth of new blood vessels). Dense granulation tissue begins to form within the clot. Phase II: Reparative phase: Granulation tissue is initially replaced with procallus (a callus precursor). Fibroblasts invade the procallus and produce a denser type of callus composed mostly of fibrocartilage. Approximately 3 to 4 weeks postinjury, denser bony callus replaces the fibrocartilaginous callus. Lamellar bone then forms as the bony callus calcifies months postinjury. Phase III: Remodelling phase: Finally, remodelling creates new bone in its former structural arrangement. Remodelling may take months to years. It is contingent on the extent of bone modification required, the function of the bone, and the functional stresses on the bone (Gunta, 2010b). Serial x-rays are used to monitor the progress of bone healing. The rate of fracture healing depends on type of bone fractured, adequacy of blood supply, surface contact of the fragments, age and general health of the injured individual, and immobility of the fracture site. Adequate immobilization is essential until x-rays confirm bone formation with ossification. Immobilization may occur with an external fibreglass cast or an orthopedic surgeon may use hardware (e.g., pins, plates, screws, nails) to perform an open reduction and internal fixation. When fractures are treated with open rigid compression plate fixation techniques, the bony fragments can be placed in direct contact. Primary bone healing occurs during cortical bone (haversian) remodelling. Little or no cartilaginous callus develops. Immature bone develops from the endosteum. An intensive regeneration of new osteons occurs in the fracture line by a process similar to that of regular bone maintenance. Fracture strength is obtained when the new osteons have become established.

Anatomy and Physiology of the Articular System The junction of two or more bones is called a joint (articulation). One method of classifying joints is according to the type of cartilage in the joint: synarthrotic, amphiarthrotic, and diarthrotic (Martini et al., 2012). Synarthrotic joints are immovable and fibrous (e.g., the skull sutures). Amphiarthrotic joints (e.g., the vertebral joints, costal cartilages, symphysis pubis) allow limited motion; their bones are joined by fibrous cartilage. Diarthrotic joints are freely movable, synovial, and the most common (Fig. 67-2). Diarthrotic joints include: • Ball-and-socket joints (e.g., the hip, the shoulder) that permit full freedom of movement (flexion, extension, abduction, adduction, internal rotation, external rotation).

Femur

Synovial (joint) cavity Bursa

Articular cartilage Medial meniscus Tibia

Patella Synovial (joint) cavity Fat pad Infrapatellar bursa

FIGURE 67-2. Hinge joint of the knee.

• Hinge joints that permit flexion and extension in one plane (e.g., the elbow, the knee, interphalangeal joints). • Saddle joints that allow movement in two planes at right angles to each other (flexion, extension, abduction, adduction, circumduction). The joint at the base of the thumb is a saddle, biaxial joint. • Condylar joints that are biaxial joints and allow angular movement in two planes (e.g., fingers with the metacarpophalangeal bones). • Pivot joint in the neck that permits rotation of the atlas on the axis. • Gliding joints that permit limited movement in all directions (e.g., the joints of the carpal bones in the wrist, intervertebral joints) (Martini et al., 2012). Smooth hyaline cartilage covers the ends of articulating bones of diarthrotic (movable) joints. A tough, fibrous sheath called the joint capsule surrounds articulating bones. The synovium, a membrane that lines the capsule, secretes lubricating and shock-absorbing synovial fluid into the joint capsule and prevents direct contact of bone surfaces. In some synovial joints (e.g., the knee), fibrocartilage disks (e.g., medial meniscus, lateral meniscus) are located between the articular cartilage surfaces and provide shock absorption (Porth, 2010). Ligaments (fibrous connective tissue bands) bind articulating bones together. Ligaments and muscle tendons, which pass over the joint, provide joint stability. In some joints, interosseous ligaments (e.g., the cruciate ligaments of the knee) are found within the capsule and add anterior and posterior stability to the joint. A bursa is a sac filled with synovial fluid that cushions the movement of tendons, ligaments, and bones at a point of friction. For example, bursae are found in the joints of the elbow, shoulder, hip, and knee. A meniscus is a crescent-shaped (semilunar) fibrocartilage found in joints (e.g., the knee, acromioclavicular joint, radiocarpal joint). It partly divides a joint cavity and is a shock absorber. In the knee, it disperses friction between the tibia and femur (Martini et al., 2012).

CHAPTER 67

Anatomy and Physiology of the Skeletal Muscle System Muscles are attached by tendons to bones, connective tissue, other muscles, soft tissue, or skin. The muscles of the body are composed of parallel groups of muscle cells (fasciculi) encased in fibrous tissue called fascia (epimysium). The more fasciculi contained in a muscle, the more precise its movements. Muscles vary in shape and size according to the activities for which they are responsible. Contractions of skeletal (striated) muscles facilitate body movement, posture, and heat-production.

Skeletal Muscle Contraction Each muscle cell (muscle fibre) contains myofibrils which are composed of a series of sarcomeres, the actual contractile units of skeletal muscle. Sarcomeres contain thick (myosin) and thin (actin) filaments. Muscle cells contract in response to electrical impulses delivered by an effector nerve cell at the motor end plate. When stimulated, the muscle cell depolarizes and generates an action potential—similar to that described for nerve cells. Action potentials propagate along the muscle cell membrane, leading to the release of calcium ions that are stored in specialized organelles called sarcoplasmic reticula. A local increase in calcium ion concentration causes the myosin and actin filaments to slide across one another. Shortly after the muscle cell membrane depolarizes, it recovers its resting membrane voltage. Calcium is rapidly removed from the sarcomeres by active reaccumulation in the sarcoplasmic reticulum. When the calcium concentration in the sarcomere decreases, the myosin and actin filaments cease to interact, and the sarcomere returns to its original resting length (relaxation). Actin and myosin do not interact in the absence of calcium (Carroll, 2010). Energy consumption occurs during muscle contraction and relaxation. The primary source of energy for muscle cells is adenosine triphosphate (ATP), which is generated through cellular oxidative metabolism. At low levels of activity (i.e., sedentary activity), the skeletal muscle synthesizes ATP from the oxidation of glucose to water and carbon dioxide. During strenuous activity, when sufficient oxygen may not be available, glucose is metabolized primarily to lactic acid, an inefficient process compared to that of oxidative pathways. Stored muscle glycogen is used to supply glucose during periods of activity. Muscle fatigue has various proposed explanations and is distinct from delayed-onset muscle soreness (Martini et al., 2012). One cause of muscle fatigue is thought to be depletion of glycogen and accumulation of lactic acid, resulting in failure of the cycle of muscle contraction and relaxation. During muscle contraction, the excess energy released from ATP is dissipated in the form of heat. During isometric contraction, almost all the energy released is in the form of heat; during isotonic contraction, some energy is expended in mechanical work. In certain situations (e.g., shivering), the primary stimulus for muscle contraction is the need to generate heat. The contraction of muscle fibres results in either isotonic or isometric contractions. In isometric contractions,

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the length of the muscles remains constant but the force generated by the muscles increases; an example of this is pushing against an immovable wall. Isotonic contractions, are characterized by shortening of the muscle with no increase in tension within the muscle; an example of this is flexing the forearm. In daily activities, many muscle movements are a combination of isometric and isotonic contraction. For example, during walking, isotonic contraction results in shortening of the leg, and isometric contraction causes the stiff leg to push against the floor. The speed of muscle contraction is variable. Myoglobulin is a hemoglobin-like protein pigment present in striated muscle cells and transports oxygen. Muscles containing large quantities of myoglobulin (red muscles) have been observed to contract slowly and powerfully (e.g., respiratory and postural muscles). Muscles containing little myoglobulin (white muscles) contract quickly (e.g., extraocular eye muscles). Most muscles contain both red and white muscle fibres (Jiricka, 2010).

Muscle Tone Relaxed muscles demonstrate a state of readiness to respond to contraction stimuli known as residual tension. This state of readiness (muscle tone) is produced by maintaining some muscle fibres in a contracted state. Muscle spindles, which are sense organs in the muscles, monitor muscle tone. Muscle tone is minimized during sleep and increased when an individual is anxious. A flaccid muscle is limp and without tone; a spastic muscle has greaterthan-expected tone. In conditions characterized by lower motor neuron destruction (e.g., polio), denervated muscle becomes atonic (soft and flabby) and atrophies (Pierazzo & Hung, 2010).

Muscle Actions Muscles accomplish movement by contraction. Using coordinated muscle groups, the body performs a wide variety of movements. The prime mover is the muscle (agonist) that causes a particular motion. The muscles assisting the prime mover are known as synergists; those causing movement opposite to that of the prime mover are antagonists (Martini et al., 2012). An antagonist must relax to allow the prime mover to contract, producing motion. For example, when contraction of the biceps causes flexion of the elbow joint, the biceps are the prime movers, and the triceps are the antagonists. A person with muscle paralysis (a loss of movement, possibly from nerve damage) may be able to retrain functioning muscles within the synergistic group to produce the needed movement. Muscles of the synergistic group then become the prime movers (Fig. 67-3).

Exercise, Disuse, and Repair Muscles need to be exercised to maintain function and strength. When muscle repeatedly reaches maximum or close to maximum tension over a long time (e.g., in regular exercise with weights), the cross-sectional area of the muscle enlarges. This hypertrophy results from an increase in the size, but not the number, of individual muscle fibres. Hypertrophy persists only if exercise continues.

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A Abduction– moving away ffrom midline Mandible Protraction– pushing forward Adduction– moving toward midline

Retraction– pulling backward Pronation–turning downward

Circumduction– umduct conelike ke movement mov

Supination–turning upward

Extension– straightening at a joint

Flexion– bending at a joint (e.g., knee)

Inversion– turning inward

Eversion– turning outward

Rotation– turning around a specific axis FIGURE 67-3. Body movements produced by muscle contraction. Flexion: bending at a joint (e.g., elbow). Extension: straightening at a

joint. Abduction: moving away from midline. Adduction: moving toward midline. Rotation: turning around a specific axis (e.g., shoulder joint). Circumduction: conelike movement. Supination: turning upward. Pronation: turning downward. Inversion: turning inward. Eversion: turning outward. Protraction: pushing forward. Retraction: pulling backward. (From Weber, J.W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.) Philadelphia: Lippincott Williams & Wilkins.)

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The opposite phenomenon, occurs with disuse of muscle over a long period of time. Age and disuse cause loss of muscular function and fibrotic tissue replaces contractile muscle tissue. Decrease in muscle size is called atrophy. Bed rest and immobility cause loss of muscle mass and strength. When a treatment modality (e.g., casting, traction, or bed rest) results in immobility, the patient can counteract the effects by performing isometric exercise of the muscles of the immobilized part. Quadriceps contraction exercises (tightening the muscles of the anterior thigh) and gluteal setting exercises (tightening of the muscles of the buttocks) help maintain the larger muscle groups important in ambulation. Active and weight-resistance exercises of uninjured parts of the body maintain muscle strength. Injured muscles need rest and immobilization for tissue repair. Healed muscle then requires progressive exercise to resume its strength and function.

Gerontologic Considerations Multiple changes in the musculoskeletal system occur with aging (Table 67-1). Height diminishes due to osteoporosis (excessive bone loss), kyphosis, thinned intervertebral disks, compressed vertebral bodies, and flexion of the knees and hips. Numerous metabolic changes, including menopausal withdrawal of estrogen, and decreased activity contribute to osteoporosis (Gunta, 2010a). Women lose more bone mass than men. Bones change shape and have reduced strength. Fractures are common. Collagen structures absorb less energy. Increased inactivity, diminished neuron stimulation, and nutritional deficiencies contribute to reduced muscle strength. Earlier musculoskeletal challenges for which the patient has compensated may become new conditions TABLE 67-1

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because of age-related changes. For example, individuals who had polio and have functioned by using synergistic muscle groups may experience increasing incapacity because of a reduced compensatory ability. Fortunately, many effects of aging can be slowed by pursuing positive lifestyle behaviours. Regular exercise improves the quality of life and makes the bones stronger (Martini et al., 2012).

HEALTH ASSESSMENT Assessment of the patient with musculoskeletal alterations includes evaluation of the effects on the patient and his or her activities of daily life. The nurse assists patients with musculoskeletal concerns to maintain their general health and manage their treatment programs. This includes encouraging optimal nutrition and addressing risks related to immobility. After completing a health history and physical examination, the nurse creates an individualized plan of nursing care to help the patient optimize health.

Health History Obtain an overall impression of the patient’s health status. After collecting identifying data, conduct a symptom/sign analysis of the patient’s presenting concern(s). Inquire about the location/radiation, nature (quality) of the symptom, the severity, and its timing (onset, frequency, duration). Ask about the factors that aggravate or alleviate the symptom, and any associated symptoms. Finally, determine if environmental factors are influencing the symptom, significance to the patient of having the symptom, and what the patient believes is causing the symptom (Stephen, 2012).

Age-Related Changes of the Musculoskeletal System

Musculoskeletal System

Structural Changes

Functional Changes

History and Physical Findings

Bones

Gradual, progressive loss of bone mass after 30 yr Vertebrae collapse

Bones fragile and prone to fracture: vertebrae, hip, wrist

Loss of height Posture changes Kyphosis Loss of flexibility Flexion of hips and knees Back pain Osteoporosis Fracture

Muscles

Increase in collagen and resultant fibrosis Muscles diminish in size (atrophy); wasting Tendons less elastic

Loss of strength and flexibility Weakness Fatigue Stumbling Falls

Loss of strength Diminished agility Decreased endurance Prolonged response time (diminished reaction time) Diminished tone Broad base of support History of falls

Joints

Cartilage—progressive deterioration Thinning of intervertebral disks

Stiffness, reduced flexibility, and pain interfere with activities of daily living

Diminished range of motion Stiffness Loss of height

Ligaments

Lax ligaments (less strength; weakness)

Postural joint alteration Weakness

Joint pain on motion; resolves with rest Crepitus Joint swelling/enlargement Osteoarthritis (degenerative joint disease)

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List the patient’s medications (name, dosage, frequency, purpose, and response) and document any allergies. Inquire about concurrent health conditions (e.g., diabetes, heart disease, chronic obstructive pulmonary disease, rheumatoid arthritis, infection, disability), past surgeries, and history of genetic or familial disorders (Stephen, 2012) (Chart 67-1). Explore the patient’s expectations related to health, and his or her lifestyle behaviours such as tobacco use, exercise patterns, alcohol consumption, and street and overthe-counter medications. Review dietary habits, including the intake of calcium and use of a vitamin D supplement (Stephen, 2012). Consider the patient’s learning ability, current occupation, and economic status in the preliminary plan of care. Update initial interview data as interac-

tions with the patient continue. Subjective data (detailed information obtained from the patient) always guide the physical examination.

Common Symptoms Nurses usually perform a focused musculoskeletal assessment if patients report a symptom such as muscle or joint pain, stiffness, joint swelling, weakness, altered sensations, or difficulty with mobility. In the event of a potential dislocation, fracture, or rupture, the nurse conducts an emergency (very focused) assessment. In contrast, when acquiring baseline data, the nurse makes the time to perform a comprehensive assessment (Stephen, 2012).

GENETICS IN NURSING PRACTICE

Chart 67-1. Musculoskeletal Disorders When assessing a patient with musculoskeletal concerns, nurses assess for the possibility of a genetic component to the patient’s condition(s).

• If indicated, refer patient for further genetic counselling

MUSCULOSKELETAL IMPAIRMENTS INFLUENCED BY GENETIC FACTORS • Achondroplasia • Congenital talipes equinovarus (clubfoot) • Developmental dysplasia of the hip (DDH) (congenital hip dysplasia) • Ehlers–Danlos syndrome • Marfan syndrome • Stickler syndrome • Osteogenesis imperfecta • Osteoporosis • Scoliosis

• • •

NURSING ASSESSMENTS Family History • Assess for other similarly affected family members. • Assess for the presence of other related genetic conditions (e.g., hematologic, cardiac, integumentary conditions). • Determine the age at onset (e.g., fractures present at birth as in osteogenesis imperfecta, hip dislocation present at birth in DDH, or early-onset osteoporosis). Patient Assessment

• Assess stature for general screening purposes (unusually

short stature may be related to achondroplasia; unusually tall stature may be related to Marfan syndrome). • Assess for disease-specific skeletal findings (e.g., pectus excavatum, scoliosis, long fingers [Marfan syndrome], osteoarthritis of the hip and waddling gait [DDH]). • Assess for disease-specific skin findings (e.g., velvety texture with unusual scarring and/or thin fragile skin [Ehlers– Danlos syndrome]). • Assess for other common disease-specific findings (e.g., vision impairment [Stickler syndrome, Marfan syndrome], blue/grey sclerae, opalescent dentin, hearing impairment [osteogenesis imperfecta]). MANAGEMENT ISSUES SPECIFIC TO GENETICS

• Inquire whether DNA gene mutation or other genetic testing has been performed on affected family members.

•

and evaluation so that family members can discuss gene inheritance, risk to other family members, and the availability of genetic testing and gene-based interventions. Offer appropriate genetic information and resources. Assess patient’s understanding of genetic information. Provide support and information to families with newly diagnosed genetic-related musculoskeletal disorders. Participate in management and coordination of care of patients with genetic conditions and people predisposed to develop or pass on a genetic condition.

GENETICS RESOURCES Canadian Association of Genetic Counsellors (CAGC), http:// cagc-accg.ca/—Listing of genetic centres across Canada Canadian Directory of Genetic Support Groups, http:// www.lhsc.onca/programs/medgenet—Resource guide for families and professionals Canadian Genetic Diseases Network, http://www.cgdc.ca/—Its stated mission is to be the primary catalyst in advancing Canada’s scientific and commercial competitiveness in genetic research and the application of genetic discoveries to the prevention, diagnosis, and treatment of human disease Canadian Organization for Rare Disorders (CORD), http:// www.cord.ca/—Information on over 6,000 rare disorders and links individuals/families together with the same rare disorder Genetics Society of Canada (GSC), http://life.biology. mcmaster.ca/GSC/—Promotion of research and communication of the results and implications of genetics to the public Genetic Alliance, http://www.geneticalliance.org—Directory of support groups for patients and families with genetic conditions Gene Clinics, http://www.geneclinics.org—Listing of common genetic disorders with up-to-date clinical summaries, genetic counselling and testing information National Organization of Rare Disorders, http://www.rarediseases.org—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—Complete listing of inherited genetic conditions

CHAPTER 67

Pain Pain is considered to be the fifth vital sign (Skillen, 2012). (See Chapter 14 for a thorough discussion of pain.) Most patients with diseases, traumatic conditions, or disorders of the muscles, bones, and joints experience pain. Characteristically, they describe bone pain as a dull, deep ache, “boring” in nature; they report muscular pain as a soreness, aching, or cramping. Fracture pain is sharp, piercing, and relieved by immobilization; a bone infection, muscle spasm, or pressure on a sensory nerve may also produce sharp pain. Pain may be related to systemic disease. Although pain is subjective, the nurse also may observe signs of pain (e.g., restlessness, legs flexed tightly against buttocks, distressed facial features, irritability) (Skillen & Bickley, 2010). It is vital that the nurse observe for signs of pain in individuals such as those who are developmentally challenged, verbally stoic, suffering a form of dementia, or unable to communicate in English (and translation is not available). Related signs that the nurse looks for include alignment of the body; indications of pressure from traction, bed lines, a cast, or other appliances; and signs of tension on the skin at a pin site. Rest, elevation, hot/cold packs, and analgesia relieve most mechanical musculoskeletal pain. Pain that increases with activity may indicate joint sprain, muscle strain, or compartment syndrome. Steadily increasing pain points to an infectious process (osteomyelitis), a malignant tumour, or neurovascular complications. Radiating pain occurs when pressure is exerted on a nerve root. Pain is exhausting. If prolonged, it can make the patient increasingly preoccupied and dependent. See Chapter 13. Questions that the nurse asks during a symptom analysis of pain include: • Where is your pain? Does it radiate? (Location, radiation) • What is the pain like? (Nature, quality) • How intense or severe is the pain using a 0 to 10 point scale (0 = no pain, 10 = worst pain)? (Intensity) • When did the pain start? How did it start? How often do you have it? How long does it last? (Timing: onset, frequency, duration) • What makes the pain worse? (Aggravating factors) • What reduces the pain? (Alleviating factors) • What other symptoms have you noticed? (Associated symptoms) • What is going on at home, school, work, or recreation that might be influencing the pain? (Environmental factors) • How is the pain affecting your daily life? (Significance to patient) • What do you think is causing the pain? (Patient perspective) (Day, 2012).

Stiffness The symptom of stiffness may be a challenge to assess, as patients report the symptom differently (Roach, Roddick, & Bickley, 2010). It can be tightness and discomfort with movement after a period of inactivity—a common description. In contrast, it has been described as “my legs are poisoned” and still refers to the same discomfort. If the stiffness lasts less than 30 minutes after arising in the morning, it is often associated with osteoarthritis, which

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can be monoarticular, aggravated by activity, and relieved by rest. If stiffness persists more than an hour and occurs regularly for at least 6 weeks, it is associated with rheumatoid arthritis, especially if polyarticular and symmetric in nature. Stiffness may also be one of the symptoms of fibromyalgia or another condition, polymyalgia rheumatica, that presents in older adults, usually over 60 years of age (Miles et al., 2010). Careful and sensitive questioning during the health history interview is required. A comprehensive symptom analysis is essential.

Joint Swelling Nonarticular swelling may be associated with constrictive clothing, lymphedema, trauma, or cardiac conditions. When the swelling is in a joint, it restricts the motion of the joint. If ligaments are torn (e.g., collateral or cruciate ligaments of the knee), the swelling subsides slowly and responds to elevation and cold applications. If swelling is associated with redness and pain, it may be related to gout syndrome that results from elevated serum uric acid levels and is aggravated by purine-rich foods (e.g., liver, sardines) and alcohol (Miles et al., 2010). A serious infection, osteomyelitis, may also evidence redness, swelling, and loss of movement. It requires blood and bone cultures to determine the causative organism; it may be difficult to treat (Gunta, 2010b).

Weakness Differentiate muscle weakness (myopathy) from neurological disease (e.g., damage to peripheral nerve (Martini et al., 2012). Weakness in proximal muscles is often a myopathy; weakness in distal muscle groups is more likely related to neuropathy (Roach et al., 2010). See Chapter 61 for a discussion of neurological disorders. Chronic use of corticosteroids tends to cause myopathies and muscle weakness. A reversible condition, hypothyroidism, can cause muscle weakness. Conversely, a progressive disease, amyotrophic lateral sclerosis (ALS), is irreversible. If muscle weakness fluctuates, it may be related to myasthenia gravis, a gradually progressive disorder with fatigue. A mild paralysis may be observed in multiple sclerosis (Roach et al., 2010). Weakness can lead to gait disturbances, the risk of falls, and difficulty with some aspects of self-care (Miles et al., 2010).

Altered Sensations Sensory disturbances are frequently associated with musculoskeletal conditions. The patient may describe paresthesias (burning, tingling, numbness). These sensations may be caused by pressure on nerves or by circulatory impairment. Soft tissue swelling or direct trauma to these structures can impair their function (e.g., compartment syndrome). In addition to the questions of a symptom/sign analysis (Stephen, 2012), always assess the neurovascular status of the involved musculoskeletal area. (See Chapter 61.) Ask the patient to compare the sensation in the unaffected extremity. Inquire about tight or constricting clothing or footwear. Determine if elevation of the affected part affects the symptom. Inspect the area and the area distal to it for colour (e.g., pallor, cyanosis, duskiness), and swelling. Palpate for peripheral pulses

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and pitting edema and compare sides. Assess capillary refill by pressing on the nail until it blanches, releasing it quickly, and observing for return of colour within 3 seconds.

Physical Examination Examination of the musculoskeletal system ranges from a basic assessment of functional capabilities to sophisticated physical examination manoeuvres that facilitate diagnosis of specific bone, muscle, and joint disorders. The extent of assessment depends on the patient’s physical concerns, health history, and physical clues that warrant further exploration. Nursing assessment is primarily a functional evaluation, focusing on the patient’s ability to perform activities of daily living, manage treatment regimens, and progress to recovery, but it also considers potential risks, and observations to share with the interprofessional team. Use techniques of inspection and palpation to evaluate the patient’s posture, gait, balance, bone integrity, range of motion (joint function), and muscle strength and size. In addition, assess the integument (skin, hair, nails) and neurovascular status as important parts of a complete musculoskeletal assessment (Stephen, Skillen, & Day, 2013–2014). Understand and be able to perform correct assessment techniques on patients with musculoskeletal trauma. When specific symptoms or physical findings of musculoskeletal dysfunction are apparent, carefully document the examination findings and share the information with the physician or nurse practitioner who may decide that a more extensive examination and a diagnostic workup are necessary.

Cervical vertebrae

Thoracic vertebrae

Posture The vertebral column (spine) supports the trunk and back, transfers upper body weight to the pelvis and legs, and cushions the effects of movements such as walking or running (Roach et al., 2010). It has concave curvatures in its cervical and lumbar sections, and convex curvatures in the thoracic and sacrococcygeal sections. Common deformities of the spine include kyphosis, an increased convex curvature of the thoracic spine; lordosis (swayback), an exaggerated concave curvature of the lumbar spine; and scoliosis, a lateral curvature of the spine (Fig. 67-4). Kyphosis is common in older patients with osteoporosis and in some patients with neuromuscular diseases. Lordosis is frequently seen during pregnancy as a woman adjusts her posture in response to changes in her centre of gravity. Scoliosis may be congenital, functional, idiopathic (without an identifiable cause), or the result of damage to the paraspinal muscles, as in polio. During inspection of the spine, expose the entire back, buttocks, and legs. Inspect the spinal curvatures and trunk symmetry from posterior and lateral views. Standing behind the patient, note any differences in the height of the shoulders, scapulae, iliac crests, posterior superior iliac spines, or gluteal folds (Stephen et al., 2013–2014). Shoulder and hip symmetry, as well as alignment of the vertebral column, are usually inspected with the patient erect, and forwardly flexed. Scoliosis is evidenced by a lateral curvature of the spine, shoulders that are not level, an asymmetric waistline, and one prominent scapula, accentuated by bending forward. Due to older adults’ experience of a loss in height from reduced water content in discs between vertebrae and osteoporosis-related vertebral

Atlas (1st cervical) Axis (2nd cervical) Transverse process

Spinous process Body (centrum) of vertebra

Lumbar vertebrae

Foramen for spinal nerve Intervertebral disk Sacrum

Sacral vertebrae Coccygeal vertebrae

Coccyx

A Kyphosis

B Lordosis

FIGURE 67-4. A healthy spine and three alterations. A, Kyphosis: an increased convexity of the spine’s thoracic curvature. B, Lordosis: exaggeration of the lumbar spine concave curvature. C, Scoliosis: a lateral curvature of the spine.

C Scoliosis

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compression fractures, measure the adult’s height during health screenings annually (Osteoporosis Canada, 2014c).

Gait Inspect gait by having the patient walk away for a short distance. Observe for a smooth, rhythmic gait. Unsteadiness or irregular movements (frequently noted in older patients) are not expected. Limping is most frequently caused by painful weight bearing. In such instances, the patient can usually pinpoint the area of discomfort, thus guiding further examination. If one extremity is shorter than another, a limp may be created as the patient’s pelvis drops downward on the affected side with each step. Limited joint motion may affect gait and a knee may be implicated. Evaluate the knee (joints, bones, ligaments, tendons, and cartilage), and consider tests of the anterior and posterior cruciate ligaments, medial and lateral collateral ligaments, and medial and lateral menisci. Know that a variety of neurologic conditions affect gait, such as stroke (spastic hemiparesis gait), lower motor neuron disease (steppage gait), and Parkinson’s disease (shuffling gait) (Anderson & Bickley, 2010).

Bone Integrity Inspect the bony skeleton for deformities and alignment. Compare symmetric parts of the body. Observe for unusual bony growths due to bone tumours (Miles et al., 2010). Note shortened extremities, amputations, and body parts that are not in anatomic alignment. Fracture findings may include unexpected angulation of long bones, movement at points other than joints, crepitus (a grating sound or palpable sensation) at the point of unusual motion, or report of pain when a body part is compressed by the nurse (e.g., foot, rib cage). Minimize movement of fracture fragments to avoid additional injury.

Integument Before focusing further on the musculoskeletal system, inspect the skin, hair, and nails of the upper and lower extremities. Compare sides. Inspect for colour and edema. Palpate for warmer or cooler temperatures, comparing distal to proximal sites as well as sides. It is important to detect increased or decreased tissue perfusion. Cuts, bruises, skin colour, hair loss, decreased circulation, inflammation, and swelling can influence nursing assessment and management of musculoskeletal conditions.

Joint Function Inspect the articular system by noting range of motion, deformity, stability, and nodular formation. Range of motion is evaluated both actively (the joint is moved by the patient using the muscles surrounding the joint) and passively (the relaxed joint is moved by the nurse). Be familiar with the expected range of motion of major joints. (See Chapter 12.) Precise measurement of range of motion can be made using a goniometer (a protractor designed for evaluating the degree of joint motion). Limited range of motion may be the result of skeletal deformity, joint pathology, or contracture (shortening) of the surrounding

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muscles, tendons, and joint capsule. In older patients, limitations of range of motion associated with osteoarthritis may reduce their ability to perform activities of daily living. If joint motion is compromised or the joint is painful, palpate the joint for effusion (excessive fluid within the capsule), swelling, and increased temperature that may reflect active inflammation. An effusion is suspected if the joint is swollen and bony landmarks are obscured. The most common site for joint effusion is the knee. Use the balloon sign and ballottement of the patella (Fig. 67-5) to identify large amounts of fluid in the joint spaces beneath the patella. Consult with a physician or nurse practitioner if inflammation or fluid is suspected in a joint. Joint deformity may be caused by contracture, dislocation (complete separation of joint surfaces), subluxation (partial separation of articular surfaces), or disruption of structures surrounding the joint. Weakness or disruption of joint-supporting structures may result in a weak joint that requires an external supporting appliance (e.g., brace). Palpation of the joint during passive motion provides information about the integrity of the joint. Usually, the joint moves smoothly. A snap or crack may indicate that a ligament is slipping over a bony prominence. Slightly roughened surfaces, as in arthritic conditions, result in crepitus (grating, crackling sounds or sensation) as the irregular joint surfaces move across one another. Inspect and palpate the tissues surrounding joints for nodule formation. Rheumatoid arthritis, gout, and osteoarthritis may produce characteristic nodules. The subcutaneous nodules of rheumatoid arthritis are soft; they occur within and along tendons that provide extensor function to the joints. The nodules of gout are hard, lying within and immediately adjacent to the joint capsule itself. They may rupture, exuding white uric acid crystals onto the skin surface. Osteoarthritic nodules are also hard, but they represent bony overgrowth that has resulted from destruction of the cartilaginous surface of bone within the joint capsule. While actively forming, they may be painful to palpation. Heberden’s nodes are palpated medially and laterally at the distal interphalangeal joints of the hand; Bouchard’s nodes are located at the proximal interphalangeal joints. Both are common in older adults (Roach et al., 2010). Often, the size of the joint is exaggerated by atrophy of the muscles proximal and distal to that joint. This is seen in rheumatoid arthritis of the knees, in which the quadriceps muscle may atrophy dramatically. In rheumatoid arthritis, joint involvement assumes a symmetric pattern (Fig. 67-6). (See Chapter 55 for further information about rheumatoid arthritis.)

Muscle Strength and Size Inspect the size (bulk) of individual muscles, the patient’s ability and method for changing position, and coordination of the upper and lower extremities. Compare sides. Various conditions may cause weakness of a group of muscles, such as polyneuropathy, electrolyte disturbances (particularly potassium and calcium), myasthenia gravis, poliomyelitis, and muscular dystrophy. Palpate for muscle tone (residual tension) by moving the relaxed extremity through passive range of motion. After assessing muscle

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FIGURE 67-5. Tests for detecting fluid in

A

Milk downward

Apply medial pressure

B

FIGURE 67-6. Rheumatoid arthritis joint deformity with ulnar devia-

tion of fingers and “swan neck” deformity of fingers (i.e., hyperextension of proximal interphalangeal joints with flexion of distal interphalangeal joints).

Tap and watch for fluid wave

the knee. A, Technique for balloon sign. Place the index finger and thumb of the dominant hand medially and laterally on each side of the patella of the extended knee. With the nondominant hand, compress the suprapatellar pouch against the femur to displace any fluid downward. Feel for fluid entering the spaces next to the patella under the dominant hand. The balloon sign test is positive when a fluid wave is palpated. (From Stephen, T.C., Skillen, D.L., Day, R.A., & Bickley, L.S. (2010). Canadian Bates’ guide to health assessment for nurses. Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.) B, Technique for the ballottement sign. After compressing the suprapatellar pouch against the femur to displace any fluid downward (see A above), “ballotte” or press the patella firmly against the femur. Observe for fluid returning to the suprapatellar pouch. When larger amounts of fluid are present, the patella elevates, there is visible return of fluid to the region directly superior to the patella, and the ballottement test is positive. (From Weber, J.W., & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.)

tone, evaluate muscle strength by having the patient perform certain manoeuvres with and without your resistance. For example, when testing the biceps, ask the patient to extend the arm fully and then to flex it against your resistance. A simple handshake may provide an indication of grasp strength. Grade muscle strength using a 0 to 5 point scale (0 = no detectable contraction, 5 = complete range of motion against gravity and full resistance) (Anderson et al., 2010). Be alert to muscle clonus (rhythmic contractions of a muscle) in the ankle or wrist associated with sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist. Observe for fasciculation (involuntary twitching of muscle fibre groups). Measure the girth of an extremity to monitor increased size due to exercise, edema, bleeding into the muscle, or decreased size because of atrophy. Measure the unaffected extremity as the reference standard for the affected

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CHART 67-2

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CHART 67-3

Assessing for Peripheral Nerve Function

Indicators of Peripheral Neurovascular Dysfunction Circulation Colour: Pale, cyanotic, or mottled Temperature: Cool Capillary refill: More than 3 seconds

Motion Weakness Paralysis

2181

Assessment of peripheral nerve function has two key elements: evaluation of sensation and evaluation of motion. Perform one or all of the following during a musculoskeletal assessment. Use a splintered tongue blade for the prick. Nerve

Test of Sensation

Test of Movement

Peroneal nerve

Prick the skin midway between the great and second toe.

Ask the patient to dorsiflex the foot and extend the toes.

Tibial nerve

Prick the medial and lateral surface of the sole.

Ask the patient to plantar flex toes and foot.

Radial nerve

Prick the skin midway between the thumb and the second finger.

Ask the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints.

Ulnar nerve

Prick the distal fat pad of the little finger.

Ask the patient to abduct all fingers.

Median nerve

Prick the top or distal surface of the index finger.

Ask the patient to touch the thumb to the little finger. Also observe whether the patient can flex the wrist.

Sensation Paresthesia Unrelenting pain Pain on passive stretch Absence of feeling

extremity. Take measurements at the same (corresponding) location on each extremity, and with the extremity in the same position, with the muscle at rest. Document the distance from a specific anatomic landmark (e.g., 10 cm below the inferior border of the patella for measurement of the calf muscle) in the patient’s health record so that subsequent measurements can be made at the same point. For ease of serial assessment, mark the skin at the point of measurement. Consider variations in size greater than 1 cm to be significant.

Neurovascular Status Assessment of neurovascular status (Chart 67-2) is frequently referred to as assessment of CMS (circulation, motion, and sensation). Perform frequent neurovascular assessments of patients with musculoskeletal disorders (especially those with fractures) because of the risk for tissue and nerve damage. Chart 67-3 describes tests of peripheral nerve function. Be especially alert to compartment syndrome, a complication described in detail later in this unit. This serious neurovascular condition is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia, and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours (Gunta, 2010b).

DIAGNOSTIC EVALUATION Imaging Procedures X-Ray Studies X-ray studies are important for evaluating patients with musculoskeletal disorders. Bone x-rays determine bone density, texture, erosion, and changes in bone relationships. X-ray study of the cortex of the bone reveals any widening, narrowing, or signs of irregularity. Joint x-rays reveal fluid, irregularity, spur formation, narrowing, and

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changes in the joint structure. Multiple x-rays, with multiple views (e.g., anterior–posterior, lateral, oblique), are needed for full assessment of the structure being examined. Serial x-rays may be indicated to determine the status of the healing process. After being positioned for the study, the patient must remain still while the x-rays are obtained.

Computed Tomography A computed tomography (CT) scan, which may be performed with or without the use of contrast agents, shows in detail a specific plane of involved bone and can reveal tumours of soft tissue or injuries to ligaments or tendons. It is used to identify the location and extent of fractures in areas that are difficult to evaluate (e.g., acetabulum). The patient must remain still during the procedure (Fischbach & Dunning, 2009).

Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses magnetic fields, radiowaves, and computers to demonstrate alterations (i.e., tumours or narrowing of tissue pathways through bone) of soft tissues such as muscle, tendon, cartilage, nerve, and fat. Because an electromagnet is used, patients with any metal implants, clips, or pacemakers are not candidates for MRI.

!

NURSING ALERT

Jewellery, hair clips, hearing aids, credit cards with magnetic strips, and other metal-containing objects must be removed before the MRI is performed because they can become dangerous projectile objects or cause burns. Credit cards with magnetic strips may be erased; nonremovable cochlear devices can become inoperable. Transdermal patches (e.g., NicoDerm, TransdermNitro, Transderm Scopolamine, Catapres-TTS) that have a thin layer of aluminized backing must be removed because they also can cause burns. Notify the physician or nurse practitioner before the patches are removed. To enhance visualization of anatomic structures, intravenous (IV) contrast agent may be used. During the MRI, the patient must lie still and will hear a rhythmic knocking sound. Patients who experience claustrophobia may be unable to tolerate the confinement of closed MRI equipment without sedation. Open MRI systems are available, but they use lower intensity magnetic fields, which produce lower quality images. Advantages of open MRI include increased patient comfort, reduction of claustrophobic reactions, and reduced noise.

Arthrography Arthrography is useful for identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or wrist. A radiopaque contrast agent or air is injected into the joint cavity to visualize irregular surfaces. The joint is put through its range of

motion to distribute the contrast agent while a series of x-rays is obtained. If a tear is present, the contrast agent leaks out of the joint and is evident on the x-ray image. A compression elastic bandage is applied after an arthrogram and the joint is usually rested for 12 hours. Provide additional comfort measures (mild analgesia, ice) as appropriate and advise the patient to expect clicking or crackling in the joint for a day or two after the procedure, until the contrast agent or air is absorbed.

Nursing Interventions for Imaging Studies Before the patient undergoes an imaging study, assess for conditions that may require special consideration during the study or that actually may be contraindications to the study (e.g., pregnancy; claustrophobia; inability to tolerate required positioning due to age, debility, or disability; metal implants). If contrast agents will be used for CT scan, MRI, or arthrography, assess the patient for possible allergies (Fischbach & Dunning, 2009).

Bone Densitometry Bone densitometry is used to estimate bone mineral density (BMD). This can be performed using x-rays or ultrasound. The most common modalities include dual-energy x-ray absorptiometry (DXA or DEXA), quantitative computed tomography (QCT), and quantitative ultrasound (QUS). Measures of the hip and spine using DXA BMD are very accurate for estimating the extent of osteoporosis and monitoring a patient’s response to treatment for osteoporosis. Peripheral DXA (pDXA) is an alternative test that measures BMD of the forearm, finger, or heel, but its ability to project hip or spine fracture risk is less accurate than DXA. While the BMD of the heel can be used to diagnose and monitor osteoporosis, predicting hip fracture risk related to osteoporosis is best achieved through DXA of the hip and is the most commonly prescribed diagnostic test for determining BMD (Insight Medical Imaging, 2014). Men and women 65 years and over need to have the BMD test which is accurate, painless, and safe (Osteoporosis Canada, 2014d). (See Chapter 69 for a further discussion of osteoporosis risks.)

Bone Scan A bone scan is performed to detect metastatic and primary bone tumours, osteomyelitis, some fractures (e.g., not visible with traditional x-rays), and aseptic necrosis. Two to three hours after a bone-seeking radioisotope is injected intravenously, the scan is performed. Distribution and concentration of the isotope (radionuclide) in the bone are measured. The degree of nuclide uptake is related to the metabolism of the bone. An increased uptake is observed in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis), and fractures that do not heal as expected.

Nursing Interventions Inquire about possible allergies to the radioisotope before the patient undergoes a bone scan. Assess for any condition

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that would contraindicate performing the procedure (e.g., pregnancy). Before the scan, ask the patient to empty the bladder, because a full bladder interferes with accurate scanning of the pelvic bones. Afterwards, encourage the patient to drink plenty of fluids to help distribute and eliminate the isotope.

Arthroscopy Arthroscopy is a procedure that allows direct visualization of a joint to diagnose joint disorders. Treatment of tears, defects, and disease processes may be performed through the arthroscope. The procedure occurs in the operating room under sterile conditions; a local anesthetic agent is injected into the joint or general anesthesia is used. A large-bore needle is inserted, and the joint is distended with saline. The arthroscope is introduced to visualize joint structures, synovium, and articular surfaces. After the procedure, the puncture wound is closed with sterile adhesive strips or sutures and covered with a sterile dressing. Complications are rare, but may include infection, hemarthrosis, neurovascular compromise, thrombophlebitis, stiffness, effusion, adhesions, and delayed wound healing.

Nursing Interventions At the end of the arthroscopic procedure, the joint is wrapped with a compression dressing to control swelling. Apply ice if prescribed to control edema and enhance comfort. Frequently, the joint is kept extended and elevated to reduce swelling. Monitor and document the neurovascular status. Administer analgesic agents as needed. Instruct the patient about activities and exercises that may be performed. Inform the patient and family about the symptoms (e.g., swelling, numbness, cool skin) of complications and the importance of notifying the physician or nurse practitioner.

Arthrocentesis Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or relief of pain due to effusion. Examination of synovial fluid is helpful in the diagnosis of septic arthritis and other inflammatory arthropathies and reveals the presence of hemarthrosis (bleeding into the joint cavity), which suggests trauma or a bleeding disorder. Usually, synovial fluid is clear, pale, straw coloured, and scanty in volume. Using aseptic technique, the physician inserts a needle into the joint and aspirates fluid. Anti-inflammatory medications may be injected into the joint. A sterile dressing is applied after aspiration to reduce the risk of infection.

Electromyography Electromyography (EMG) provides information about the electrical potential of the muscles and the nerves innervating them. The test is performed to evaluate muscle weakness, pain, and disability. The purpose of the procedure is to determine any alteration of function and differentiate muscle and nerve disorders. Needle electrodes are inserted into selected muscles, and responses to electrical stimuli are recorded on an oscilloscope. Warm compresses may relieve residual discomfort after the study.

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Biopsy To aid with diagnosis, a biopsy may be performed to determine the structure and composition of bone marrow, bone, muscle, or synovium. Teach the patient about the procedure and assure the patient that analgesic agents will be provided. Monitor the biopsy site for edema, bleeding, pain, and infection. Apply ice as prescribed to control bleeding and edema and administer prescribed analgesic agents for comfort.

Laboratory Studies Examination of the patient’s blood and urine can provide information about a primary musculoskeletal problem (e.g., Paget’s disease of the bone [Gunta, 2010b]), a developing complication (e.g., infection), the baseline for instituting therapy (e.g., anticoagulant therapy), or the response to therapy. Before surgery, coagulation studies are performed to detect bleeding tendencies because bone is vascular tissue. Serum calcium levels are altered in patients with osteomalacia, parathyroid dysfunction, Paget’s disease, metastatic bone tumours, or prolonged immobilization (Pagana & Pagana, 2010). Serum phosphorus levels are inversely related to calcium levels and are diminished in osteomalacia associated with malabsorption syndrome. Acid phosphatase is elevated in Paget’s disease and metastatic cancer. Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumours) (HealthLink BC, 2012a; Pagana & Pagana, 2010). Bone metabolism may be evaluated using thyroid studies and determination of calcitonin, PTH, and vitamin D levels. Serum enzyme levels of creatine kinase and aspartate aminotransferase become elevated with muscle damage (Pagana & Pagana, 2010). Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Urine calcium levels increase with bone destruction (e.g., parathyroid dysfunction, metastatic bone tumours, multiple myeloma) (HealthLink BC, 2012b). Specific urine and serum biochemical markers can be used to provide information about bone formation. These include urinary N-telopeptide of type 1 collagen (N-Tx) and deoxypyridinoline (Dpd), both of which reflect increased osteoclast activity and increased bone resorption. Conversely, elevated serum levels of bone-specific alkaline phosphatase (ALP), osteocalcin, and intact N-terminal propeptide of type 1 collagen (P1NP) reflect increased activity of osteoblasts and enhanced bone remodelling activity (Coates, 2013).

Critical Thinking Exercises 1 A 72-year-old Caucasian woman arrives at the emergency department where you are the triage nurse. She reports severe pain in her right groin and some discomfort when she puts weight on or moves her right hip. She states that she did not fall or injure the leg; she was just walking down the steps and felt a “force” on her right leg. You see no obvious deformities. What are the most important medical

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history questions you would ask her? What are the first physical assessments that you would perform? What evidence base indicates that this woman may be at increased risk for osteoporosis-related fractures? What recommendations might be made for testing in this patient? 2 A 15-year-old high school football player comes into the orthopedic clinic after sustaining a “direct blow” to the left knee last night during a game. He reports some swelling, and pain with movement and weight bearing. What is your first physical examination activity? How would you assess the stability of his left knee? What diagnostic tests are most likely indicated? 3 You are a parish nurse teaching a class to senior citizens in your church community about age-related changes in the musculoskeletal system. Participants report many of the changes you identify and ask what they can do about them. What evidence base supports strategies that these older adults might implement to minimize the changes and maximize musculoskeletal health? What is the strength of the evidence related to the effectiveness of these strategies? Outline your teaching strategies for falls prevention and prevention of osteoporosis.

REFERENCES AND SELECTED READINGS BOOKS Anderson, M. C., & Bickley, L. S. (2010). The nervous system. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates guide to health assessment for nurses (1st ed., pp. 683–758). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Carroll, E. W. (2010). Cell and tissue characteristics. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 56–90). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Day, R. A. (2012). Pain assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 91–124). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Fischbach, F. T., & Dunning, M. B. (2009). A manual of laboratory and diagnostic test (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Gunta, K. E. (2010a). Disorders of musculoskeletal function: Developmental and metabolic disorders. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1427–1451). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Gunta, K. E. (2010b). Disorders of musculoskeletal function: Trauma, infection, and neoplasms. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1400–1426). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Jiricka, M. K. (2010). Activity tolerance and fatigue. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 222–241). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2012). Human anatomy (7th ed.). Toronto, ON: Pearson Benjamin Cummings. Matfin, G. (2010). Disorders of endocrine control of growth and metabolism. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 980–1104). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Miles, L., Hannon, R. A., & Rizzo, D. B. (2010). Disorders of musculoskeletal function: Trauma, infection, and neoplasms. In R. A. Hannon,

C. Pooler., & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1452–1475). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pagana, K. D., & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests (4th ed.). St. Louis, MO: Mosby. Pierazzo, J., & Hung, S. W. (2010). Disorders of motor function. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1210–1245). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Porth, C. M. (2010). Structure and function of the musculoskeletal system. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states (1st Canadian ed., pp. 1390–1399). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Roach, S., Roddick, P., & Bickley, L. S. (2010). The musculoskeletal system. In T. C. Stephen, D. L. Skillen, R. A. Day, & L. S. Bickley (Eds.), Canadian Bates guide to health assessment for nurses (1st ed., pp. 601– 681). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012). General survey and vital signs assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, & S. Jensen (Eds.), Canadian Jensen nursing health assessment: A best practice approach (1st ed., pp. 91– 124). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L., & Bickley, L. S. (2010). General survey and vital signs. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates guide to health assessment for nurses (1st ed., pp. 129–146). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012). The health history. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen nursing health assessment: A best practice approach (1st ed., pp. 37–51). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T., Skillen, D. L., & Day, R. A. (2013–2014). A syllabus for adult health assessment. Edmonton, AB: University of Alberta, Faculty of Nursing.

JOURNALS AND ELECTRONIC DOCUMENTS Coates, P. (2013). Bone turnover markers. Retrieved from http://www. racgp.org.au/alp/2013/may/bone-turnover-markers/ Dreyer, P., & Vieira, J. G. (2010). Bone turnover assessment: A good surrogate marker? Retrieved from http://www.ncbi.nlm.nih.gov/pubmet/20485896 HealthLink BC. (2012a). Alkaline phosphatase: Test overview. Retrieved from http://www.healthlinkbc.ca/kb/content/medicaltest/hw1717.html HealthLink BC. (2012b). Calcium (Ca) in urine. Retrieved from http:// www.healthlinkbc.ca/kb/content/medicaltest/hw27965.html Insight Medical Imaging. (2014). Densitometry. Retrieved from http:// www.insightimaging.ca/scr-densitometry.htm Naylor, K., & Eastell, R. (2012). Bone turnover markers: Use in osteoporosis. Retrieved from http://www. Ncbi.nlm.nih.gov/pubmed/22664836 O’Donnell, S., Lagacé, C., McRae, L., et al. (2011). Report summary – Life with arthritis in Canada: a personal and public health challenge. Retrieved from http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/31-3/ ar-08-eng.php Osteoporosis Canada. (2014a). Vitamin D: An important nutrient that protects you against falls and fractures. Retrieved from http://www.osteoporosis.ca/osteoporosis-and-you/nutirtion/vitamin-d/ Osteoporosis Canada. (2014b). Calcium: An important nutrient that builds stronger bones. Retrieved from http://www.osteoporosis.ca/osteoporosis-and-you/nutirtion/calcium-requirements. Osteoporosis Canada. (2014c). Osteoporosis month: Capture the fracture. Retrieved from http://www.osteoporosis.ca/news/osteoporosis-month/ Osteoporosis Canada. (2014d). Testing: About BMD testing. Retrieved from http://www.osteoprosis.ca/osteoprosis-and-you/diagnosis/testing/ Public Health Agency of Canada. (2010a). What is the impact of osteoporosis in Canada and what are Canadians doing to maintain health bones? Retrieved from Public Health Agency of Canada. (2010b). Life with arthritis in Canada: A personal and public health challenge. Retrieved from http://www. phac-aspc.gc.ca/cd-mc/arthritis-arthrite/lwaic-vaaac-10/l-eng.php The Arthritis Society. (2014). Arthritis facts & figures. Retrieved from http://www.arthritis.ca/facts

CHAPTER

68 Musculoskeletal Care Modalities Adapted by Jim Rankin and Karen Then

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify the health teaching needs of the patient with a cast, brace, or splint. 2. Describe the nursing management of the patient with a cast, brace, or splint. 3. Describe the various types of traction and the principles of effective traction. 4. Identify preventative nursing measures to avoid complications with the patient in traction. 5. Describe the nursing management of the patient in traction. 6. Compare the nursing needs of the patient undergoing total hip replacement with those of the patient undergoing total knee replacement. 7. Use the nursing process as a framework for care of the patient undergoing orthopedic surgery.

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The management of musculoskeletal injuries and disorders frequently includes the use of casts, braces, splints, traction, surgery, or a combination of these. Patient education is essential for optimal outcomes. The nurse prepares the patient for immobilization with casts or traction, and for surgery, when indicated. Nursing care is planned to maximize the effectiveness of these treatment modalities and to prevent potential complications associated with each of the interventions. The patient is taught to manage care at home and how to safely resume activities.

THE PATIENT IN A CAST, SPLINT, OR BRACE Casts A cast is a rigid external immobilizing device that is molded to the contours of the body. A cast is used specifically to immobilize a reduced fracture, to correct a deformity, to apply uniform pressure to underlying soft tissue, or to support and stabilize weakened joints; (Maxwell, 2011). Generally, casts permit mobilization of the patient while restricting movement of a body part. The condition being treated influences the type and thickness of the cast applied. Generally, the joints proximal and distal to the area to be immobilized are included in the cast. However, with some fractures, cast construction and molding may allow movement of a joint while immobilizing a fracture (e.g., three-point fixation in a patellar tendon weight-bearing cast). Various types of casts include the following: Short-arm cast: Extends from below the elbow to the palmar crease, secured around the base of the thumb. If the thumb is included, it is known as a thumb spica or gauntlet cast. Long-arm cast: Extends from the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle.

Short-leg cast: Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. Long-leg cast: Extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. Walking cast: A short- or long-leg cast reinforced for strength. Body cast: Encircles the trunk. Shoulder spica cast: A body jacket that encloses the trunk, shoulder, and elbow. Hip spica cast: Encloses the trunk and a lower extremity. A double hip spica cast includes both legs. Figure 68-1 illustrates long-arm and long-leg casts and areas in which pressure problems commonly occur with these casts.

Fibreglass Casts Fibreglass casts are composed of water-activated polyurethane materials that have the versatility of plaster (see later discussion), but are lighter in weight, stronger, and more durable than plaster. In addition, they are water resistant (Maxwell, 2011). They consist of an open-weave, nonabsorbent fabric impregnated with cool water–activated hardeners that bond and reach full rigid strength in minutes. Heat is given off (an exothermic reaction) while the cast is applied. Therefore, a newly applied fibreglass cast should not be placed on a plastic surface. The heat given off during this reaction can be uncomfortable, and the nurse should prepare the patient for the sensation of increasing warmth so that the patient does not become alarmed. While the cast is setting, it can be dented. Therefore, it must be handled with the palms of the hands and not allowed to rest on hard surfaces or sharp edges. Cast dents may press on the skin, causing irritation and skin breakdown. Some fibreglass casts use a waterproof lining (Gore-Tex), which permits the patient to shower, swim, or engage in hydrotherapy (use of water for treatment). When the cast is wet, the patient is instructed to shake or drain water out of

Glossary abduction: movement away from the midline of the body adduction: movement toward the midline of the body avascular necrosis: death of tissue due to insufficient blood supply brace: externally applied device to support the body or a body part, control movement, and prevent injury cast: rigid external immobilizing device molded to contours of body part cast syndrome: psychological (claustrophobic reaction) or physiologic (superior mesenteric artery syndrome) responses to confinement in body cast continuous passive motion (CPM) device: a device that promotes range of motion, circulation, and healing edema: soft tissue swelling due to fluid accumulation external fixator: external metal frame attached to bone fragments to stabilize them fracture: a break in the continuity of the bone

heterotopic ossification: misplaced formation of bone neurovascular status: neurologic (motor and sensory components) and circulatory functioning of a body part open reduction with internal fixation (ORIF): open surgical procedure to repair and stabilize a fracture osteomyelitis: inflammation of bone or bone marrow, usually due to infection osteotomy: surgical cutting of bone sling: bandage used to support an arm splint: device designed specifically to support and immobilize a body part in a desired position traction: application of a pulling force to a part of the body trapeze: overhead assistive device to promote patient mobility in bed

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Peroneal nerve

Radial styloid

Lateral malleolus FIGURE 68-1. Pressure areas in com-

mon types of casts. Left, Long-arm cast. Right, Short-leg cast.

Ulna styloid

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Olecranon

it; thorough drying is important to prevent skin breakdown. The best results are achieved with casts that can easily drain, such as short-arm casts. Heels and elbows encased in wet casts may become macerated from the trapped water and therefore are associated with more skin breakdown.

Plaster Casts Casts made of plaster are less costly and achieve a better mold than fibreglass casts; however, they are not as durable and take longer to dry. Rolls of plaster of Paris–impregnated bandages are wet in cool water and applied smoothly to the body. These will also cause an exothermic reaction, similar to that seen with fibreglass casts. The crystallization process produces a rigid dressing in 15 to 20 minutes. After the plaster sets, the cast remains wet and somewhat soft. It does not have its full strength until it is dry. The plaster cast requires 24 to 72 hours to dry completely, depending on its thickness and the environmental drying conditions. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding. A wet plaster cast appears dull and grey, sounds dull on percussion, feels damp, and smells musty. A dry plaster cast is white and shiny, resonant to percussion, odourless, and firm.

Splints and Braces Many injuries that were previously treated with casts may now be treated with other immobilization devices (e.g., braces, splints) (Gravlee & Van Durme, 2007). Contoured splints of plaster or pliable thermoplastic materials may be used for conditions that do not require rigid immobilization, for those in which swelling may be anticipated, and for those that require special skin care. Splints made of thermoplastics are warmed and molded to fit the patient (e.g., hand splints and thoracolumbosacral orthotics [TLSOs], clamshell-type back braces). The splint needs to immobilize and support the body part in a functional position and it must be well padded to prevent pressure, skin abrasion, and skin breakdown. The splint is

Tibial tuberosity

Lateral epicondyle

overwrapped with an elastic bandage applied in a spiral fashion and with pressure uniformly distributed so that circulation is not restricted. Splints are generally indicated for short-term use (Gravlee & Van Durme, 2007). Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are custom fitted to various parts of the body. The orthotist adjusts the brace for fit, positioning, and motion so that movement is enhanced, any deformities are corrected, and discomfort is minimized. Braces are generally indicated for longer use than splints (Gravlee & Van Durme, 2007). Many splints and braces are prefabricated. They may be made of plastic and other materials such as cloth, leather, metal, elastic and Velcro. Knee immobilizers, ankle stirrups, and cock-up wrist splints are types of prefabricated splints and braces.

General Nursing Management of a Patient in a Cast, Splint, or Brace Before the cast, brace, or splint is applied, the nurse completes an assessment of the patient’s general health, presenting signs and symptoms, emotional status, understanding of the need for the device, and condition of the body part to be immobilized. Physical assessment of the part to be immobilized must include assessment of the neurovascular status (i.e., neurologic and circulatory functioning) of the body part and degree and location of swelling, bruising, and skin abrasions. In addition, the nurse gives the patient information about the underlying pathologic condition and the purpose and expectations of the prescribed treatment regimen. This knowledge promotes the patient’s active participation in and compliance with the treatment program. It is important to prepare the patient for the application of the cast, brace, or splint by describing the anticipated sights, sounds, and sensations (e.g., heat from the hardening reaction of the fibreglass or plaster). The patient needs to know what to expect during application and the reason the body part must be immobilized (Chart 68-1).

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CHART 68-1

GUIDELINES for Applying a Cast Equipment

• Drape for patient • Knitted material (e.g., stockinette)

• Nonwoven roll padding • Casting material

• Water and basin • Cast knife or cutter

Implementation PROCEDURE 1. Support extremity or body part to be casted. 2. Position and maintain part to be casted in position indicated by physician during casting procedure. 3. Drape patient. 4. Wash and dry part to be casted. 5. Place at least three layers of knitted materiala (e.g., stockinette) over part to be casted. • Apply in smooth and nonconstrictive manner. • Allow additional material. 6. Wrap soft, nonwoven roll paddinga smoothly and evenly around part. • Use additional padding around bony prominences to protect superficial nerves (e.g., head of fibula, olecranon process). 7. Apply plaster or fibreglass casting material evenly on body part. • Choose appropriate-width bandage. • Overlap preceding turn by half the width of the bandage. • Use continuous motion, maintaining constant contact with body part. • Use additional casting material (splints) at joints and at points of anticipated cast stress. 8. “Finish” cast. • Smooth edges. • Trim and reshape with cast knife or cutter. 9. Remove particles of casting materials from skin. 10. Support cast during hardening. • Handle hardening casts with palms of hands. • Support cast on firm, smooth surface. • Do not rest cast on hard surfaces or on sharp edges. • Avoid pressure on cast. 11. Promote drying of cast. • Leave cast uncovered and exposed to air. • Turn patient every 2 hours, supporting major joints. • Fans may be used to increase air flow and speed drying.

RATIONALE 1. Minimizes movement; maintains reduction and alignment; increases comfort 2. Facilitates casting; reduces incidence of complications (e.g., malunion, nonunion, contracture) 3. Avoids undue exposure; protects other body parts from contact with casting materials 4. Reduces incidence of skin breakdown 5. Protects skin from casting materials Protects skin from pressure Folds over edges of cast when finishing application; creates smooth, padded edge; protects skin from abrasion 6. Protects skin from pressure of cast Protects skin at bony prominences Protects superficial nerves 7. Creates smooth, solid, well-contoured cast Facilitates smooth application Creates smooth, solid, immobilizing cast Shapes cast properly for adequate support Strengthens cast 8. Protects skin from abrasion Allows full range of motion of adjacent joints 9. Prevents particles from loosening and sliding underneath cast 10. Casting materials begin to harden in minutes. Maximum hardness of nonplaster cast occurs in minutes. Maximum hardness of plaster cast occurs with drying (24 to 72 hours, depending on the environment and thickness of cast). Avoids denting of cast and development of pressure areas 11. Facilitates drying

a

Nonabsorbent materials are used with nonplaster casts.

The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain to help determine its cause. Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesic agents as prescribed.

!

NURSING ALERT

A patient’s unrelieved pain must be immediately reported to the physician to avoid possible paralysis and necrosis.

Pain associated with the underlying condition (e.g., fracture) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of cold packs. Ice bags (one-third to one-half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Pain may be indicative of complications. Pain associated with compartment syndrome (see Chapter 70 and later in this chapter) is relentless and is not controlled by modalities such as elevation, application of cold if prescribed, and usual dosages of analgesic agents. Severe burning pain over

CHAPTER 68

bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. These may also occur from too-tight ace wraps used to hold splints in place. Pain decreases when ulceration occurs. Discomfort due to pressure on the skin may be relieved by elevation that controls edema or by positioning that alters pressure. It may be necessary to modify the dressing, ace wrap, or cast, or to apply a new cast.

!

NURSING ALERT

The nurse must never ignore complaints of pain from the patient in a cast because of the possibility of problems, such as impaired tissue perfusion or pressure ulcer formation. Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function. If the patient has a leg cast, brace, or splint, the nurse encourages toe exercises. If the patient has an arm immobilized, the nurse encourages finger exercises. To promote healing, it is important to treat any skin lacerations and abrasions that may have occurred as a result of the trauma that caused the fracture before the cast, brace, or splint is applied. The nurse thoroughly cleans the skin and treats it as prescribed. The patient may require a tetanus booster if the wound is dirty and if the last known booster was administered more than 5 years ago. Sterile dressings are used to cover the injured skin. If the skin wounds are extensive, an alternative method (e.g., external fixator) may be chosen to immobilize the body part. While the cast is on, the nurse observes the patient for systemic signs of infection; odours from the cast, brace, or splint; and purulent drainage staining the cast. It is important to notify the physician if any of these occur. The nurse monitors circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity and comparing them with those of the opposite extremity. Normal findings include minimal Anterior compartment

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Musculoskeletal Care Modalities

edema, minimal discomfort, pink colour, warm to touch, rapid capillary refill response, normal sensations, and ability to exercise fingers or toes (Konstantakos, Dalstrom, Nelles, et al., 2007; Rasul, 2013). The nurse encourages the patient to move all fingers or toes hourly when awake to stimulate circulation. It is important to perform frequent, regular assessments of neurovascular status. The “five P’s” that require assessment are symptoms of neurovascular compromise: pain, pallor, pulselessness, paresthesia, and paralysis. Early recognition of diminished circulation and nerve function is essential to prevent loss of function. The nurse adjusts the extremity so that it is no higher than heart level to enhance arterial perfusion and control edema and notifies the physician at once if signs of compromised neurovascular status are present.

Monitoring and Managing Potential Complications Potential complications related to casts, braces, and splints include compartment syndrome, pressure ulcer formation, and disuse syndrome. These most commonly occur when a cast is applied, because the cast is not easily removable, and are least commonly associated with use of a splint, because splints tend to be used for the short term.

Compartment Syndrome Edema is a natural response of the tissue to trauma. The patient may complain that the cast, brace, or splint is too tight. Vascular insufficiency and nerve compression due to unrelieved swelling can result in compartment syndrome (Fig. 68-2). Compartment syndrome occurs when there is increased tissue pressure within a limited space (e.g., cast, muscle compartment) that compromises the circulation and the function of the tissue within the confined area. To relieve the pressure, the cast must be bivalved (cut in half longitudinally) while maintaining alignment, and the extremity must be elevated no higher than heart level to ensure arterial perfusion (Chart 68-2). If pressure is not

Tibial bone Deep posterior compartment

Lateral compartment

Fibular bone

Superficial posterior compartment

A

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Nerves and blood vessels

B

FIGURE 68-2. A, Cross-section of normal lower leg with muscle compartments. B, Cross-section of lower

leg with compartment syndrome. Swelling of muscles causes compression of nerves and blood vessels.

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CHART 68-2

CHART 68-3

Procedure for Bivalving a Cast The following procedure is followed when a cast is bivalved. 1. With a cast cutter, a longitudinal cut is made to divide the cast in half. 2. The underpadding is cut with scissors. 3. The cast is spread apart with cast spreaders to relieve pressure and to inspect and treat the skin without interrupting the reduction and alignment of the bone. 4. After the pressure is relieved, the anterior and posterior parts of the cast are secured together with an elastic compression bandage to maintain immobilization. 5. To control swelling and promote circulation, the extremity is elevated (but no higher than heart level, to minimize the effect of gravity on perfusion of the tissues).

relieved and circulation is not restored, a fasciotomy may be necessary to relieve the pressure within the muscle compartment. The nurse closely monitors the patient’s response to conservative and surgical management of compartment syndrome (Konstantakos et al., 2007). The nurse records neurovascular responses and promptly reports changes to the physician. (See Chapter 70 for further discussion of compartment syndrome.)

Pressure Ulcers Pressure of a cast or an inappropriately applied brace on soft tissues may cause tissue anoxia and pressure ulcers. Lower extremity sites most susceptible to pressure ulcers are the heel, malleoli, dorsum of the foot, head of the fibula, and anterior surface of the patella. The main pressure sites on the upper extremity are located at the medial epicondyle of the humerus and the ulnar styloid (Fig. 68-1). Usually, the patient with a pressure ulcer reports pain and tightness in the area. A warm area on the cast or brace suggests underlying tissue erythema. Skin breakdown may occur. The drainage may stain the cast or brace and emit an odour. Even if discomfort does not occur with skin breakdown and tissue necrosis, there may still be extensive loss of tissue. The nurse must monitor the patient with a cast or brace for pressure ulcer development and report findings to the physician. To inspect the pressure ulcer area, the brace may be removed. For a patient with a cast, the physician may bivalve or cut an opening (window) in the cast. If the physician elects to create a window to inspect the pressure site, a portion of the cast is cut out. The affected area is inspected and possibly treated. The portion of the cast is replaced and held in place by an elastic compression dressing or tape. This prevents window edema, which is the swelling of soft tissue through the area unopposed by casting material (National Association of Orthopedic Nurses [NAON], 2013).

Disuse Syndrome Immobilization in a cast, brace, or splint can cause muscle atrophy and loss of strength, known as disuse syndrome. To prevent this, the patient needs to learn to tense or contract muscles (e.g., isometric muscle contraction)

Muscle-Setting Exercises Isometric contractions of the muscle maintain muscle mass and strength and prevent atrophy.

Quadriceps-Setting Exercise • Position patient supine with leg extended. • Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles.

• Encourage patient to hold the position for 5 to 10 seconds. • Let patient relax. • Have patient repeat the exercise 10 times each hour when awake.

Gluteal-Setting Exercise • Position patient supine with legs extended, if possible. • Instruct patient to contract the muscles of the buttocks. • Encourage patient to hold the contraction for 5 to 10 seconds.

• Let the patient relax. • Have patient repeat the exercise 10 times each hour when awake.

without moving the part. The nurse teaches the patient with a leg cast, brace, or splint to “push down” the knee and teaches the patient in an arm cast, brace, or splint to “make a fist.” Muscle-setting exercises (e.g., quadricepssetting and gluteal-setting exercises) are important in maintaining muscles essential for walking (Chart 68-3). Isometric exercises should be performed hourly while the patient is awake.

Promoting Home and Community-Based Care Teaching the Patient Self-Care Self-care deficits occur when a portion of the body is immobilized. The nurse encourages the patient to participate actively in personal care and to use assistive devices safely. The nurse must assist the patient in identifying areas of self-care deficit and in developing strategies to achieve independence in activities of daily living (ADLs) (Chart 68-4). The patient’s participation in planning and accomplishing ADLs is an important aspect of self-care, independence, maintaining control, and avoiding untoward psychological reactions, such as depression. Patient and caregiver education is also described in Chart 68-4.

Continuing Care For the patient with a cast that is ready for removal, the nurse should prepare the patient by explaining what to expect. The cast is cut with a cast cutter, which vibrates. The patient can feel the vibration and pressure during its use. The cutter does not penetrate deeply enough to injure the patient’s skin. The cast padding is cut with scissors. After removal of a splint, and especially after removal of a brace or cast, both of which are typically applied for longer periods of time, the formerly immobilized body

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CHART 68-4

HOME CARE CHECKLIST •

The Patient With a Cast, Splint, or Brace Patient

Caregiver

• Describe techniques to promote cast drying (e.g., do not cover, leave exposed to circulating air,

✔

✔

• Describe approaches to controlling swelling and pain (e.g., elevate immobilized extremity to

✔

✔

• Report pain uncontrolled by elevating the immobilized limb and by analgesic agents (may be an

✔

• Demonstrate ability to transfer (e.g., from a bed to a chair).

✔

• Use mobility aids safely.

✔

• Avoid excessive use of injured extremity; observe prescribed weight-bearing limits.

✔

• Manage minor skin irritations (e.g., for skin irritation from edge of cast, splint, or brace; pad

✔

• Demonstrate exercises to promote circulation and minimize disuse syndrome.

✔

• State indicators of complications to report promptly to physician (e.g., uncontrolled swelling

✔

✔

• Describe care of extremity following cast, splint, or brace removal (e.g., skin care; gradual

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to: handle damp plaster cast with palms of hands and do not rest the cast on hard surfaces or sharp edges that can dent soft cast). heart level, apply intermittent ice bag if prescribed, take analgesic agents as prescribed). indicator of impaired tissue perfusion—compartment syndrome or pressure ulcer).

✔

rough edges with tape; to relieve itching, blow cool air from hair dryer; do not insert objects inside the cast, splint, or brace).

and pain; cool, pale fingers or toes; paresthesia; paralysis; purulent drainage staining cast; signs of systemic infection; cast, splint, or brace breaks). resumption of normal activities to protect limb from undue stresses; management of swelling).

part is weak from disuse, is stiff, and may appear atrophied. There may be extreme stiffness even after only a few weeks of immobilization. Therefore, support is needed when the cast, brace, or splint is removed. The skin, which is usually dry and scaly from accumulated dead skin, is vulnerable to injury from scratching. The skin needs to be washed gently and lubricated with an emollient lotion. The nurse and physical therapist teach the patient to resume activities gradually within the prescribed therapeutic regimen. Exercises prescribed to help the patient regain joint motion are explained and demonstrated. Because the muscles are weak from disuse, the body part that has been immobilized cannot withstand normal stresses immediately. In addition, the nurse teaches the patient with noticeable swelling of the affected extremity after removal of the immobilizing device (e.g., cast, brace, or splint) to continue to elevate the extremity to control swelling until normal muscle tone and use are re-established.

Nursing Management of the Patient With an Immobilized Upper Extremity The patient whose arm is immobilized must readjust to many routine tasks. The unaffected arm must assume all the upper extremity activities. The nurse, in consultation with an occupational therapist, suggests devices designed to aid one-handed activities. The patient may experience

fatigue due to modified activities and the weight of the cast, brace, or splint. Frequent rest periods are necessary. To control swelling, the immobilized arm is elevated. When the patient is lying down, the arm is elevated so that each joint is positioned higher than the preceding proximal joint (e.g., elbow higher than the shoulder, hand higher than the elbow). A sling may be used when the patient ambulates. To prevent pressure on the cervical spinal nerves, the sling should distribute the supported weight over a large area and not on the back of the neck. The nurse encourages the patient to remove the arm from the sling and elevate it frequently. Circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling, and an inability to move the fingers. One serious effect of impaired circulation in the arm is Volkmann’s contracture, a specific type of compartment syndrome. Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand. The patient is unable to extend the fingers, describes abnormal sensation (e.g., unrelenting pain, pain on passive stretch), and exhibits signs of diminished circulation to the hand. Permanent damage develops within a few hours if action is not taken (see Chapter 70). This serious complication can be prevented with nursing surveillance and proper care. Neurovascular checks must be done frequently (see Chapter 67). If a cast is used for immobility, compartment syndrome is managed in part by bivalving (cutting) the cast and releasing the constricting cast and dressings. A fasciotomy may be necessary to improve vascular status.

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Nursing Management of the Patient With an Immobilized Lower Extremity The application of a leg cast, brace, or splint imposes a degree of immobility on the patient. Casts may include short-leg casts, extending to the knees, or long-leg casts, extending to the groin. Hinged knee braces and immobilizers typically extend from ankle to groin. The patient’s leg must be supported on pillows to heart level to control swelling, and ice packs should be applied as prescribed over the fracture site for 1 or 2 days. The patient is taught to elevate the immobilized leg when seated. The patient should also assume a recumbent position several times a day with the immobilized leg elevated to promote venous return and control swelling. The nurse assesses circulation by observing the colour, temperature, and capillary refill of the exposed toes. Nerve function is assessed by observing the patient’s ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may be caused by peroneal nerve injury from pressure at the head of the fibula.

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NURSING ALERT

Injury to the peroneal nerve as a result of pressure is a cause of footdrop (the inability to maintain the foot in a normally flexed position). Consequently, the patient drags the foot when ambulating.

The nurse and physical therapist teach the patient how to transfer and ambulate safely with assistive devices (e.g., crutches, walker) (see Chapter 12). The gait to be used depends on whether the patient is permitted to bear weight. If weight bearing is allowed, the cast, splint, or brace is reinforced to withstand the body weight. A cast boot, worn over the casted foot, provides a broad, nonskid walking surface.

Nursing Management of the Patient With a Body or Spica Cast Casts that encase the trunk (body cast) and portions of one or two extremities (spica cast) require special nursing strategies. Body casts are used to immobilize the spine. Hip spica casts are used for some femoral fractures and after some hip joint surgeries, and shoulder spica casts are used for some humeral neck fractures. Nursing responsibilities include preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome, (see discussion on next page) (NAON, 2013). Explaining the casting procedure helps reduce the patient’s apprehension about being encased in a large cast. The nurse reassures the patient that several

people will provide care during the application, support for the injured area will be adequate, and care providers will be as gentle as possible. Medications for pain relief and relaxation administered before the procedure enable the patient to cooperate during application of the cast. The nurse turns the patient as a unit toward the uninjured side every 2 hours to relieve pressure and to allow the cast to dry. It is important to avoid twisting the patient’s body within the cast. Sufficient personnel (at least three people) or mechanical assistive devices are needed when the patient is turned because of the added weight of the cast. The nurse encourages the patient to assist in the repositioning, if not contraindicated, by use of the trapeze or bed rail. A stabilizing abduction bar incorporated into a spica cast should never be used as a turning device. The nurse adjusts the pillows to provide support without creating areas of pressure. The nurse turns the patient to a prone position, twice daily if tolerated, to provide postural drainage of the bronchial tree and to relieve pressure on the back. A small pillow under the abdomen enhances comfort. The nurse can either place a pillow lengthwise under the dorsa of the feet or allow the toes to hang over the edge of the bed to prevent the toes from being forced into the mattress. The nurse inspects the skin around the edges of the cast frequently for signs of irritation. The nurse can inspect some of the skin under the cast by pulling the skin taut and using a flashlight. The skin can be bathed and massaged by reaching under the cast edges with the fingers. The perineal opening must be large enough for hygienic care. To protect the cast from soiling, Gore-Tex liners are used prior to hip spica casting. If the cast is not Gore-Tex lined, the nurse can insert clean dry plastic sheeting under the dry cast and over the cast edge before elimination by the patient. Usually, fracture bedpans are easier to use than regular bedpans for patients with a hip spica cast. Patients immobilized in large casts may develop cast syndrome that may include psychological or physiologic manifestations. The psychological component is similar to a claustrophobic reaction. The patient exhibits an acute anxiety reaction characterized by behavioural changes and autonomic responses (e.g., increased respiratory rate, diaphoresis, dilated pupils, increased heart rate, elevated blood pressure). The nurse needs to recognize the anxiety reaction and provide an environment in which the patient feels secure. Physiologic cast syndrome responses (e.g., superior mesenteric artery syndrome) are associated with immobility in a body cast. With decreased physical activity, gastrointestinal motility decreases, intestinal gases accumulate, intestinal pressure increases, and ileus may occur. The patient exhibits abdominal distention, abdominal discomfort, nausea, and vomiting. As with other instances of adynamic ileus, the patient is treated conservatively with decompression (nasogastric intubation connected to suction) and intravenous (IV) fluid therapy until gastrointestinal motility is restored (Merrett, Wilson, Cosman, et al., 2009). If the cast restricts the abdomen, the abdominal window must be enlarged. After the ileus resolves and bowel sounds resume, the patient gradually resumes an oral diet. Rarely, the distention places traction on the superior mesenteric artery, reducing the blood supply to the bowel, which can result in gangrenous bowel. The

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descending aorta may also sustain pressure as it may be compressed between the spine and the pressure of abdominal distention, which results in ischemia. If the descending aorta becomes ischemic, its rupture could cause exsanguination and death.

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NURSING ALERT

The nurse monitors the patient in a large body cast for potential cast syndrome, noting bowel sounds every 4 to 8 hours, and reports distention, nausea, and vomiting to the physician.

The patient with a body or spica cast is often cared for at home. The nurse teaches family members how to care for the patient, which includes providing hygienic and skin care, ensuring proper positioning, preventing complications, and recognizing symptoms that should be reported to the health care provider.

THE PATIENT WITH AN EXTERNAL FIXATOR External fixators are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damaged soft tissues (Fig. 68-3). Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are managed with external skeletal fixators. The fracture is reduced, aligned, and immobilized by a series of pins inserted in the bone. Pin position is maintained through attachment to a portable frame. The fixator facilitates patient comfort, early mobility, and active exercise of adjacent uninvolved joints; thus, complications due to disuse and immobility are minimized (Holmes & Brown, 2005).

Nursing Management It is important to prepare the patient psychologically for application of the external fixator. The apparatus looks clumsy and foreign. Reassurance that the discomfort associated with the device is minimal and that early mobility is anticipated promotes acceptance of the device. After the external fixator is applied, the extremity is elevated to reduce swelling. If there are sharp points on the fixator or pins, they are covered with caps to prevent device-induced injuries. The nurse monitors the neurovascular status of the extremity every 2 to 4 hours and assesses each pin site for redness, drainage, tenderness, pain, and loosening of the pin. Some serous drainage from the pin sites is to be expected. The nurse must be alert for potential problems caused by pressure from the device on the skin, nerves, or blood vessels and for the development of compartment syndrome (see Chapter 70). The nurse carries out pin care as prescribed to prevent pin tract infection. This typically includes cleaning each pin site separately with cotton-tipped applicators soaked in nor-

FIGURE 68-3. External fixation device. Pins are inserted into bone. The

fracture is reduced and aligned and then stabilized by attaching the pins to a rigid portable frame. The device facilitates treatment of soft tissue damaged in complex fractures.

mal saline. Chlorhexidine glugonate in alcohol is not advised as a significant number of patients may be allergic or sensitive to the solution. (Royal College of Nursing, 2011). If signs of infection are present or if the pins or clamps seem loose, the nurse notifies the physician.

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NURSING ALERT

The nurse never adjusts the clamps on the external fixator frame. It is the physician’s responsibility to do so.

The nurse encourages isometric and active exercises as tolerated. When the swelling subsides, the nurse helps the patient become mobile within the prescribed weightbearing limits (non–weight bearing to full weight bearing). Adherence to weight-bearing instructions minimizes the chance of loosening of the pins when stress is applied to the bone–pin interface. The fixator is removed after the

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CHART 68-5

HOME CARE CHECKLIST •

The Patient With an External Fixator Patient

Caregiver

• Demonstrate prescribed pin site care.

✔

✔

• State signs of pin site infection (e.g., redness, tenderness, increased or purulent pin site

✔

✔

• Describe approaches to controlling swelling and pain (e.g., elevate extremity to heart level,

✔

✔

• Report pain uncontrolled by elevation and analgesic agents (may be an indicator of impaired

✔

• Demonstrate ability to transfer.

✔

• Use mobility aids safely.

✔

• Avoid excessive use of injured extremity; observe prescribed weight-bearing limits.

✔

• State indicators of complications to report promptly to physician (e.g., uncontrolled swelling

✔

✔

• Describe care of extremity after fixator removal (e.g., gradual resumption of normal activities

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

drainage) to be reported promptly.

take analgesic agents as prescribed).

tissue perfusion, compartment syndrome, or pin tract infection).

and pain; cool, pale fingers or toes; paresthesia; paralysis; purulent drainage; signs of systemic infection; loose fixator pins or clamps). to protect limb from undue stresses).

soft tissue heals. The fracture may require additional stabilization by a cast or molded orthosis while healing. The Ilizarov external fixator is a special device used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal), and to lengthen limbs (Spiegelberg, Parratt, Dheerendra, et al., 2010). Tension wires are attached to fixator rings, which are joined by telescoping rods. Bone formation is stimulated by prescribed daily adjustment of the telescoping rods. It is important to teach the patient how to adjust the telescoping rods and how to perform skin care. Generally, the nurse can encourage weight bearing. After the desired correction has been achieved, no additional adjustments are made, and the fixator is left in place until the bone heals. The nurse teaches the patient to perform pin site care according to the prescribed protocol (clean technique can be used at home [Holmes & Brown, 2005]) and to report promptly any signs of pin site infection: redness, tenderness, increased or purulent pin site drainage, or fever. The nurse also instructs the patient and family to monitor neurovascular status and report any changes promptly. The nurse teaches the patient or family member to check the integrity of the fixator frame daily and to report loose pins or clamps. A physical therapy referral is helpful in teaching the patient how to transfer, use ambulatory aids safely, and adjust to weight-bearing limits and altered gait patterns (Chart 68-5).

mity; and to increase space between opposing surfaces. Traction must be applied in the correct direction and magnitude to obtain its therapeutic effects. As muscle and soft tissues relax, the amount of weight used may be changed to obtain the desired effect (NAON, 2013). At times, traction needs to be applied in more than one direction to achieve the desired line of pull. When this is done, one of the lines of pull counteracts the other. These lines of pull are known as the vectors of force. The actual resultant pulling force is somewhere between the two lines of pull (Fig. 68-4). The effects of traction are evaluated with x-ray studies, and adjustments are made if necessary.

Vector of force

Resultant line of pull Vector of force

THE PATIENT IN TRACTION Traction is the application of a pulling force to a part of the body. Traction is used to minimize muscle spasms; to reduce, align, and immobilize fractures; to reduce defor-

FIGURE 68-4. Traction may be applied in different directions to achieve the desired therapeutic line of pull. Adjustments in applied forces may be prescribed over the course of treatment.

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• Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated. • The patient must be in good body alignment in the centre of the bed when traction is applied. • Ropes must be unobstructed. • Weights must hang freely and not rest on the bed or floor. • Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

Types of Traction

Traction is used primarily as a short-term intervention until other modalities, such as external or internal fixation, are possible. These modalities reduce the risk of disuse syndrome and minimize the length of hospitalization, often allowing the patient to be cared for in the home setting (NAON, 2013).

There are several types of traction. Straight or running traction applies the pulling force in a straight line with the body part resting on the bed. Buck’s extension traction (Fig. 68-5) is an example of straight traction. Balanced suspension traction (Fig. 68-6) supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull. Traction may be applied to the skin (skin traction) or directly to the bony skeleton (skeletal traction). The mode of application is determined by the purpose of the traction. Traction can be applied with the hands (manual traction). This is temporary traction that may be used when applying a cast, giving skin care under a Buck’s extension foam boot, or adjusting the traction apparatus.

Principles of Effective Traction

Skin Traction

FIGURE 68-5. Buck’s extension traction. Lower extremity in unilateral Buck’s extension traction is aligned in a foam boot and traction applied by the free-hanging weight.

Whenever traction is applied, countertraction must be used to achieve effective traction. Countertraction is the force acting in the opposite direction. Usually, the patient’s body weight and bed position adjustments supply the needed countertraction. The following are additional principles to follow when caring for the patient in traction: • Traction must be continuous to be effective in reducing and immobilizing fractures. • Skeletal traction is never interrupted. • Weights are not removed unless intermittent traction is prescribed.

FIGURE 68-6. Balanced suspension skeletal traction with Thomas leg splint. The patient can move vertically as long as the resultant line of pull is maintained.

Skin traction is used to control muscle spasms and to immobilize an area before surgery. Skin traction is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin. The amount of weight applied must not exceed the tolerance of the skin. No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity. Pelvic traction is usually 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient. Types of skin traction used for adults include Buck’s extension traction (applied to the lower leg) (described below), the cervical head halter (occasionally used to treat neck pain), and the pelvic belt (sometimes used to treat back pain).

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Buck’s Extension Traction Buck’s extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired (Fig. 68-5). It is used to immobilize fractures of the proximal femur before surgical fixation. Before the traction is applied, the nurse inspects the skin for abrasions and circulatory disturbances. The skin and circulation must be in healthy condition to tolerate the traction. The extremity should be clean and dry before the foam boot or traction tape is applied. To apply Buck’s traction, one nurse elevates and supports the extremity under the patient’s heel and knee while another nurse places the foam boot under the leg, with the patient’s heel in the heel of the boot. Next, the nurse secures Velcro straps around the leg. Traction tape overwrapped with elastic bandage in a spiral fashion may be used instead of the boot. Excessive pressure is avoided over the malleolus and proximal fibula during application to prevent pressure ulcers and nerve damage. The nurse then passes the rope affixed to the spreader or footplate over a pulley fastened to the end of the bed and attaches the prescribed weight—usually 5 to 8 pounds—to the rope.

Nursing Interventions ENSURING EFFECTIVE TRACTION. To ensure effective skin traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. Proper positioning must be maintained to keep the leg in a neutral position. To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Skin Breakdown. During the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults). The nurse also closely monitors the status of the skin in contact with tape or foam to ensure that shearing forces are avoided. The nurse performs the following procedures to monitor and prevent skin breakdown: • Removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care. • Palpates the area of the traction tapes daily to detect underlying tenderness. • Provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a supine position is at increased risk for development of a pressure ulcer. • Uses special mattress overlays (e.g., air-filled, highdensity foam) to prevent pressure ulcers. Nerve Damage. Skin traction can place pressure on peripheral nerves. When traction is applied to the lower extremity, care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee. Pressure at this point can cause footdrop. The nurse regularly questions the patient about sen-

sation and asks the patient to move the toes and foot. The nurse should immediately investigate any complaint of a burning sensation under the traction bandage or boot. Dorsiflexion of the foot demonstrates function of the peroneal nerve. Weakness of dorsiflexion or foot movement and inversion of the foot might indicate pressure on the common peroneal nerve. Plantar flexion demonstrates function of the tibial nerve. In addition, the nurse should promptly report altered sensation or impaired motor function. Circulatory Impairment. After skin traction is applied, the nurse assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. Circulatory assessment consists of the following: • Peripheral pulses, colour, capillary refill, and temperature of the fingers or toes • Indicators of deep vein thrombosis (DVT), including unilateral calf tenderness, warmth, redness, and swelling The nurse also encourages the patient to perform active foot exercises every hour when awake.

Skeletal Traction Skeletal traction is applied directly to the bone. This method of traction is used occasionally to treat fractures of the femur, the tibia, and the cervical spine. The traction is applied directly to the bone by use of a metal pin or wire (e.g., Steinmann pin, Kirschner wire) that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints. Tongs applied to the head (e.g., Gardner-Wells or Vinke tongs) are fixed to the skull to apply traction that immobilizes cervical fractures. The orthopedic surgeon applies skeletal traction, using surgical asepsis. The insertion site is prepared with a surgical scrub agent such as povidone–iodine solution. A local anesthetic agent is administered at the insertion site and periosteum. The surgeon makes a small skin incision and drills the sterile pin or wire through the bone. The patient feels pressure during this procedure and possibly some pain when the periosteum is penetrated. After insertion, the pin or wire is attached to the traction bow or caliper. The ends of the pin or wire are covered with caps to prevent injury to the patient or caregivers. The weights are attached to the pin or wire bow by a rope-and-pulley system that exerts the appropriate amount and direction of pull for effective traction. Skeletal traction frequently uses 7 to 12 kg to achieve the therapeutic effect. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. The Thomas splint with a Pearson attachment which was often used for skeletal tractions for fractures of the femur is no longer used in Canada but can still be seen in developing countries (Fig. 68-6). When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin

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is cut close to the skin and removed by the physician. Internal fixation, casts, or splints are then used to immobilize and support the healing bone.

Nursing Interventions MAINTAINING EFFECTIVE TRACTION. When skeletal traction is used, the nurse checks the traction apparatus to see that the ropes are in the wheel grooves of the pulleys, that the ropes are not frayed, that the weights hang freely, and that the knots in the rope are tied securely. The nurse also evaluates the patient’s position, because slipping down in bed results in ineffective traction.

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NURSING ALERT

The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient. MAINTAINING POSITIONING. The nurse must maintain alignment of the patient’s body in traction as prescribed to promote an effective line of pull. The nurse positions the patient’s foot to avoid footdrop (plantar flexion), inward rotation (inversion), and outward rotation (eversion). The patient’s foot may be supported in a neutral position by orthopedic devices (e.g., foot supports). PREVENTING SKIN BREAKDOWN. The patient’s elbows frequently become sore, and nerve injury may occur if the patient repositions by pushing on the elbows. In addition, patients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. Therefore, the nurse should protect the elbows and heels and inspect them for pressure ulcers. To encourage movement without using the elbows or heel, a trapeze can be suspended overhead within easy reach of the patient. The trapeze helps the patient move about in bed and move on and off the bedpan. Specific pressure points are assessed for redness and skin breakdown. Areas that are particularly vulnerable to pressure caused by a traction apparatus applied to the lower extremity include the ischial tuberosity, popliteal space, Achilles tendon, and heel. If the patient is not permitted to turn on one side or the other, the nurse must make a special effort to provide back care and to keep the bed dry and free of crumbs and wrinkles. The patient can assist by holding the overhead trapeze and raising the hips off the bed. If the patient cannot do this, the nurse can push down on the mattress with one hand to relieve pressure on the back and bony prominences and to provide for some shifting of weight. A pressure-relieving air-filled or high-density foam mattress overlay may reduce the risk of pressure ulcer. For change of bed linens, the patient raises the torso while nurses on both sides of the bed roll down and replace the upper mattress sheet. Then, as the patient raises the buttocks off the mattress, the nurses slide the sheets under the buttocks. Finally, the nurses replace the lower section of the bed linens while the patient rests on the back. Sheets and blankets are placed over the patient in such a way that the traction is not disrupted.

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MONITORING NEUROVASCULAR STATUS. The nurse assesses the neurovascular status of the immobilized extremity at least every hour initially and then every 4 hours. The nurse instructs the patient to report any changes in sensation or movement immediately so that they can be promptly evaluated. DVT is a significant risk for the immobilized patient. The nurse encourages the patient to do active flexion–extension ankle exercises and isometric contraction of the calf muscles (calf-pumping exercises) 10 times an hour while awake to decrease venous stasis. In addition, antiembolism stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent thrombus formation.

!

NURSING ALERT

The nurse must promptly investigate every report of discomfort expressed by the patient in traction. Prompt recognition of a developing neurovascular problem is essential so that corrective measures can be instituted promptly.

Providing Pin Site Care. The wound at the pin insertion site requires attention. The goal is to avoid infection and development of osteomyelitis. For the first 48 hours after insertion, the site is covered with a sterile absorbent nonstick dressing and a rolled gauze or Ace-type bandage. After this time, a loose cover dressing or no dressing is recommended. (A bandage is necessary if the patient is exposed to airborne dust.) Pin site care is performed initially one or two times a day. The frequency of pin care needs to be increased if mechanical looseness of pins or early signs of infection are present (e.g., edema, purulent drainage, erythema, tenderness). Normal saline is recommended as the most effective cleansing solution; (Royal College of Nursing, 2011). Although chlorhexidine, hydrogen peroxide and Betadine solutions have been used, they are cytotoxic to osteoblasts and actually damage healthy tissue (Lethaby, Temple, & Santy, 2008; Royal College of Nursing, 2011). The nurse must inspect the pin sites every 8 hours for reaction (i.e., normal changes that occur at the pin site after insertion) and infection. Signs of reaction may include redness, warmth, and serous or slightly sanguinous drainage at the site. These signs subside after 72 hours. Signs of infection may mirror those of reaction but also include the presence of purulent drainage, pin loosening, and odour. Minor infections may be readily treated with antibiotics, whereas infections that result in systemic manifestations may additionally warrant pin removal until the infection resolves (Holmes & Brown, 2005). When pins are mechanically stable (after 48 to 72 hours), weekly pin site care is recommended.

!

NURSING ALERT

The nurse must inspect the pin site at least every 8 hours for signs of inflammation and evidence of infection.

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Due to a lack of evidence-based research findings, controversy remains about management of crusts that may form at the pin insertion site, frequency of pin care and showering, and use of massage to release skin adherence to pins (Holmes & Brown, 2005). The patient should be taught to perform any prescribed pin site care prior to discharge from the hospital and should be provided with written follow-up instructions that include the signs and symptoms of infection. Patients permitted to take showers within 5 to 10 days of pin insertion are encouraged to leave the pins exposed to water flow. The sites are dried with a clean towel and left open to air, or dressings are applied as prescribed. Promoting Exercise. Patient exercises, within the therapeutic limits of the traction, assist in maintaining muscle strength and tone and in promoting circulation. Active exercises include pulling up on the trapeze, flexing and extending the feet, and range-of-motion and weightresistance exercises for noninvolved joints. Isometric exercises of the immobilized extremity (quadriceps-setting and gluteal-setting exercises) are important for maintaining strength in major ambulatory muscles (see Chart 68-3). Without exercise, the patient will lose muscle mass and strength, and rehabilitation will be greatly prolonged.

Nursing Management Assessing Anxiety The nurse must consider the psychological and physiologic impact of the musculoskeletal problem, traction device, and immobility. Traction restricts mobility and independence. The equipment often looks threatening, and its application can be frightening. Confusion, disorientation, and behavioural problems may develop in patients who are confined in a limited space for an extended time. Therefore, the nurse must assess and monitor the patient’s anxiety level and psychological responses to traction.

Assisting With Self-Care Initially, the patient may require assistance with self-care activities. The nurse helps the patient eat, bathe, dress, and toilet. Convenient arrangement of items such as the telephone, tissues, water, and assistive devices (e.g., reachers, overbed trapeze) may facilitate self-care. With resumption of self-care activities, the patient feels less dependent and less frustrated and experiences improved self-esteem. Because some assistance is required throughout the period of immobility, the nurse and the patient can creatively develop routines that maximize the patient’s independence. It is important to evaluate the body part to be placed in traction and its neurovascular status (i.e., colour, temperature, capillary refill, edema, pulses, ability to move, and sensations) and compare it to the unaffected extremity. The nurse also assesses skin integrity along with body system functioning for baseline data. Ongoing assessment is indicated for the patient in traction.

Monitoring and Managing Potential Complications Immobility-related complications may include pressure ulcers, atelectasis, pneumonia, constipation, loss of appe-

tite, urinary stasis, urinary tract infections, and venous thromboemboli formation. Early identification of preexisting or developing conditions facilitates prompt interventions to resolve them. ATELECTASIS AND PNEUMONIA. The nurse auscultates the patient’s lungs every 4 to 8 hours to assess respiratory status and teaches the patient deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. If the patient history and baseline assessment indicate that the patient is at risk for development of respiratory complications, specific therapies (e.g., use of incentive spirometer) may be indicated. If a respiratory complication develops, prompt institution of prescribed therapy is needed. CONSTIPATION AND ANOREXIA. Reduced gastrointestinal motility results in constipation and anorexia. A diet high in fibre and fluids may help stimulate gastric motility. If constipation develops, therapeutic measures may include stool softeners, laxatives, suppositories, and enemas. To improve the patient’s appetite, the patient’s food preferences are included, as appropriate, within the prescribed therapeutic diet. URINARY STASIS AND INFECTION. Incomplete emptying of the bladder related to positioning in bed can result in urinary stasis and infection. In addition, the patient may find use of the bedpan uncomfortable and may limit fluids to minimize the frequency of urination. The nurse monitors the fluid intake and the character of the urine. The nurse teaches the patient to consume adequate amounts of fluid and to void every 3 to 4 hours. If the patient exhibits signs or symptoms of urinary tract infection, the nurse notifies the physician. VENOUS THROMBOEMBOLISM. Venous stasis that predisposes the patient to venous thromboembolism occurs with immobility. The nurse teaches the patient to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. The patient is encouraged to drink fluids to prevent dehydration and associated hemoconcentration, which contribute to stasis. The nurse monitors the patient for signs of DVT, including unilateral calf tenderness, warmth, redness, and swelling (increased calf circumference). The nurse promptly reports findings to the physician for definitive evaluation and therapy. During traction therapy, the nurse encourages the patient to exercise muscles and joints that are not in traction to prevent deterioration, deconditioning, and venous stasis. The physical therapist can design bed exercises that minimize loss of muscle strength. During the patient’s exercise, the nurse ensures that traction forces are maintained and that the patient is properly positioned to prevent complications resulting from poor alignment.

THE PATIENT UNDERGOING ORTHOPEDIC SURGERY Many patients with musculoskeletal dysfunction undergo surgery to correct the condition. Conditions that may be corrected by surgery include unstabilized fracture, deformity, joint disease, necrotic or infected tissue, and tumours. Frequent surgical procedures include open reduction with

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CHART 68-6

Common Orthopedic Surgical Procedures Open reduction: the correction and alignment of the fracture after surgical dissection and exposure of the fracture Internal fixation: the stabilization of the reduced fracture by the use of metal screws, plates, wires, nails, and pins Arthroplasty: the repair of joint problems through the operating arthroscope (an instrument that allows the surgeon to operate within a joint without a large incision) or through open joint surgery Hemiarthroplasty: the replacement of one of the articular surfaces (e.g., in a hip hemiarthroplasty, the femoral head and neck are replaced with a femoral prosthesis—the acetabulum is not replaced) Joint arthroplasty or replacement: the replacement of joint surfaces with metal or synthetic materials Total joint arthroplasty or replacement: the replacement of both articular surfaces within a joint with metal or synthetic materials Meniscectomy: the excision of damaged joint fibrocartilage Amputation: the removal of a body part Bone graft: the placement of bone tissue (autologous or homologous grafts) to promote healing, to stabilize, or to replace diseased bone Tendon transfer: the insertion of tendon to improve function Fasciotomy: the incision and diversion of the muscle fascia to relieve muscle constriction, as in compartment syndrome, or to reduce fascia contracture

internal fixation (ORIF) and closed reduction with internal fixation (fracture fragments are not surgically exposed) for fractures; arthroplasty, meniscectomy, and joint replacement for joint conditions; amputation for severe extremity conditions (e.g., gangrene, massive trauma); bone graft for joint stabilization, defect filling, or stimulation of bone healing; and tendon transfer for improving motion. The goals include improving function by restoring motion and stability and relieving pain and disability. Chart 68-6 describes common orthopedic surgeries. Indications for a surgical procedure are based on the patient’s age, underlying orthopedic condition, and general physical health and the impact of joint disability on daily activities. Timing of these procedures is important to ensure maximum function. In general, surgery should be performed before surrounding muscles become contracted and atrophied and serious structural abnormalities occur. Because most of these are elective procedures, many patients donate their own blood during the weeks preceding their surgery. This blood is used to replace blood lost during surgery. Autologous blood transfusions eliminate many of the risks of transfusion therapy (see Chapter 34). Blood is conserved during surgery to minimize loss. During orthopedic surgery on a limb (e.g., total knee replacement [TKR]), a pneumatic tourniquet may be applied to produce a “bloodless field.” This technique has the advantages of keeping the surgical field dry, minimizing blood loss, and providing some additional limb anesthesia (O’Connor & Murphy, 2007). Intraoperative blood salvage with reinfusion is used when a large volume of blood loss is anticipated. Postoperative blood salvage with

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intermittent autotransfusion also reduces the need for blood transfusion.

Joint Replacement Patients with severe joint pain and disability may undergo joint replacement. Conditions contributing to joint degeneration include osteoarthritis, rheumatoid arthritis, trauma, and congenital deformity. Some fractures (e.g., femoral neck fracture) may cause disruption of the blood supply and subsequent avascular necrosis; management with joint replacement may be elected over ORIF. Joints frequently replaced include the hip, knee (Fig. 68-7), and finger joints. Less frequently, more complex joints (shoulder, elbow, wrist, ankle) are replaced. Most joint replacements consist of metal (e.g., cobaltchromium, titanium) and high-density polyethylene components. The joint implants may be cemented in the prepared bone with polymethylmethacrylate (PMMA), a

Acetabular (pelvic) component

Femoral (proximal) component

Femoral (distal) component

Tibial component

FIGURE 68-7. Examples of hip and knee replacement.

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bone-bonding agent that has properties similar to bone. Loosening of the prosthesis due to cement–bone interface failure is a common cause of prosthesis failure. Press-fit, ingrowth prostheses (porous-coated, cementless artificial joint components) that allow the patient’s bone to grow into and securely fix the prosthesis in the bone are alternatives to cemented prostheses. Accurate fitting and the presence of healthy bone with adequate blood supply are important in the use of cementless components (Lucas, 2008a). Much progress has been made in reducing prosthesis failure rates through improved techniques, improved materials, and use of bone grafts. With joint replacement, excellent pain relief is obtained in most patients. Return of motion and function depends on preoperative soft tissue condition, soft tissue reactions, and general muscle strength. Early failure of joint replacement is associated with excessive activity and preoperative joint and bone pathology.

Nursing Interventions Assessment of the patient and preoperative management are aimed at having the patient in optimal health at the time of surgery. Preoperatively, it is important to evaluate cardiovascular, respiratory, renal, and hepatic functions. Age, obesity, preoperative leg edema, a history of any venous thromboemboli, and varicose veins increase the risk for postoperative DVT and pulmonary embolism (PE). Preoperatively, it is important to assess the neurovascular status of the extremity undergoing joint replacement (Lucas, 2008a). Postoperative assessment data are compared with preoperative assessment data to identify changes and deficits. For example, an absent pulse postoperatively is of concern unless the pulse was also absent preoperatively. Nerve palsy could occur as a result of surgery.

Preventing Infection Preoperative assessment of the patient for infections, including urinary tract infection, is necessary because of the risk for postoperative infection. Any infection 2 to 4 weeks before planned surgery may result in postponement of surgery. Preoperative skin preparation frequently begins 1 or 2 days before the surgery. Airborne bacteria that contaminate the wound at the time of surgery cause most deep infections. Therefore, as with any surgery, there is strict adherence to aseptic principles, and the operating area is made as bacteria free as possible (Lucas, 2008a). Research findings suggest that prophylactic antibiotics given 60 minutes prior to incision are effective in preventing postoperative infection (Hawn, Gray, Vick, et al., 2006). Culture of the joint during surgery may be important in identifying and treating subsequent infections. If osteomyelitis develops, it is difficult to treat. Persistent infection at the site of the prosthesis usually requires removal of the implant and joint revision. It is not always possible to achieve a functional joint when the reconstruction procedure has to be repeated.

Promoting Ambulation Patients with total hip or TKR begin ambulation with a walker or crutches within a day after surgery. The nurse and the physical therapist assist the patient in achieving

the goal of independent ambulation. At first, the patient may be able to stand for only a brief period because of orthostatic hypotension. Specific weight-bearing limits on the prosthesis are based on the patient’s condition, the procedure, and the fixation method. Usually, patients with cemented prostheses can proceed to weight bearing as tolerated. If the patient has a press-fit, cementless, ingrowth prosthesis, weight bearing immediately after surgery may be limited to minimize micromotion of the prosthesis in the bone (Lucas, 2008b). As the patient is able to tolerate more activity, the nurse encourages transferring to a chair several times a day for short periods and walking for progressively greater distances.

Total Hip Replacement Total hip replacement is the replacement of a severely damaged hip with an artificial joint. Indications for this surgery include osteoarthritis, rheumatoid arthritis, femoral neck fractures, failure of previous reconstructive surgeries (failed prosthesis, osteotomy), and conditions resulting from developmental dysplasia or Legg-CalvePerthes (avascular necrosis of the hip in childhood). A variety of total hip prostheses are available. Most consist of a metal femoral component topped by a spherical ball, of metal, ceramic, or plastic, fitted into a plastic or metal acetabular socket (Fig. 68-7). The surgeon selects the prosthesis that is best suited to the individual patient, considering various factors, including skeletal structure and activity level. The patient has irreversibly damaged hip joints, and the potential benefits, including improved quality of life, outweigh the surgical risks. With the advent of improved prosthetic materials and operative techniques, the life of the prosthesis has been extended, and today younger patients with severely damaged and painful hip joints are undergoing total hip replacement.

Nursing Interventions The nurse must be aware of and monitor for specific potential complications associated with total hip replacement. Complications that may occur include dislocation of the hip prosthesis, excessive wound drainage, thromboembolism, infection, and heel pressure ulcer (Chart 68-7). Other complications for which the nurse must monitor include those associated with immobility. Long-term complications include heterotopic ossification (formation of bone in the periprosthetic space), avascular necrosis (bone death caused by loss of blood supply), and loosening of the prosthesis. PREVENTING DISLOCATION OF THE HIP PROSTHESIS.

For patients undergoing a posterior or posterior-lateral approach for total hip arthroplasty, maintenance of the femoral head component in the acetabular cup is essential. The nurse teaches the patient about positioning the leg in abduction, which helps prevent dislocation of the prosthesis. The use of an abduction splint, a wedge pillow (Fig. 68-8), or two or three pillows between the legs keeps the hip in abduction. When the nurse turns the patient in bed, it is important to keep the operative hip in abduction. (text continued on page 2204)

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Plan of Nursing Care NURSING INTERVENTIONS

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Chart 68-7. The Patient With a Total Hip Replacement

RATIONALE

EXPECTED OUTCOMES

Nursing Diagnosis: Pain related to total hip replacement Goal: Relief of pain 1. Assess patient for pain using a standard pain intensity scale.

2. Ask patient to describe discomfort.

3. Acknowledge existence of pain; inform patient of available analgesic agents or muscle relaxants. 4. Use pain-modifying techniques. a. Administer analgesic agents as prescribed. b. Change position within prescribed limits. c. Modify environment.

d. Notify surgeon about persistent pain. 5. Evaluate and record discomfort and effectiveness of pain-modifying techniques.

1. Pain is expected after a surgical procedure because of the surgical trauma and tissue response. Muscle spasms occur after total hip replacements. Immobility causes discomfort at pressure points. 2. Pain characteristics may help to determine the cause of discomfort. Pain may be due to complications (hematoma, infection, dislocation). Pain is an individual experience—it means different things to different people. 3. The nurse can reduce the stress experienced by patient by communicating concern and availability of assistance to help the patient deal with the pain. 4. a. Patient will require parenteral opioids during the first 24–48 hours, and then will progress to oral analgesic agents. b. Use of pillows to provide adequate support and relief of pressure on bony prominences assists in minimizing pain. c. Interactions with others, distractions, and sensory overload or deprivation may affect pain experience. d. Surgical intervention may be necessary if pain is due to hematoma or excessive edema. 5. Effectiveness of action is based on experience; data provide a baseline about pain experiences, management, and pain relief.

• Describes discomfort • Expresses confidence in efforts to control pain

• States pain is reduced; pain intensity scores are decreasing

• Appears comfortable and relaxed • Uses physical, psychological, and

pharmacologic measures to reduce pain and discomfort

Nursing Diagnosis: Impaired physical mobility related to positioning, weight-bearing, and activity restrictions after hip replacement Goal: Achieves pain-free, functional, stable hip joint 1. Maintain proper positioning of hip joint (abduction, neutral rotation, limited flexion). 2. Keep pressure off heel. 3. Instruct and assist in position changes and transfers. 4. Instruct and supervise isometric quadriceps- and gluteal-setting exercises. 5. In consultation with physical therapist, instruct and supervise progressive safe ambulation within limitations of weight-bearing prescription.

1. Prevents dislocation of hip prosthesis 2. Prevents pressure ulcer on heel 3. Encourages patient’s active participation while preventing dislocation 4. Strengthens muscles needed for walking 5. Amount of weight-bearing depends on patient’s condition and prosthesis; ambulatory aids are used to assist the patient with non–weightbearing and partial weight-bearing ambulation.

• • • • • • • •

Maintains prescribed position No heel pressure Assists in position changes Shows increased independence in transfers Exercises hourly Participates in progressive ambulation program Actively participates in exercise regimen Uses ambulatory aids correctly and safely

continued >

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Plan of Nursing Care

Chart 68-7. The Patient With a Total Hip Replacement, Continued

NURSING INTERVENTIONS

RATIONALE

6. Offer encouragement and support exercise regimen.

6. Reconditioning exercises can be uncomfortable and fatiguing; encouragement helps patient comply with exercise program. 7. Prevents injury from unsafe use and prevents falls.

7. Instruct and supervise safe use of ambulatory aids.

EXPECTED OUTCOMES

Collaborative Problems: Hemorrhage; neurovascular compromise; dislocation of prosthesis; deep vein thrombosis; infection related to surgery

Goal: Absence of complications

Hemorrhage 1. Monitor vital signs, observing for shock.

2. Note character and amount of drainage.

3. Notify surgeon if patient develops shock or excessive bleeding and prepare for administration of fluids, blood component therapy, and medications. 4. Monitor hemoglobin and hematocrit values. Neurovascular Dysfunction 1. Assess affected extremity for colour and temperature. 2. Assess toes for capillary refill response. 3. Assess extremity for edema and swelling. Report patient complaints of leg tightness. 4. Elevate extremity (keep leg lower than hip when in chair). 5. Assess for deep, throbbing, unrelenting pain. 6. Assess for pain on passive flexion of foot. 7. Assess for change in sensations and numbness.

1. Changes in pulse, blood pressure, and respirations may indicate development of shock. Blood loss and stress of surgery may contribute to development of shock. 2. Within 48 hours, bloody drainage collected in portable suction device should decrease to 25–30 mL per 8 hours. Excessive drainage (more than 250 mL in first 8 hours after surgery) and bright red drainage may indicate active bleeding. 3. Corrective measures need to be instituted.

• Vital signs stabilize within normal limits.

• Amount of drainage decreases. • No bright red bloody drainage. • Hematology values are within normal limits.

4. Anemia due to blood loss may develop. Blood replacement or iron supplementation may be needed. 1. The skin becomes pale and feels cool with decreased tissue perfusion. Venous congestion may produce cyanosis. 2. After compression of the nail, rapid return of pink colour indicates good capillary perfusion. 3. The trauma of surgery will cause edema. Excessive swelling and hematoma formation can compromise circulation and function. 4. Minimizes dependent edema 5. Surgical pain can be controlled; pain due to neurovascular compromise is not relieved by treatment. 6. With nerve ischemia, there will be pain on passive stretch. In addition, pain or tenderness may indicate deep vein thrombosis. 7. Diminished pain and sensory function may indicate nerve damage. Sensation in web between great and second toe—peroneal nerve; sensation on sole of foot—tibial nerve

• • • • • • • • • • •

Colour normal Extremity warm Normal capillary refill Moderate edema and swelling; tissue not palpably tense Pain controllable No pain with passive dorsiflexion Normal sensations No paresthesia Normal motor abilities No paresis or paralysis Pulses strong and equal

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Plan of Nursing Care NURSING INTERVENTIONS 8. Assess ability to move foot and toes.

9. Assess pedal pulses in both feet. 10. Notify surgeon if altered neurovascular status is noted. Dislocation of Prosthesis 1. Position patient as prescribed. 2. Use abductor splint or pillows to maintain position and to support extremity. 3. Support leg and place pillows between legs when patient is turning and side-lying; turn to the unaffected side. 4. Avoid acute flexion of hip (head of bed at 60 degrees or less). 5. Avoid crossing legs. 6. Assess for dislocation of prosthesis (extremity shortens, internally or externally rotated, severe hip pain, patient unable to move extremity) 7. Notify surgeon of possible dislocation.

Deep Vein Thrombosis 1. Use antiembolism stocking or sequential compression device as prescribed. 2. Remove stocking for 20 minutes twice a day and provide skin care. 3. Assess popliteal, dorsalis pedis, and posterior tibial pulses. 4. Assess skin temperature of legs. 5. Assess for unilateral calf pain or tenderness every 8 hours. 6. Avoid pressure on popliteal blood vessels from equipment (e.g., abductor splint straps, sequential compression stockings) or pillows. 7. Change position and increase activity as prescribed. 8. Supervise ankle exercises hourly. 9. Monitor body temperature. 10. Encourage fluids.

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Chart 68-7. The Patient With a Total Hip Replacement, Continued

RATIONALE

EXPECTED OUTCOMES

8. Dorsiflexion of ankle and extension of toes indicate function of peroneal nerve. Plantar flexion of ankle and flexion of toes indicate function of tibial nerve. 9. Indicator of extremity circulation 10. Function of extremity needs to be preserved. 1. Hip component positioning (femoral component in acetabular component) needs to be maintained. 2. Keeps hip in abduction and in a neutral rotation to prevent dislocation 3–5. Prevent dislocation

• Prosthesis not dislocated • Adheres to recommendations to prevent dislocation

6. Findings may indicate dislocation of prosthesis. 7. Joint dislocations compromise neurovascular status and future function of extremity. 1. Aids in venous blood return and prevents stasis 2. Skin care is necessary to avoid breakdown. Extended removal of stockings defeats purpose of stockings. 3. Pulses indicate arterial perfusion of extremity. 4. Local inflammation will increase local skin temperature. 5. Pain or tenderness may indicate deep vein thrombosis. 6. Compression of blood vessels diminishes blood flow.

• Wears antiembolism stockings; uses

compression device No skin breakdown Pulses equal and strong Skin temperature normal No calf pain or tenderness Changes position with assistance and supervision • Participates in exercise regimen • Well hydrated • No chest pain; lungs clear to auscultation; no evidence of pulmonary emboli

• • • • •

7. Activity promotes circulation and diminishes venous stasis. 8. Muscle exercise promotes circulation. 9. Body temperature increases with inflammation. 10. Dehydration increases blood viscosity. continued >

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Plan of Nursing Care NURSING INTERVENTIONS Infection 1. Monitor vital signs.

2. Use aseptic technique for dressing changes and emptying of portable drainage. 3. Assess wound appearance and character of drainage. 4. Assess complaints of pain.

5. Administer prophylactic antibiotics if prescribed, and observe for side effects.

Chart 68-7. The Patient With a Total Hip Replacement, Continued

RATIONALE

EXPECTED OUTCOMES

1. Temperature, pulse, and respirations increase in response to infection. (Magnitude of response may be minimal in an older patient.) 2. Avoids introducing organisms

• Vital signs normal • Well-approximated incision without drainage or excessive inflammatory response • Minimal discomfort; no hematoma • Tolerates antibiotics

3. Red, swollen, draining incision is indicative of infection. 4. Pain may be due to wound hematoma—a possible locus of infection—that needs to be surgically evacuated. 5. Infected prosthesis is avoided.

Nursing Diagnosis: Risk for ineffective health maintenance related to total hip replacement Goal: Cares for self at home 1. Assess home environment for discharge planning. 2. Encourage patient to express concerns about care at home; explore together possible solutions to the problem. 3. Assess availability of physical assistance for health care activities. 4. Teach home health care regimen to caregiver. 5. Instruct patient on posthospital care: a. Activity limitations (hip precautions, weight-bearing limits) b. Exercise instructions c. Safe use of ambulatory aids d. Wound care e. Measures to promote healing f. Medications, if any g. Potential problems h. Continuing health care supervision and management

1. Physical barriers (especially stairs, bathrooms) may limit patient’s ability to ambulate and care for self at home. 2. Patient may have special problems that need to be identified and resolved. 3. Because of limitation of mobility and limited hip range of motion, patient may require some assistance in routine health care. 4. Understanding of rehabilitative regimen is necessary for compliance. 5. Lack of knowledge and poor preparation for care at home contribute to patient anxiety, insecurity, and nonadherence to therapeutic regimen.

FIGURE 68-8. An abduction pillow may be used after a total hip replacement to prevent dislocation of the prosthesis.

• Home is accessible for patient at time of discharge

• Appears relaxed and develops strategies to deal with identified problems

• Personal assistance is available • Demonstrates ability to provide necessary assistance within therapeutic prescription • Complies with home care program • Keeps follow-up health care appointments

The patient’s hip is never flexed more than 90 degrees. For use of the fracture bedpan, the nurse instructs the patient to flex the unaffected hip and to use the trapeze to lift the pelvis onto the pan. The patient is also reminded not to flex the affected hip. Limited flexion is maintained during transfers and when sitting. When the patient is initially assisted out of bed, an abduction splint or pillows are kept between the legs. The nurse encourages the patient to keep the affected hip in extension, instructing the patient to pivot on the unaffected leg with assistance by the nurse, who protects

CHAPTER 68

the affected hip from adduction, flexion, internal or external rotation, and excessive weight bearing. High-seat (orthopedic) chairs, semireclining wheelchairs, and raised toilet seats are used to minimize hip joint flexion. When sitting, the patient’s hips should be higher than the knees. The patient’s affected leg should not be elevated when sitting. The patient may flex the knee. The nurse teaches the patient protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion. A cradle boot may be used to prevent leg rotation and to support the heel off the bed, preventing development of a pressure ulcer. The patient should use pillows between the legs when in a supine or side-lying position and when turning. Generally, the nurse instructs the patient not to sleep on the side on which the surgery was performed. At no time should the patient cross his or her legs. The patient should not bend at the waist to put on shoes and socks. Occupational therapists can provide the patient with devices to assist with dressing below the waist (Lucas, 2008b). Hip precautions should be enforced for 4 or more months after surgery (Chart 68-8). A patient who has had an anterior surgical approach may not need these precautions. Dislocation may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Indicators are as follows: • Increased pain at the surgical site, swelling, and immobilization

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Musculoskeletal Care Modalities

2205

• Acute groin pain in the affected hip or increased discomfort • Shortening of the leg • Abnormal external or internal rotation • Restricted ability or inability to move the leg • Reported “popping” sensation in the hip If a prosthesis becomes dislocated, the nurse (or the patient, if at home) immediately notifies the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck’s traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest (Lucas, 2008b). MONITORING WOUND DRAINAGE. Fluid and blood accumulating at the surgical site are usually drained with a portable suction device. This prevents accumulation of fluid, which could contribute to discomfort and provide a site for infection. Drainage of 200 to 500 mL in the first 24 hours is expected; by 48 hours postoperatively, the total drainage in 8 hours usually decreases to 30 mL or less, and the suction device is then removed. The nurse promptly notifies the physician of any drainage volumes greater than anticipated. If extensive blood loss is anticipated after total joint replacement surgery, an autotransfusion drainage system

CHART 68-8

Patient Education: Avoiding Hip Dislocation After Replacement Surgery With Posterior or Posterolateral Approach Until the hip prosthesis stabilizes after hip replacement surgery, it is necessary to follow instructions for proper positioning so that the prosthesis remains in place. Dislocation of the hip is a serious complication of surgery that causes pain and loss of function and necessitates reduction under anesthesia to correct the dislocation. Desirable positions include abduction, neutral rotation, and flexion of less than 90 degrees. When you are seated, the knees should be lower than the hip.

• • • • • • •

Methods for avoiding displacement include the following: Keep the knees apart at all times. Put a pillow between the legs when sleeping. Never cross the legs when seated. Avoid bending forward when seated in a chair. Avoid bending forward to pick up an object on the floor. Use a high-seated chair and a raised toilet seat. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes. Positions to avoid after total hip replacement are illustrated below. 90°

120°

Affected leg should not cross the centre of the body

Hip should not bend more than 90 degrees

Affected leg should not turn inward

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(in which the drained blood is filtered and reinfused into the patient during the immediate postoperative period) may be used to decrease the need for homologous blood transfusions. PREVENTING DEEP VEIN THROMBOSIS. The risk of venous thromboembolism (VTE) is particularly great after reconstructive hip surgery. The incidence of DVT is 48% for patients who have not had any type of VTE preventive measures instituted, which includes mechanical prophylaxis (e.g., antiembolism stockings) and pharmacologic prophylaxis (e.g., antithrombotic medications) (Ennis, 2014; Haas, Barrack, Westrich, et al., 2008). DVT formation can lead to PE, which can be fatal. Therefore, the nurse must institute preventive measures and monitor the patient closely for the development of DVT and PE. Signs of DVT include calf pain, swelling, and tenderness. Medications that include fondaparinux (Arixtra) or low-molecular-weight heparin (e.g., enoxaparin [Lovenox], dalteparin [Fragmin]) are indicated as prophylaxis for VTE after hip replacement surgery (Hirsh, Guyatt, Albers, et al., 2008). Rivaroxaban (Xaralto) a new direct Xa inhibitor, which is administered orally, has been shown to have superior thomboprophylaxis in total knee and total hip arthroplasty surgery than enoxaparin (Lassen, Ageno, Borris et al., 2008; Eriksson, Borris, Friedman et al., 2008). PREVENTING INFECTION. Infection, a serious complication of total hip replacement, may necessitate removal of the prosthesis. Patients who are older, are obese, are poorly nourished, smoke cigarettes, or use corticosteroid medications (e.g., prednisone) and patients who have diabetes,

rheumatoid arthritis, concurrent infections (e.g., urinary tract infection, dental abscess), or hematomas are at high risk for infection (Jamsen, Furnes, Engesaeter, et al., 2010). Potential sources of infection are avoided. If indwelling urinary catheters or portable wound suction devices are used, they are removed as soon as possible to avoid infection. Prophylactic antibiotics are prescribed if the patient needs any future surgical or invasive procedures, such as tooth extraction or cystoscopic examination. Acute infections may occur within 3 months after surgery and are associated with progressive superficial infections or hematomas. Delayed surgical infections may appear 4 to 24 months after surgery and may cause return of discomfort in the hip. Infections occurring more than 2 years after surgery are attributed to the spread of infection through the bloodstream from another site in the body. If an infection occurs, antibiotics are prescribed. These infections may cause the prosthesis to loosen (Lucas, 2008b). Severe infections may require surgical débridement or removal of the prosthesis. PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching the Patient Self-Care. Before the patient prepares to leave the acute care setting, the nurse provides thorough teaching to promote continuity of the therapeutic regimen and active participation in the rehabilitation process (Chart 68-9). The nurse advises the patient of the importance of the daily exercise program in maintaining the functional motion of the hip joint and strengthening the abductor muscles of the hip, and reminds the patient that it will take time to strengthen and retrain the muscles.

CHART 68-9

Providing Home Care After Hip Replacement Considerations • • • • •

Pain management Wound care Mobility Self-care (activities of daily living) Potential complications

Nursing Interventions Discuss with patient methods to reduce pain: • Periodic rest • Distraction and relaxation techniques • Medication therapy (e.g., nonsteroidal anti-inflammatory drugs, opioid analgesic agents): actions of medications, administration, schedule, side effects Instruct patient in the following: • Keeping incision clean and dry • Taking care of the wound and changing the dressing • Recognizing signs of wound infection (e.g., pain, swelling, drainage, fever) Explain that sutures or staples will be removed 10 to 14 days after surgery. Teach patient about the following: • Safe use of assistive devices • Weight-bearing limits • How to change positions frequently • Limitations on hip flexion and adduction (e.g., avoid acute flexion and crossing legs)

• • • •

How to stand without flexing hip acutely Avoidance of low-seated chairs Sleeping with pillow between legs to prevent adduction Gradual increase in activities and participation in prescribed exercise regimen • Use of important medications such as warfarin (Coumadin) and aspirin Assess home environment for physical barriers. Instruct patient to use elevated toilet seat and to use reachers to aid in dressing. Encourage patient to accept assistance with activities of daily living during early convalescence until mobility and strength improve. Arrange services and accommodations to address the patient’s disability or illness, as appropriate. Assess patient for development of potential problems, and instruct patient to report signs of potential complications: • Dislocation of prosthesis (e.g., increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation) • Deep vein thrombosis (e.g., calf pain, swelling) • Wound infection (e.g., swelling, purulent drainage, pain, fever) • Pulmonary emboli (e.g., sudden dyspnea, tachypnea, pleuritic chest pain) Discuss with patient the need to continue regular health care (routine physical examinations) and screenings.

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Assistive devices (crutches, walker, or cane) are used for a time. After sufficient muscle tone has developed to permit a normal gait without discomfort, these devices are not necessary. In general, by 3 months, the patient can resume routine ADLs. Stair climbing is permitted as prescribed but is kept to a minimum for 3 to 6 months. Frequent walks, swimming, and use of a high rocking chair are excellent for hip exercises. Sexual intercourse should be carried out with the patient in the dependent position (flat on the back) for 3 to 6 months to avoid excessive adduction and flexion of the new hip. At no time during the first 4 months should the patient cross the legs or flex the hip more than 90 degrees. Assistance in putting on shoes and socks may be needed. The patient should avoid low chairs and sitting for longer than 45 minutes at a time. These precautions minimize hip flexion and the risks of prosthetic dislocation, hip stiffness, and flexion contracture. Travelling long distances should be avoided unless frequent position changes are possible. Other activities to avoid include tub baths, jogging, lifting heavy loads, and excessive bending and twisting (e.g., lifting, shoveling snow, forceful turning). Continuing Care. A home care nurse may assess the patient at home to assess for potential problems and monitor wound healing (see Chart 68-10). The nurse, physical therapist, or occupational therapist assesses the home environment for physical barriers that may impede the patient’s rehabilitation. In addition, the nurse or therapist may need to assist the patient in acquiring devices such as reachers or long-handled tongs to help with dressing, or toilet seat extenders to elevate the toilet. After successful surgery and rehabilitation, the patient can expect a hip joint that is free or almost free of pain, has good motion, is stable, and permits normal or nearnormal ambulation.

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Total Knee Replacement TKR surgery is considered for patients who have severe pain and functional disabilities related to destruction of joint surfaces by osteoarthritis or rheumatoid arthritis. Metal and acrylic prostheses designed to provide the patient with a functional, painless, stable joint may be used. If the patient’s ligaments have weakened, a fully constrained (hinged) or semiconstrained prosthesis may be used to provide joint stability. A nonconstrained prosthesis depends on the patient’s ligaments for joint stability.

Nursing Interventions Postoperatively, the knee is dressed with a compression bandage. Ice may be applied to control edema and bleeding. The nurse assesses the neurovascular status of the leg. It is important to encourage active flexion of the foot every hour when the patient is awake. Efforts are directed at preventing complications (thromboembolism, peroneal nerve palsy, infection, limited range of motion) (Lucas, 2008b). A wound suction drain removes fluid accumulating in the joint. Drainage ranges from 200 to 400 mL during the first 24 hours after surgery and diminishes to less than 25 mL by 48 hours, at which time the surgeon removes the drains. If extensive bleeding is anticipated, an autotransfusion drainage system may be used during the immediate postoperative period. The colour, type, and amount of drainage are documented, and any excessive drainage or change in characteristics of the drainage is promptly reported to the physician. Use of a continuous passive motion (CPM) device in conjunction with physical therapy has been associated with decreased hospital length of stay as well as improved patient postoperative knee mobility and decreased use of

CHART 68-10

HOME CARE CHECKLIST •

The Patient Who Has Had Orthopedic Surgery Patient

Caregiver

• Describe wound care.

✔

✔

• State indicators of wound infections (e.g., redness, swelling, tenderness, purulent drainage,

✔

✔

• Consume a healthy diet to promote wound and bone healing.

✔

• Participate in prescribed exercise regimen to promote circulation and mobility.

✔

• Use mobility aids safely.

✔

• Observe prescribed weight-bearing and activity limits.

✔

• Take prescribed therapeutic and prophylactic medications (e.g., antibiotics, anticoagulants,

✔

• State indicators of complications to report promptly to physician (e.g., uncontrolled swelling

✔

✔

• Identify modifications of home environment to promote safe environment and independence

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

fever).

analgesic agents).

and pain; cool, pale fingers or toes; paresthesia; paralysis; purulent drainage; signs of systemic infection; signs of deep vein thrombosis or pulmonary embolism). during recovery and rehabilitation.

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FIGURE 68-9. Lower-limb continuous passive motion (CPM) device. The Otto Bock 480E Knee CPM is 11 kg (24 lb) and combines durable construction with portability and ease of operation. CPM is best applied immediately after surgery and continued, uninterrupted, for up to 6 weeks as prescribed by the physician. Photo courtesy of Otto Bock Healthcare, Minneapolis, MN.

analgesic agents (Milne, Brosseau, Robinson, et al., 2008). However, in a recent Cohcrane review, Harvey, Brosseau, & Herbert (2014) have concluded that there is not sufficient evidence to support that CPM has important clinical benefits. When using CPM the patient’s leg is placed in this device, which increases circulation and range of motion of the knee joint. The rate and amount of extension and flexion are prescribed. Usually, 10 degrees of extension and 50 degrees of flexion are prescribed initially, increasing to 90 degrees of flexion with full extension (0 degrees) by discharge (Fig. 68-9). The nurse encourages the patient to use the CPM device. The physical therapist supervises exercises for strength and range of motion. If satisfactory flexion is not achieved, gentle manipulation of the knee joint under general anesthesia may be necessary about 2 weeks after surgery. The nurse assists the patient to get out of bed on the evening or the day after surgery. The knee is usually protected with a knee immobilizer (e.g., cast, brace, splint) and is elevated when the patient sits in a chair. The physician prescribes weight-bearing limits. Progressive ambulation, using assistive devices and within the prescribed weight-bearing limits, begins on the day after surgery.

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Preoperative Care of the Patient Undergoing Orthopedic Surgery Assessment Assessment of the patient is focused on hydration status, current medication history, and possible infection. Adequate hydration is an important goal for orthopedic patients. Immobilization and bed rest contribute to

the following complications: DVT, PE, urinary stasis and associated bladder infections, and kidney stone formation. Adequate hydration decreases blood viscosity and venous stasis and ensures adequate urine flow. To determine preoperative hydration status, the nurse assesses the skin and mucous membranes, vital signs, urinary output, and laboratory values. The medication history provides information for perioperative management. The patient with chronic illness (e.g., adrenal insufficiency, rheumatoid arthritis, chronic pulmonary disease, multiple sclerosis) or with a transplanted organ frequently has received long-term administration of corticosteroid medications to control disease symptoms or prevent rejection. The corticosteroid should be administered preoperatively, intraoperatively, and postoperatively as prescribed to prevent the occurrence of acute adrenal insufficiency from suppressed adrenal function. The patient’s use of other medications, such as anticoagulants, cardiovascular agents, or insulin, needs to be documented and discussed with the surgeon and anesthesiologist to ensure adequate management. The nurse asks the patient specifically about the occurrence of colds, dental problems, urinary tract infections, and other infections within the 2 weeks before surgery. Osteomyelitis could develop through hematologous spread. Permanent disability can result if infection occurs within a bone or joint. Preexisting infections must be resolved before elective orthopedic surgery is performed.

Nursing Diagnoses Based on the nursing assessment data, the patient’s major preoperative nursing diagnoses related to orthopedic status may include the following: • Acute pain related to fracture, joint degeneration, swelling, or inflammation • Risk for peripheral neurovascular dysfunction related to swelling, constricting devices, or impaired venous return • Risk for ineffective therapeutic regimen management related to insufficient knowledge or lack of available support and resources • Impaired physical mobility related to pain, swelling, and possible presence of an immobilization device • Risk for situational low self-esteem and/or disturbed body image related to impact of musculoskeletal disorder

Planning and Goals The major goals for the patient before orthopedic surgery may include relief of pain, adequate neurovascular function, health promotion, improved mobility, and positive self-esteem.

Nursing Interventions Relieving Pain Discomfort is decreased with immobilization of a fractured bone or an injured, inflamed joint. Elevation

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of an edematous extremity promotes venous return and reduces associated discomfort. Ice, if prescribed, relieves swelling and reduces discomfort by diminishing nerve stimulation. Analgesic agents are frequently prescribed to control the acute pain of musculoskeletal injury or surgery and associated muscle spasm. During the immediate postoperative period, the nurse needs to discuss and coordinate the administration of effective analgesic medications (e.g., opioids, nonsteroidal anti-inflammatory drugs) with the anesthesia provider and surgeon. (See Chapter 14 for a further discussion of assessment and management of pain.)

Maintaining Adequate Neurovascular Function Trauma, edema, or immobilization devices may interrupt tissue perfusion. The nurse must frequently assess neurovascular status (i.e., colour, temperature, capillary refill, pulses, edema, pain, sensation, motion) of the extremity and document the findings. If circulation is compromised, the nurse institutes measures to restore adequate circulation. These include promptly notifying the physician, elevating the extremity, and releasing constricting wraps or assisting with bivalving constrictive casts as prescribed.

Promoting Health The nurse assists the patient in performing activities that promote health during the perioperative period. The nurse assesses nutritional status and hydration. The nurse monitors fluid intake, urinary output, and urinalysis findings. At times, patients may intentionally limit their fluid intake to minimize the use of a bedpan. A small fracture bedpan may be more comfortable for the patient to use. An indwelling catheter should be used only when necessary to minimize the risk of urinary tract infection. A pre-existing urinary tract infection must be effectively treated prior to surgery. If the surgery is elective, the orthopedic surgeon may instruct the patient to shower with a germicidal soap at home prior to surgery. The patient may also be asked to mark the operative site prior to surgery to minimize the risk that the wrong site is selected in the operating room. The nurse discusses with the patient and the family the need for assistance with ADLs and the therapeutic regimen during convalescence so that adequate support is available when the patient is discharged. Modification of the home environment may be necessary to accommodate the altered mobility of the patient after surgery. Referral to a social worker and case manager may be needed to ensure a smooth transition to home care.

Improving Mobility Preoperatively, the patient’s mobility may be impaired by pain, swelling, and immobilizing devices (e.g., splints, casts, traction). The nurse should elevate and adequately support edematous extremities with pillows. It is important to control pain before an injured

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part is moved by administering analgesic medication in time for it to take effect. The injured part is supported when it is moved. The nurse encourages movement within the limits of therapeutic immobility. The patient should perform active range-ofmotion exercises of uninvolved joints, and, unless contraindicated, the nurse teaches gluteal-setting and quadriceps-setting isometric exercises to maintain the muscles needed for ambulation (see Chart 68-3). The patient who will be using assistive devices postoperatively may exercise to strengthen the upper extremities and shoulders. If the use of assistive devices (e.g., crutches, walker, wheelchair) is anticipated, the nurse encourages the patient to practice with them preoperatively to facilitate their safe use and to promote earlier independent mobility.

Helping the Patient Maintain Self-Esteem Preoperatively, orthopedic patients may need assistance in accepting changes in body image, diminished self-esteem, or inability to perform their roles and responsibilities. The degree of assistance required in this area varies greatly, depending on the events preceding hospitalization, the surgery and rehabilitation planned, and the temporary or permanent nature of the problems. The nurse promotes a trusting relationship so that the patient feels comfortable expressing concerns and anxieties, and helps the patient examine his or her feelings about changes in self-concept. The nurse clarifies any misconceptions the patient may have and helps the patient work through modifications needed to adapt to alterations in physical capacity and to reestablish positive self-esteem.

Evaluation Expected Patient Outcomes Expected patient outcomes may include: 1. Reports relief of pain a. Uses multiple approaches to reduce pain b. States that medication is effective in relieving pain c. Moves with increasing comfort 2. Exhibits adequate neurovascular function a. Exhibits normal skin colour b. Has warm skin c. Has normal capillary refill response d. Reports normal sensation and demonstrates joint motion e. Demonstrates reduced swelling 3. Promotes health a. Consumes diet appropriate to meet nutritional needs b. Maintains adequate hydration c. Abstains from smoking d. Practices respiratory exercises e. Repositions self to relieve skin pressure f. Engages in strengthening and preventive exercises g. Plans for assistance during convalescence at home

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4. Maximizes mobility within therapeutic limits a. Requests assistance when moving b. Elevates edematous extremity after transfer c. Uses immobilizing devices and assistive devices safely as prescribed 5. Expresses positive self-esteem a. Acknowledges temporary or permanent changes in body image b. Discusses role performance changes c. Participates in decisions about care

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Postoperative Care of the Patient Undergoing Orthopedic Surgery Assessment After orthopedic surgery, the nurse continues the preoperative care plan, modifying it to match the patient’s current postoperative status. The nurse reassesses the patient’s needs related to pain, neurovascular status, health promotion, mobility, and self-esteem. Skeletal trauma and surgery performed on bones, muscles, or joints can produce significant pain, especially during the first 1 or 2 postoperative days. Tissue perfusion must be monitored closely, because edema and bleeding into the tissues can compromise circulation and result in compartment syndrome. Inactivity contributes to venous stasis and the development of venous thromboemboli that may include DVTs or PEs. General anesthesia, analgesia, and immobility can result in altered functioning of the respiratory, gastrointestinal, and urinary systems. The nurse notes the prescribed limits on mobility and assesses the patient’s understanding of the mobility restrictions. The nurse discusses the plan of care with the patient and encourages his or her active participation in the plan. Frequent assessment of vital signs including pain, level of consciousness, neurovascular status, wound drainage, breath sounds, bowel sounds, and fluid balance provides the nurse with data that may suggest the possible development of complications. The nurse reports abnormal findings to the physician promptly. With major orthopedic surgery, there is a risk for hypovolemic shock because of blood loss. Muscle dissection frequently produces wounds in which hemostasis is poor. Wounds that are closed under tourniquet control may bleed during the postoperative period. The nurse must be alert for signs of hypovolemic shock. Changes in the patient’s pulse rate, respiratory rate, or colour of the skin or mucous membranes

may indicate pulmonary or cardiovascular complications. Atelectasis and pneumonia are common and may be related to pre-existing pulmonary disease, deep anesthesia, decreased activity, and reduced respiratory reserve due to advanced age or an underlying musculoskeletal disorder (e.g., restrictive lung expansion secondary to kyphosis, rheumatoid arthritis, or osteoporosis). Voiding in unnatural positions may contribute to urinary retention. In addition, older men usually have some degree of prostate enlargement and may already have difficulty voiding. Therefore, it is important to monitor urinary output. Temperature elevations within the first 48 hours are frequently related to atelectasis or other respiratory problems. Temperature elevations during the next few days are frequently associated with urinary tract infections. Superficial wound infections take 4 to 6 days to develop. Fever from phlebitis usually occurs during the end of the first week through the second week. Venous thromboembolus (see discussions of DVT in Chapter 32 and PE in Chapter 24) is one of the most common and most dangerous of all complications occurring in the postoperative orthopedic patient. Advanced age, venous stasis, lower extremity orthopedic surgery, and immobilization are significant risk factors. The nurse assesses the patient daily for unilateral calf swelling, tenderness, warmth, and redness. The nurse promptly reports abnormal findings to the physician. In addition, fat emboli syndrome (FES) (see Chapter 70) may occur with orthopedic surgery. The nurse must be alert to any signs and symptoms that may suggest the development of FES. These may include respiratory distress; onset of delirium or any acute change in level of consciousness; and development of unusual skin rashes, especially a papular rash on the upper torso.

Diagnosis Nursing Diagnoses Based on all assessment data, the patient’s major nursing diagnoses after orthopedic surgery may include the following: • Acute pain related to the surgical procedure, swelling, and immobilization • Risk for peripheral neurovascular dysfunction related to swelling, constricting devices, or impaired circulation • Risk for ineffective therapeutic regimen management related to insufficient knowledge or available support and resources • Impaired physical mobility related to pain, edema, or the presence of an immobilizing device (e.g., splint, cast, or brace) • Risk for situational low self-esteem, disturbed body image, or ineffective role performance related to impact of the musculoskeletal disorder

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Collaborative Problems/ Potential Complications Based on the assessment data, potential complications may include the following: • • • • • •

Hypovolemic shock Atelectasis; pneumonia Urinary retention Infection Venous thromboembolism, including DVT or PE Constipation and fecal impaction

Planning and Goals The major goals for the patient after orthopedic surgery may include relief of pain, adequate neurovascular function, health promotion, improved mobility, positive self-esteem, and absence of complications.

Nursing Interventions Relieving Pain After orthopedic surgery, pain can be intense. Edema, hematomas, and muscle spasms contribute to the pain. Some patients report that the pain is less than that experienced preoperatively, and only moderate amounts of analgesic agents are needed. The nurse assesses the patient’s level of pain, evaluates the patient’s response to therapeutic measures, and makes every effort to relieve the pain and discomfort. Pain assessment must occur on an ongoing basis and take place at least as often as vital signs are assessed. Multiple pharmacologic approaches to pain management exist. Patient-controlled analgesia (PCA) and epidural analgesia may be prescribed to relieve the pain. If the patient is receiving pre-emptive analgesia on an ongoing basis via a PCA IV pump, the nurse ensures that the patient receives boluses of the analgesic agent prior to performing planned physical activities. If intramuscular and oral analgesic agents are prescribed on an as-needed basis (PRN), the nurse should administer medications on a preventive basis within the prescribed intervals if the onset of pain can be predicted (e.g., 30 minutes before planned activity such as transfer or exercise). The nurse should offer the medication at set intervals. In addition to pharmacologic approaches to controlling pain, elevation of the operative extremity and application of cold packs, if prescribed, help control edema and pain. Surgical drains inserted in the wound decrease fluid accumulation and hematoma formation. The nurse may find that repositioning, relaxation, distraction, and guided imagery help in reducing the patient’s pain. The nurse should report increasing and uncontrollable pain to the orthopedic surgeon for evaluation. Pain should diminish rapidly after the initial postoperative period. After 2 to 3 days, most patients require only occasional oral analgesia for residual muscle soreness and spasm.

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Maintaining Adequate Neurovascular Function The nurse monitors the neurovascular status of the involved body part and notifies the physician promptly of any indications of diminished tissue perfusion. The patient is reminded to perform musclesetting, ankle, and calf-pumping exercises hourly while awake to enhance circulation.

Maintaining Health It is important to encourage the patient to participate in the postoperative treatment regimen. A diet that includes adequate protein and vitamins is essential for wound healing. The patient progresses to a regular diet as soon as possible. The nurse assesses the patient for early manifestations of pressure ulcers (e.g., redness over bony prominences), which are a threat to any patient who must spend an extended time in bed or who is older, malnourished, or unable to move without assistance. Turning the patient frequently at preset intervals (e.g., at least every 2 hours), washing and drying the skin, and minimizing pressure over bony prominences are necessary to avoid skin breakdown.

Improving Physical Mobility Patients are frequently reluctant to move after orthopedic surgery. Preoperative education about the planned postoperative treatment regimen promotes patient adherence to an optimal rehabilitation regimen. Patients often increase their mobility once they have been reassured that movement within therapeutic limits is beneficial, that the nurse will provide assistance, and that discomfort can be controlled. Metal pins, screws, rods, and plates used for internal fixation are designed to maintain the position of the bone until ossification occurs. They are not designed to support the body’s weight, and they can bend, loosen, or break if stressed. The estimated strength of the bone, the stability of the fracture, reduction and fixation, and the amount of bone healing are important considerations in determining weight-bearing limits. Although the incision may appear healed, the underlying bone requires more time to repair and regain normal strength. Some orthopedic procedures require weight-bearing restrictions. The orthopedic surgeon will prescribe the weight-bearing limits and the use of protective devices (orthoses), if necessary, after surgery. The physical therapist tailors the rehabilitation program to each patient’s needs. The goal is the patient’s return to the highest level of function in the shortest time possible. Rehabilitation involves progressive increases in the patient’s activities and exercises. Assistive devices (crutches, walker) may be used for postoperative mobility. Preoperative practice with assistive devices helps the patient use them appropriately postoperatively. The nurse makes sure that the patient uses these devices safely (see discussions of crutch walking and use of a walker in Chapter 12).

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Maintaining Self-Esteem The nurse and the patient set realistic goals. Increased ability to perform self-care activities within the limits of the therapeutic regimen and resumption of roles facilitate the patient’s recognition of abilities and promote self-esteem, personal identity, and role performance. Acceptance of altered body image is facilitated by support provided by the nurse, family, and others.

Monitoring and Managing Potential Complications HYPOVOLEMIC SHOCK. Excessive loss of blood during or after surgery can result in shock. The nurse monitors the patient for signs and symptoms of hypovolemic shock: increased pulse rate (e.g., greater than 100 bpm), decreased blood pressure (e.g., less than 90/60 mm Hg), narrowed pulse pressure (e.g., less than 20 mm Hg), urine output less than 30 mL/h, restlessness, change in mentation, thirst, and decreased hemoglobin and hematocrit. The nurse reports these findings to the orthopedic surgeon and assists in appropriate management. (See Chapter 16 for a discussion of managing shock.) ATELECTASIS AND PNEUMONIA. The nurse monitors the patient’s breath sounds and encourages deepbreathing and coughing exercises. Full expansion of the lungs prevents the accumulation of pulmonary secretions and the development of atelectasis and pneumonia. Incentive spirometry use is encouraged. If signs of respiratory problems develop (e.g., increased respiratory rate, productive cough, diminished or adventitious breath sounds, fever), the nurse reports the findings to the surgeon. URINARY RETENTION. The nurse closely monitors the patient’s urinary output after surgery. The nurse encourages the patient to void every 3 to 4 hours to prevent urinary retention and bladder distention. It is important to provide privacy during toileting. Because the patient may need to void in an unusual position, the nurse assists the patient with positioning. Fracture bedpans may be more comfortable to use than other bedpans. Voiding in the side-lying position may be helpful to the male patient. Some male patients can void only if standing, and clarification with the surgeon of the activity prescription may be needed before the patient is assisted to a standing position. If the patient cannot void, intermittent catheterizations may be prescribed until the patient can void independently. Indwelling urinary catheters should be used only when necessary and should be removed as soon as possible. The patient may follow a catheterization protocol that incorporates the use of a bladder scanner to estimate the amount of urine in the bladder, thereby determining if catheterization is necessary. Catheterization protocol use has decreased the number of nosocomial urinary tract infections associated with unnecessary catheterizations (Palese, Buchini, Deroma, et al., 2010). INFECTION. Infection is a risk after any surgery, but it is of particular concern for the postoperative

orthopedic patient because of the risk of osteomyelitis. Osteomyelitis often requires prolonged courses of IV antibiotics. At times, the infected bone and prosthesis or internal fixation device must be surgically removed. Therefore, prophylactic systemic antibiotics are usually prescribed during the perioperative and immediate postoperative periods. The nurse assesses the patient’s response to these antibiotics. When changing dressings and emptying wound drainage devices, aseptic technique is essential. The nurse monitors the patient’s vital signs, incision, and drainage. The nurse monitors the patient for signs of urinary tract infection. Prompt assessment for and treatment of infection are essential. VENOUS THROMBOEMBOLISM AND DEEP VEIN THROMBOSIS. Prevention of DVT requires use of

ankle and calf-pumping exercises, antiembolism stockings, and sequential compression devices. Adequate hydration and early mobilization are equally important. Prophylactic fondaparinux, low-molecularweight heparin (e.g., enoxaparin, dalteparin), warfarin (Coumadin), or low-dose unfractionated heparin may be prescribed in the immediate postoperative period. Typically, fondaparinux, a low-molecular-weight heparin, or warfarin is prescribed during the later rehabilitation period for DVT prophylaxis (Hirsh et al., 2008). The nurse monitors the patient for signs of DVT and promptly reports findings to the physician for management. CONSTIPATION. Constipation is a frequently overlooked complication, because patients are discharged to a rehabilitation or home setting in 3 or 4 days. Constipation occurs because of decreased mobility and hydration, coupled with the use of opioids. Prevention of constipation requires continual monitoring of bowel function. Adequate hydration, early mobilization, and stool softeners may be prescribed to prevent fecal impaction (see Chapter 39).

Promoting Home and Community-Based Care TEACHING THE PATIENT SELF-CARE. Because the length of stay in the hospital after orthopedic surgery is usually 3 or 4 days, most convalescence and rehabilitation take place at home or in a nonacute care setting. The nurse teaches the patient and the family to recognize complications that must be reported promptly to the orthopedic surgeon. The patient must understand the prescribed medication regimen. The nurse should demonstrate proper wound care. The patient gradually resumes physical activities and adheres to weight-bearing limits. The patient must be able to perform transfers and to use mobility aids safely. If the patient has a cast or other immobilizing device, family members are instructed about how to assist the patient in a way that is safe for the patient and for the family member (e.g., using proper body mechanics when assisting the patient). Specific exercises need to be taught and practiced before discharge. The nurse discusses recovery and health promotion, emphasizing a healthy lifestyle and diet (Chart 68-10). CONTINUING CARE. If special equipment or home modifications are needed for safe care at home, they

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must be in place before the patient is discharged home. Discharge planning begins immediately after surgery. The nurse, physical therapist, and social worker can assist the patient and family in identifying their needs and in getting ready to care for the patient at home. Frequently, home health nursing and home physical therapy are part of the discharge plan of care. These referrals provide resources and help the patient and the family cope with the demands of care during recovery and rehabilitation. The nurse assesses the patient’s progress and monitors for possible complications. Regular medical follow-up care after discharge needs to be arranged. The nurse reminds the patient and family about the importance of continuing health promotion and screening practices.

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c. Has clear lung sounds d. Demonstrates wound healing without signs of infection e. Does not experience urinary retention f. Voids clear urine g. Exhibits no signs of DVT or PE h. Does not experience constipation

Critical Thinking Exercises 1

Evaluation Expected Patient Outcomes Expected patient outcomes may include: 1. Reports decreased level of pain a. Uses multiple approaches to reduce pain b. Uses oral analgesic medication as needed to control discomfort c. Elevates extremity to control edema and discomfort d. Moves with greater comfort 2. Exhibits adequate neurovascular function a. Exhibits normal colour and temperature of skin b. Has warm skin c. Has normal capillary refill response d. Demonstrates intact sensory and motor function e. Demonstrates reduced swelling 3. Promotes health a. Eats diet appropriate for nutritional needs b. Maintains adequate hydration c. Abstains from smoking d. Practices respiratory exercises e. Repositions self to relieve pressure on skin f. Engages in strengthening and preventive exercises 4. Maximizes mobility within the therapeutic limits a. Requests assistance when moving b. Elevates edematous extremity after transfer c. Uses immobilizing devices as prescribed d. Complies with prescribed weight-bearing limitation 5. Expresses positive self-esteem a. Discusses temporary or permanent changes in body image b. Discusses role performance c. Views self as capable of assuming responsibilities d. Actively participates in planning care and in the therapeutic regimen 6. Exhibits absence of complications a. Does not experience shock b. Maintains normal vital signs and blood pressure

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A 64-year-old man has had a right total knee replacement for osteoarthritis. On his second postoperative day, he complains to you that he would rather not use his CPM device, and wonders why his participation in physical therapy alone is not sufficient. How would you respond to him? Why is CPM indicated for patients who have had knee replacement surgery? What is the strength of the evidence that supports the use of CPM either singly or in tandem with physical therapy postoperatively in this patient population?

2 A 50-year-old woman has had a repair of a fracture of her right tibia. She has a plaster cast over her right leg, with a window placed over her incision. During the evening of her second postoperative day, she complains of increasing pain and slight paresthesias of her right toes. Opioid analgesic agents have only moderately relieved her pain. The night-shift nurse documents her findings and asks you, as the oncoming day-shift nurse, to report these findings to the orthopedic surgeon when he makes his rounds. You assess the patient after report and find that she now describes her right lower leg as “feeling tight” and that she has sensations of “pins and needles.” Capillary refill of her right toes is longer than 3 seconds, and they feel much cooler than the left toes. What additional assessments might you make at this time? What is your priority nursing diagnosis and intervention? 3

You are an experienced perioperative nurse. You note that different orthopedic surgical groups have different preoperative hygiene protocols for patients undergoing total knee replacement surgery who come to the surgical centre where you work. One surgical group tells its patients to shower with Betadine solution once daily for 2 days prior to surgery; another tells its patients to shower with chlorhexidine solution the morning of surgery; while another does not give any specific preoperative hygiene instructions. What is the strength of the evidence that identifies which preoperative hygiene protocol is most effective for patients scheduled to have total knee replacement surgery?

4 A 70-year-old woman with a long-standing history of osteoarthritis has had a right total hip replacement. On the second postoperative day, a physical therapy assistant helps the patient get out of bed. She has been sitting out of bed for approximately an hour when she requests to be placed back in bed. What is the best way to accomplish this transfer from chair to bed? What specific precautions might you follow?

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REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS National Association of Orthopedic Nurses. (2013). Core curriculum for orthopaedic nursing (7th ed.). Boston, MA: Pearson.

JOURNALS AND ELECTRONIC DOCUMENTS Ennis, R. S., (2014). Deep venous thrombosis prophylaxis in orthopedic surgery. Medscape: http://emedicine.medscape.com/article/1268573overview Eriksson, B. I., Borris, L. C., & Friedman, R. J., et al. (2008). Rivaroxaban versus Enoxaparin for thromboprophylaxis after hip arthroplasty. New England Journal of Medicine, 358, 2765–2775. Gravlee, J. R., & Van Durme, D. J. (2007). Braces and splints for musculoskeletal conditions. American Family Physician, 75(3), 342–348. Haas, S. B., Barrack, R. L., Westrich, G., et al. (2008). Venous thromboembolic disease after total hip and knee arthroplasty. Journal of Bone and Joint Surgery, 90(12), 2763–2780. Harvey, L. A., Brosseau, L., & Herbert, R. D. (2014). Continuous passive motion following total knee arthroplasty in people with arthritis (Review). The Cochrane Library, 2, 1–87. Hawn, M. T., Gray, S. H., Vick, C. C., et al. (2006). Timely administration of prophylactic antibiotics for major surgical procedures. Journal of the American College of Surgeons, 203(6), 803–811. Hessmann, M., Ingelfinger, P., & Rommens, P. M. (2007). Compartment syndrome of the lower extremity. European Journal of Trauma and Emergency Surgery, 33(6), 589–599. Hirsh, J., Guyatt, G., Albers, G. W., et al. (2008). ACCP guidelines: Antithrombotic and thrombolytic therapy. Chest, 133(6), 71S–105S. Holmes, S. B., & Brown, S. J. (2005). Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthopaedic Nursing, 24(2), 99–107. Iyengar, K. P., Ivanovic, N., & Mahale, A. (2007). Targeted early rehabilitation at home after total hip and knee joint replacement: Does it work? Disability and Rehabilitation, 29(6), 495–502. Jamsen, E., Furnes, O., Engesaeter, L. B., et al. (2010). Prevention of deep infection in joint replacement surgery. Acta Orthopaedica, 81(6), 660-666. Janzing, H. M. (2007). Epidemiology, etiology, pathophysiology and diagnosis of the acute compartment syndrome of the extremity. European Journal of Trauma and Emergency Surgery, 33(6), 576–583. Kearon, C., Kahn, S. R., Agnelli, G., et al. (2008). Antithrombotic therapy for venous thromboembolic disease. American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 133(Suppl. 6), 4545–5455. Khan, R. J., Carey-Smith, R. L., Alakeson, R., et al. (2006). Operative and non-operative treatment options for dislocation of the hip following total hip arthroplasty: A perioperative pain experience. Cochrane Database of Systematic Reviews, CD005320. Konstantakos, E. K., Dalstrom, D. J., Nelles, M. E., et al. (2007). Diagnosis and management of extremity compartment syndromes: An orthopaedic perspective. American Surgeon, 73(12), 1199–1209.

Lassen, M. R., Ageno, W., Borris, L. C., et al. (2008). Rivaroxaban versus Enoxaparin for thromboprophylaxis after total knee arthroplasty. New England Journal of Medicine, 358, 2776–2786. Lethaby, A., Temple, J., & Santy, J. (2008). Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews, CD004551. Lucas, B. (2008a). Total hip and total knee replacement: Preoperative nursing management. British Journal of Nursing, 17(21), 1346–1351. Lucas, B. (2008b). Total hip and total knee replacement: Postoperative nursing management. British Journal of Nursing, 17(22), 1410–1414. Marx, R. G., Jones, E. C., Atwan, N. C., et al. (2005). Measuring improvement following total hip and knee arthroplasty using patient-based measures of outcome. Journal of Bone and Joint Surgery, 87(9), 1999–2005. Maxwell, W. (2011). Casting and immobilization. In L. Micheli (Ed.), Encyclopedia of sports medicine. (pp. 242–244). Thousand Oaks, CA: SAGE Publications, Inc. McMurray, A., Grant, S., Griffiths, S., et al. (2005). Mapping recovery after total hip replacement surgery: Health-related quality of life after three years. Australian Journal of Advanced Nursing, 22(4), 20–25. Merrett, N. D., Wilson, R. B., Cosman, P., et al. (2009). Superior mesenteric artery syndrome: Diagnosis and treatment strategies. Journal of Gastrointestinal Surgery, 13(2), 287-292 Milne, S., Brosseau, L., Robinson, V., et al. (2008). Continuous passive motion following total knee arthroplasty. Cochrane Database of Systematic Reviews, CD004260. O’Connor, C., & Murphy, S. (2007). Pneumatic tourniquet use in the perioperative environment. Journal of Perioperative Practice, 17(8), 391–397. Palese, A., Buchini, S., Deroma, L., et al. (2010). The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections: A metaanalysis. Journal of Clinical Nursing, 19 (21–22), 2970–2979. Rasanen, P., Paavoalinen, P., Sintonen, H., et al. (2007). Effectiveness of hip or knee replacement surgery in terms of quality-adjusted life years and costs. Acta Orthopaedica, 78(1), 108–115. Rasul, A. T., (2013). Acute compartment syndrome. Medscape. http:// emedicine.medscape.com/article/307668-overview#aw2aab6b2b2 Royal College of Nursing. (2011). Guidance on pin iste care: Report and recomm4ndations from the 2010 Consensus project on pin site care. Royal College of Nursing: London. http://www.rcn.org.uk/__data/ assets/pdf_file/0009/413982/004137.pdf Sanchez-Sotelo, J., Haidukewych, G. J., & Boberg, C. J. (2006). Hospital cost of dislocation after primary total hip arthroplasty. Journal of Bone and Joint Surgery, 88(2), 290–294. Spiegelberg, B., Parrate, T., Dheerendra, S. K., et al., (2010). Ilizarov principles of deformity correction. Annals of the Royal College of Surgeons of England, 92(2), 101–105. *Stomberg, M. W., & Oman, U. (2006). Patients undergoing total hip arthroplasty: A perioperative pain experience. Journal of Clinical Nursing, 15(4), 451–458.

RESOURCES Canadian Orthopedic Nurses Association (CONA), http://www.conanurse.org/ National Association of Orthopaedic Nurses (NAON), www.orthonurse. org National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, www.niams.nih.gov

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69 Management of Patients With Musculoskeletal Disorders Adapted by Jim Rankin and Karen Then

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the nursing management, rehabilitation, and health education needs of the patient with low back pain. 2. Identify common conditions of the hand or wrist and nursing care of the patient undergoing surgery of the hand or wrist. 3. Describe common conditions of the foot and nursing care of the patient undergoing foot surgery. 4. Explain the pathophysiology, pathogenesis, prevention, and management of osteoporosis. 5. Use the nursing process as a framework for care of the patient with osteoporosis. 6. Identify the causes and related medical management of osteomalacia. 7. Identify medication modalities for the patient with Paget’s disease. 8. Use the nursing process as a framework for care of the patient with osteomyelitis. 9. Describe the nursing management of the patient with a bone tumour.

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Musculoskeletal disorders, particularly impairment of the back and spine, are leading health problems and causes of disability. The functional and psychological limitations imposed on the patient may be severe. The economic costs, in terms of loss of productivity, medical expenses, and other costs that are not compensated, are estimated to exceed $100 billion in direct and indirect costs in North America yearly (Sahar, Cohen, Matan, et al., 2008).

LOW BACK PAIN The number of visits to primary care providers resulting from low back pain is second only to the number of visits for upper respiratory illnesses (Sahar et al., 2008). Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, osteoarthritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg length. Obesity, stress, and occasionally depression may contribute to low back pain. Back pain due to musculoskeletal disorders usually is aggravated by activity, whereas pain due to other conditions is not. Older patients may experience back pain associated with osteoporotic vertebral fractures, osteoarthritis of the spine, and spinal stenosis (Dionyssiotis, 2010). Other causes include kidney disorders, pelvic problems, retroperitoneal tumours, and abdominal aortic aneurysms.

Pathophysiology The spinal column can be considered an elastic rod constructed of rigid units (vertebrae) and flexible units (intervertebral disks) held together by complex facet joints, multiple ligaments, and paravertebral muscles. Its unique construction allows for flexibility while providing maximum protection for the spinal cord. The spinal curves absorb vertical shocks from running and jumping. The trunk muscles help stabilize the spine. The abdominal and thoracic muscles are important in lifting activities, working together to minimize stress on the spinal units. Disuse weakens these supporting muscular structures. Obesity, postural problems, structural problems, and overstretching of the spinal supports may result in back pain (McCance & Huether, 2014). The intervertebral disks change in character as a person ages. A young person’s disks are mainly fibrocartilage with a gelatinous matrix. As a person ages, the fibrocartilage becomes dense and irregularly shaped. Disk degeneration is a common cause of back pain. The lower lumbar disks,

L4–L5 and L5–S1, are subject to the greatest mechanical stress and the greatest degenerative changes. Disk protrusion (herniated nucleus pulposus) or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve (McCance & Huether, 2014). Management of intervertebral disk disease is discussed in Chapter 66.

Clinical Manifestations The typical patient reports either acute back pain (lasting less than 3 months) or chronic back pain (lasting more than 3 months without improvement) and fatigue. The patient may report pain radiating down the leg, which is known as radiculopathy or sciatica; presence of this symptom suggests nerve root involvement. The patient’s gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be affected. Physical examination may disclose paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) with a loss of the normal lumbar curve and possible spinal deformity.

Assessment and Diagnostic Findings The initial evaluation of acute low back pain includes a focused history and physical examination, including general observation of the patient, back examination, and neurologic testing (reflexes, sensory impairment, straightleg raising, muscle strength, and muscle atrophy). The findings suggest either nonspecific back symptoms or potentially serious problems, such as sciatica, spine fracture, cancer, infection, or rapidly progressing neurologic deficit. If the initial examination does not suggest a serious condition, no additional testing is performed during the first 4 weeks of symptoms. The diagnostic procedures described in Chart 69-1 may be indicated for the patient with potentially serious or prolonged low back pain. The nurse prepares the patient for these studies, provides the necessary support during the testing period, and monitors the patient for any adverse responses to the procedures.

Medical Management Most back pain is self-limited and resolves within 4 weeks with analgesic agents, rest, and relaxation. Based on initial assessment findings, the patient is reassured that the assessment indicates that the back pain is not due to a serious

Glossary bursitis: inflammation of a bursa which is a synovial fluid-filled sac contracture: abnormal shortening of muscle or fibrosis of joint structures involucrum: new bone growth around a sequestrum radiculopathy: typically pain, numbness, or weakness in part of the body due to irritation or injury of a nerve root, e.g., sciatic

sciatica: sciatic nerve pain; pain travels down back of thigh into foot sequestrum: piece of necrotic bone typically seen in osteomyelitis tendinitis: inflammation of a tendon

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CHART 69-1

Diagnostic Procedures for Low Back Pain X-ray of the spine—may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis Bone scan and blood studies—may disclose infections, tumours, and bone marrow abnormalities Computed tomography (CT)—useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks Magnetic resonance imaging (MRI)—permits visualization of the nature and location of spinal pathology Electromyogram (EMG) and nerve conduction studies—used to evaluate spinal nerve root disorders (radiculopathies) Myelogram—permits visualization of segments of the spinal cord that may have herniated or may be compressed Ultrasound—useful in detecting tears in ligaments, muscles, tendons, and soft tissues in the back

condition. Management focuses on relief of pain and discomfort, activity modification, and patient education. Nonprescription analgesic agents such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen [Motrin]) and prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain, while tricyclic antidepressants (e.g., amitriptyline [Elavil) are effective in relieving chronic low back pain. Other medications, including opioids (e.g., morphine), tramadol (Ultram), benzodiazepines (e.g., diazepam [Valium]), and gabapentin (Neurontin) (i.e., prescribed for pain from radiculopathy) are also effective, though the evidence of their effectiveness is not as strong as that for the previously noted medications. Systemic corticosteroids are generally not considered effective in alleviating low back pain (Knight, Deyo, Staiger, et al., 2013). Effective nonpharmacologic interventions for acute low back pain include the application of cold Cognitivebehavioural therapy (e.g., biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga are all effective nonpharmacologic interventions for treating chronic low back pain but not acute low back pain (Knight et al., 2013). Most patients need to alter their activity patterns to avoid aggravating the pain. They should avoid twisting, bending, lifting, and reaching, all of which stress the back. The patient is taught to change position frequently. Sitting should be limited to 20 to 50 minutes based on level of comfort. Bed rest is recommended for 1 to 2 days, for a maximum of 4 days and only if pain is severe. A gradual return to activities and a program of low-stress aerobic exercise are recommended. Conditioning exercises for the trunk muscles are begun after about 2 weeks. If there is no improvement within 1 month, additional assessments for physiologic abnormalities are performed. Management is based on findings.

Nursing Assessment The nurse asks the patient with low back pain to describe the discomfort (e.g., location, severity, duration, character-

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istics, radiation, associated weakness in the legs). Descriptions of how the pain occurred—with a specific action (e.g., opening a garage door) or with an activity in which weak muscles were overused (e.g., weekend gardening)— and how the patient has dealt with the pain often suggest areas for intervention and patient teaching. If back pain is a recurrent problem, information about previous successful pain control methods helps in planning current management. The nurse also asks how the back pain affects the patient’s lifestyle. Information about work and recreational activities helps identify areas for back health education. Because stress and anxiety can evoke muscle spasms and pain, the nurse assesses environmental variables, work situations, and family relationships. In addition, the nurse assesses the effect of chronic pain on the emotional well-being of the patient. Referral to a mental health professional (e.g., psychiatric advanced practice nurse) for assessment and management of stressors contributing to the low back pain and related depression may be appropriate. During the interview, the nurse observes the patient’s posture, position changes, and gait. Often, the patient’s movements are guarded, with the back kept as still as possible. The patient often selects a chair of standard seat height with arms for support. The patient may sit and stand in an unusual position, leaning away from the most painful side, and may ask for assistance when undressing for the physical examination. On physical examination, the nurse assesses the spinal curve, any leg length discrepancy, and pelvic crest and shoulder symmetry. The nurse palpates the paraspinal muscles and notes spasm and tenderness. When the patient is in a prone position, the paraspinal muscles relax, and any deformity caused by spasm subsides. The nurse asks the patient to bend forward and then laterally and notes any discomfort or limitations in movement. It is important to determine the effect of these limitations in movement on activities of daily living (ADLs). The nurse evaluates nerve involvement by assessing deep tendon reflexes, sensations (e.g., paresthesia), and muscle strength. Back and leg pain on straight-leg raising (with the patient supine, the patient’s leg is lifted upward with the knee extended) suggest nerve root involvement. Obesity can contribute to low back pain. If the patient is obese, the nurse completes a nutritional assessment (Stephen, Skillen, Day, et al., 2010).

Nursing Management The major nursing goals for the patient may include relief of pain, improved physical mobility, use of back-conserving techniques of body mechanics, improved self-esteem, and weight reduction (as necessary) (Chart 69-2). The nurse assesses the patient’s response to analgesic agents. As the acute pain subsides, medication dosages are reduced. The nurse evaluates and notes the patient’s response to various pain management modalities. (Other generic interventions that may relieve pain are discussed in Chapter 14.) The nurse instructs the patient with severe pain to limit activities for 1 to 2 days. Extended periods of inactivity are not effective and result in deconditioning. A firm, nonsagging mattress (a bed board may be used) is recommended. Lumbar flexion is increased by elevating

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CHART 69-2

Patient Education: Strategies for Treating and Preventing Acute Low Back Pain Treatment • Limit bed rest; keep your knees flexed to decrease strain on your back.

• Try nonpharmacologic approaches such as application of superficial heat or chiropractic therapy.

• Pharmacologic approaches: Take nonsteroidal anti-

inflammatory drugs, acetaminophen (Tylenol), and muscle relaxants as prescribed. • Weight reduction as needed: Modify diet to achieve ideal body weight.

Prevention EXERCISE • Stretch to enhance flexibility. Do strengthening exercises. • Perform prescribed back exercises to increase function, gradually increasing time and repetitions.

the head and thorax 30 degrees using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 69-1). A prone position should be avoided because it accentuates lordosis. The nurse instructs the patient to get out of bed by rolling to one side and placing the legs down while pushing the torso up, keeping the back straight (National Institute of Neurological Disorders and Stroke [NINDS], 2009). As the patient achieves comfort, activities are gradually resumed, and an exercise program is initiated. Initially, low-stress aerobic exercises, such as short walks or swimming, are suggested. After 2 weeks, conditioning exercises for the abdominal and trunk muscles are started. The physical therapist designs an exercise program for the individual patient to reduce lordosis, increase flexibility, and reduce strain on the back. It may include hyperextension exercises to strengthen the paravertebral muscles, flexion exercises to increase back movement and strength, and isometric flexion exercises to strengthen trunk muscles. Each exercise period begins with relaxation. Exercise begins gradually and increases as the patient recovers.

FIGURE 69-1. Positioning to promote lumbar flexion. (© B. Proud.)

BODY MECHANICS • Practice good posture. • Avoid twisting your body. • Push objects rather than pull them. • Keep load close to your body when lifting. • Bend your knees and tighten abdominal muscles when lifting. • Avoid overreaching. • Use a wide base of support. WORK MODIFICATIONS • Adjust work area to avoid stress on back. • Adjust height of chair or work table. • Use lumbar support in chair. • Avoid prolonged standing and repetitive tasks. • Avoid bending, twisting, and lifting heavy objects. • Avoid work involving continuous vibrations.

The nurse encourages the patient to adhere to the prescribed exercise program. The patient should exercise 30 minutes daily using low-impact activities that may include speed walking, swimming, stationary bike riding,

FIGURE 69-2. Proper and improper standing postures. Left, Abdominal muscles contracted, giving a feeling of upward pull, and gluteal muscles contracted, giving a downward pull. Right, Slouch position, showing abdominal muscles relaxed and body out of proper alignment.

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or yoga. Some patients may find it difficult to adhere to a program of prescribed exercises for a long period; in these instances, alternating activities may help facilitate compliance (NINDS, 2009). Patients are encouraged to improve their posture and use good body mechanics on a regular basis. Activities should not cause excessive lumbar strain, twisting, or discomfort; for example, activities such as horseback riding and weight lifting should be avoided. Good body mechanics and posture are essential to avoid recurrence of back pain. The patient must be taught how to stand, sit, lie, and lift properly (Fig. 69-2). Providing the patient with a list of suggestions helps in making these long-term changes (Chart 69-3). The patient who wears high heels is encouraged to change to low heels with good arch support. The patient who is required to stand for long periods should shift weight frequently and should rest one foot on a low stool, which decreases lumbar lordosis. Patients who stand in place for a long period of time (e.g., cashiers) should stand on a foot cushion made of foam or rubber. The proper posture can be verified by looking in a mirror to see whether the chest is up, the abdomen is tucked in, and the shoulders are down and relaxed. Locking the knees when standing is avoided, as is bending forward for long periods. When the patient is sitting, the knees and hips should be flexed, and the knees should be level with the hips or higher to minimize lordosis. The feet should be flat on the floor. The back needs to be supported, so patients should avoid sitting on stools or chairs that do not provide firm back support. The patient should sleep on the side with

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FIGURE 69-3. Proper and improper lifting techniques. Left, Correct

position for lifting. This person is using the long and strong muscles of the arms and legs and holding the object so that the line of gravity falls within the base of support. Right, Incorrect position for lifting because pull is exerted on the back muscles and leaning causes the line of gravity to fall outside the base.

knees and hips flexed, or supine with knees supported in a flexed position. Sleeping prone should be avoided (NINDS, 2009). The nurse instructs the patient in the safe and correct way to lift objects—using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles (Fig. 69-3). With feet placed hip-width apart to provide a wide base of support, the patient should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jarring motions. To prevent recurrence of acute low back

CHART 69-3

Health Promotion: Activities to Promote a Healthy Back Standing Advise the patient to adhere to the following guidelines: • Avoid prolonged standing and walking. • When standing for any length of time, rest one foot on a small stool or box to relieve lumbar lordosis. • Avoid forward flexion work positions. • Avoid high heels.

Sitting Discuss the following strategies with the patient: • Avoid sitting for prolonged periods. • Sit in a straight-back chair with back well supported and arm rests to support some of the body weight; use a footstool to position knees higher than hips if necessary. • Eradicate the hollow of the back by sitting with the buttocks “tucked under.” • Maintain back support; use a soft support at the small of the back. • Avoid knee and hip extension. When driving a car, have the seat pushed forward as far as possible for comfort. • Guard against extension strains—reaching, pushing, sitting with legs straight out. • Alternate periods of sitting with walking.

Lying Encourage the patient to do the following: • Rest at intervals; fatigue contributes to spasm of the back muscles.

• Place a firm bed board under the mattress. • Avoid sleeping in a prone position. • When lying on the side, place a pillow under the head and one between the legs, with the legs flexed at the hips and knees. • When supine, use a pillow under the knees to decrease lordosis.

Lifting Emphasize the importance of the following strategies: • When lifting, keep the back straight and hold the load as close to the body as possible. • Lift with the large leg muscles, not the back muscles. • Use trunk muscles to stabilize the spine. • Squat while keeping the back straight when it is necessary to pick something off the floor. • Avoid twisting the trunk of the body, lifting above waist level, and reaching up for any length of time.

Exercising Daily exercise is important in the prevention of back problems. • Walk daily and gradually increase the distance and pace of walking. • Perform prescribed back exercises twice daily, increasing exercise gradually. • Avoid jumping and jarring activities.

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pain, the nurse may instruct the patient to avoid lifting more than one-third of his or her weight without help. Because of the immobility associated with low back pain, the patient may depend on other people to do various tasks. Role-related responsibilities may have been modified with the onset of low back pain. As recovery from acute low back pain and immobility progresses, the patient may resume former role-related responsibilities. However, if these activities contributed to the development of low back pain, it may be difficult to resume them without the development of chronic low back pain, with associated disability and depression. If the patient experiences secondary gains associated with low back disability (e.g., worker’s compensation, easier lifestyle or workload, increased emotional support), a “low back neurosis” may develop. The patient may need help in coping with specific stressors and in learning how to control stressful situations. Psychotherapy or counselling may be needed to assist the person in resuming a full, productive life. Back clinics use multidisciplinary approaches to help the patient with pain and with resumption of role-related responsibilities. Obesity contributes to back strain by stressing the relatively weak back muscles. Exercises are less effective and more difficult to perform when the patient is overweight. Weight reduction through diet modification may prevent recurrence of back pain. Weight reduction is based on a sound nutritional plan that includes a change in eating habits to maintain desirable weight. Monitoring weight reduction, noting achievement, and providing encouragement and positive reinforcement facilitate adherence. Frequently, back problems resolve as optimal weight is achieved (NINDS, 2009).

COMMON UPPER EXTREMITY PROBLEMS The structures in the upper extremities are frequently the sites of painful syndromes. The structures most frequently affected are the shoulder, wrist, and hand.

Bursitis and Tendinitis Bursitis and tendinitis are inflammatory conditions that commonly occur in the shoulder. Bursae are fluid-filled sacs that prevent friction between joint structures during joint activity. When inflamed, they are painful. Similarly, muscle tendon sheaths become inflamed with repetitive stretching. The inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement. Traditional conservative treatment includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs to control the inflammation and pain. Newer therapies that include extracorporeal shock wave therapy (i.e., use of focused high-intensity acoustic radiation), pulsed magnetic field therapy, laser phototherapy, and radiofrequency coblation therapy (i.e., use of focused radiowaves) may accelerate tendon healing. A meta-analysis has demonstrated the efficacy of laser phototherapy for pain in soft tissue conditions (Fulop, Dhimmer, Deluca, et al., 2010).

Arthroscopic synovectomy may be considered if shoulder pain and weakness persist.

Loose Bodies Loose bodies may occur in a joint as a result of articular cartilage wear and bone erosion. These fragments interfere with joint movement, locking the joint, resulting in painful movement. Loose bodies are removed by arthroscopic surgery.

Impingement Syndrome Impingement syndrome is a general term that describes all lesions that involve the rotator cuff of the shoulder (Dixon, Kruse, & Simons, 2013). Impingement usually occurs from repetitive overhead movement of the arm or from acute trauma (Dixon et al., 2013; Trojian, Stevenson, & Agrawal, 2005), resulting in irritation and eventual inflammation of the rotator cuff tendons or the subacromial bursa as they grate against the coracoacromial arch. Stage I impingement syndrome is characterized by edema and hemorrhage of the rotator cuff tendons or subacromial bursa (Dixon et al., 2013). The patient experiences pain, shoulder tenderness, limited movement, muscle spasm, and eventual atrophy. The process may progress to a partial or complete rotator cuff tear (referred to as Stage II or Stage III impingement syndrome, respectively) (Trojian et al., 2005 see Chapter 70 for a discussion of rotator cuff tears). Medications used to treat Stage I impingement syndrome include oral NSAIDs (e.g., ibuprofen) or intraarticular (i.e., subacromial) injections of corticosteroids (e.g., triamcinolone [Aristocort]). Treatment with corticosteroids generally results in speedier symptomatic improvement than that with NSAIDs, though the use of both medications concomitantly does not appear to confer any additional improvements (Dixon et al., 2013; Trojian et al., 2005). Application of superficial cold or heat does not improve patients’ symptoms, but a therapeutic exercise program (e.g., physical therapy) does reduce pain and improve shoulder function (Dixon et al., 2013) (Chart 69-4).

Carpal Tunnel Syndrome Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass. It most commonly occurs in women between 30 and 60 years of age. It is commonly caused by repetitive hand and wrist movements, but it may also be associated with arthritis, diabetes, tumours, or trauma (Barbosa, Rodrigues, Tamanini, et al., 2012). Patients who perform repetitive movements or those whose hands are repeatedly exposed to cold temperatures, vibrations, or extreme direct pressure are at an increased risk for carpal tunnel syndrome. The patient experiences pain, numbness, paresthesia, and possibly weakness along the median nerve (thumb, index, and middle fingers). Tinel’s

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CHART 69-4

Patient Education: Measures to Promote Shoulder Healing of Impingement Syndrome • Rest the joint in a position that minimizes stress on the • • • •

joint structures to prevent further damage and the development of adhesions. Support the affected arm on pillows while sleeping to keep from turning onto the shoulder. Gradually resume motion and use of the joint. Assistance with dressing and other activities of daily living may be needed. Avoid working and lifting above shoulder level or pushing an object against a “locked” shoulder. Perform the prescribed daily range-of-motion and strengthening exercises.

sign may be used to help identify carpal tunnel syndrome (Fig. 69-4). The Hand Elevation Test (HET) is more sensitive (88%) and specific (98%) (Amirfeyz, Gozzard, & Leslie, 2005). Night pain is common. Treatment of carpal tunnel syndrome is based on the cause of the condition. Research findings suggest that intra-articular injections of corticosteroids (e.g., methylprednisolone [Medrol]) or oral corticosteroids (e.g., prednisone) are very effective at relieving symptoms. Application of wrist splints to prevent hyperextension and prolonged flexion of the wrist are also effective interventions. However, yoga, laser therapy, and ultrasound therapy are ineffective therapies, as are the use of NSAIDs, diuretics, and vitamin B6 (Piazzini, Aprile, Ferrara, et al., 2007). Traditional open nerve release or endoscopic laser surgery are the two most common surgical management options for treatment of carpal tunnel syndrome. Both of these procedures are performed under local anesthesia and involve making small incisions into the affected

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wrist, cutting the carpal ligament so that the carpal tunnel is widened. Smaller incisions are made with the endoscopic laser procedure, and there is less scar formation and a shorter recovery time than with the open method. Following either of these procedures, the patient wears a hand splint and limits hand use during healing. The patient may need assistance with personal care and ADLs. Full recovery of motor and sensory function after either type of nerve release surgery may take several weeks or months.

Ganglion A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It most frequently occurs in women younger than 50 years. The ganglion is locally tender and may cause an aching pain. When a tendon sheath is involved, weakness of the finger occurs. Treatment may include aspiration, corticosteroid injection, or surgical excision. After treatment, a compression dressing and immobilization splint are used.

Dupuytren’s Disease Dupuytren’s disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren’s contracture, which causes flexion of the fourth and fifth fingers, and frequently the middle finger. This renders the fingers more or less useless (Fig. 69-5). It is caused by an inherited autosomal dominant trait and occurs most frequently in men who are older than 50 years and who are of Scandinavian or Celtic origin. It is also associated with arthritis, diabetes, gout, cigarette smoking, and alcoholism (Black & Blazar, 2011). It starts as a nodule of the palmar fascia. The nodule may not change, or it may progress so that the fibrous thickening extends to involve the skin in the distal palm and produces a contracture of the fingers. The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected. Finger-stretching exercises or intranodular injections of cortico steroids (e.g., triamcinolone) may prevent contractures (Trojian & Chu, 2007). With contracture development, palmar and digital fasciectomies are performed to improve function. Finger exercises are begun on postoperative day 1 or 2.

FIGURE 69-4. Tinel’s sign may be elicited in patients with carpal tun-

nel syndrome by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the patient reports tingling, numbness, and pain, the test for Tinel’s sign is considered positive. (From Weber, J. W., & Kelley, J. (2006). Health assessment in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. © B. Proud.)

FIGURE 69-5. Dupuytren’s contracture, a flexion deformity caused by an inherited trait, is a slowly progressive contracture of the palmar fascia, which severely impairs the function of the fourth, fifth, and sometimes, middle finger.

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Nursing Management of the Patient Undergoing Surgery of the Hand or Wrist Surgery of the hand or wrist, unless related to major trauma, is generally an ambulatory procedure. Before surgery, the nurse assesses the patient’s level and type of discomfort and limitations in function caused by the ganglion, carpal tunnel syndrome, Dupuytren’s contracture, or other condition of the hand. Neurovascular assessment of the exposed fingers every hour for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion of the hand. The nurse instructs the patient and any family caregivers on these parameters for periodic neurovascular assessment and gives instructions on when to notify the physician. The nurse compares the affected hand with the unaffected hand and the postoperative status with the documented preoperative status. The patient describes sensations in the hands and demonstrates finger mobility. With tendon repairs and nerve, vascular, or skin grafts, motor function is tested as necessary. The temperature of the affected hand is assessed. Dressings provide support but are nonconstrictive. Pain uncontrolled by analgesic agents suggests compromised neurovascular functioning. Pain may be related to surgery, edema, hematoma formation, or restrictive bandages. To control swelling that may increase the patient’s pain and discomfort, the nurse instructs the patient to elevate the hand to heart level with pillows. If the patient is ambulatory, the arm is elevated in a conventional sling with the hand at heart level. Intermittent use of ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control edema. Unless contraindicated, active extension and flexion of the fingers to promote circulation are encouraged, even though movement is limited by the bulky dressing. Generally, the pain and discomfort can be controlled by oral analgesic agents. If the patient is hospitalized, the nurse evaluates the patient’s response to analgesic agents and to other pain control measures. Patient education concerning analgesic agents is important. During the first few days after surgery, the patient needs assistance with ADLs because one hand is bandaged and independent self-care is impaired. The patient may need to arrange for assistance with feeding, bathing and hygiene, dressing, grooming, and toileting. Within a few days, the patient develops skills in one-handed ADLs and is usually able to function with minimal assistance and use of assistive devices. The nurse encourages the patient to use the involved hand, unless contraindicated, within the limits of discomfort. As rehabilitation progresses, the patient resumes use of the injured hand. Physical or occupational therapy–directed exercises may be prescribed. The nurse emphasizes compliance with the therapeutic regimen. As with all surgery, there is a risk of infection. The nurse teaches the patient to monitor temperature and signs and symptoms that suggest an infection. It also is important to instruct the patient to keep the dressing clean and dry and to report any drainage, foul odour, or increased pain and swelling. Patient education includes aseptic wound care as

well as education related to prescribed prophylactic antibiotics.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. After the patient has undergone hand surgery, the nurse teaches the patient how to monitor neurovascular status and the signs of complications that need to be reported to the surgeon (e.g., paresthesia, paralysis, uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding, purulent drainage, fever). The nurse discusses prescribed medications with the patient. In addition, the nurse teaches the patient to elevate the hand above the elbow and to apply ice (if prescribed) to control swelling. Unless contraindicated, the nurse encourages extension and flexion exercises of the fingers to promote circulation. The use of assistive devices is encouraged if they would be helpful in promoting accomplishment of ADLs. For bathing, the nurse instructs the patient to keep the dressing dry by covering it with a secured plastic bag. Generally, the wound is not redressed until the patient’s follow-up visit with the surgeon (Chart 69-5).

COMMON FOOT PROBLEMS Disorders of the foot may be caused by poorly fitting shoes, which distort normal anatomy while inducing deformity and pain. Dermatologic problems commonly affect the feet in the form of fungal infections and plantar warts. Several systemic diseases affect the feet. Patients with diabetes are prone to develop corns and peripheral neuropathies with diminished sensation, leading to ulcers at pressure points of the foot. Patients with peripheral vascular disease and arteriosclerosis complain of burning and itching feet, resulting in scratching and skin breakdown. Foot deformities may occur with rheumatoid arthritis. Obesity can cause a host of foot anomalies, including plantar fasciitis (Orchard, 2012). The discomforts of foot strain are treated with rest, elevation, physiotherapy, supportive strappings, and orthotic devices. The patient must inspect the foot and skin under pads and orthotic devices for pressure and skin breakdown daily. If a “window” is cut into shoes to relieve pressure over a bony deformity, the skin must be monitored daily for breakdown from pressure exerted at the “window” area. Active foot exercises promote circulation and help strengthen the feet. Walking in properly fitting shoes is considered the ideal exercise.

Plantar Fasciitis Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Management includes stretching exercises, wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports, night splints), and corticosteroid injections (Cole, Seto, & Gazewood, 2005). Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.

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Management of Patients With Musculoskeletal Disorders

CHART 69-5

HOME CARE CHECKLIST •

Hand Surgery Patient

Caregiver

• Demonstrate how to assess neurovascular status.

✔

✔

• State abnormal findings (e.g., unrelenting pain; paralysis; paresthesia; cool, nonblanching

✔

✔

• Demonstrate control of edema by elevating hand above elbow and applying ice intermit-

✔

✔

• Identify signs and symptoms of infection (e.g., elevated temperature, purulent drainage).

✔

✔

• Demonstrate finger exercises to promote circulation, unless contraindicated.

✔

• Describe methods to prevent wound infection (e.g., keeping hand dressing clean and dry

✔

✔

• Describe use of prescribed medications.

✔

✔

• Demonstrate use of assistive devices, if appropriate.

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

fingers) to report to physician promptly. tently if prescribed.

during activities of daily living).

Corn A corn is an area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of a congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is the most frequent, but any toe may be involved. Corns are treated by a podiatrist by soaking and scraping off the horny layer, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure. Soft corns are located between the toes and are kept soft by moisture. Treatment consists of drying the affected spaces and separating the affected toes with lamb’s wool or gauze. A wider shoe may be helpful. Usually, a podiatrist is consulted to treat the underlying cause.

or granulation tissue may develop. This painful condition is caused by improper self-treatment, external pressure (tight shoes or stockings), internal pressure (deformed toes, growth under the nail), trauma, or infection. Trimming the nails properly (clipping them straight across and filing the corners consistent with the contour of the toe) can prevent this problem. Active treatment consists of washing the foot twice a day, followed by the application of a local antibiotic ointment, and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue. Warm, wet soaks help drain an infection. A toenail may need to be excised by the podiatrist if there is severe infection.

Hammer Toe

A callus is a discretely thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus. Treatment consists of eliminating the underlying causes and having the callus treated by a podiatrist if it is painful. A keratolytic ointment may be applied and a thin plastic cup worn over the heel if the callus is on this area. Felt padding with an adhesive backing is also used to prevent and relieve pressure. Orthotic devices can be made to remove the pressure from bony protuberances, or the protuberance may be excised.

Hammer toe is a flexion deformity of the interphalangeal joint, which may involve several toes (Fig. 69-6A). The condition is usually an acquired deformity. Tight socks or shoes may push an overlying toe back into the line of the other toes. The toes usually are pulled upward, forcing the metatarsal joints (ball of the foot) downward. Corns develop on top of the toes, and tender calluses develop under the metatarsal area. The treatment consists of conservative measures: wearing open-toed sandals or shoes that conform to the shape of the foot, carrying out manipulative exercises, and protecting the protruding joints with pads. Surgery (osteotomy) may be used to correct a resulting deformity. There is little evidence to support treatment of hammer toe when the patient does not report pain or other symptoms (Badlissi, Dunn, Link, et al., 2005).

Ingrown Toenail

Hallux Valgus

An ingrown toenail (onychocryptosis) is a condition in which the free edge of a nail plate penetrates the surrounding skin, either laterally or anteriorly. A secondary infection

Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally (Fig. 69-6C). Associated with this is a marked prominence of the medial

Callus

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tus of the toes is assessed. The duration of immobility and initiation of ambulation depend on the procedure used. Toe flexion and extension exercises are initiated to facilitate walking. Shoes that fit the shape and size of the foot are recommended.

Pes Cavus A Hammer toe

B Pes cavus (claw foot)

Pes cavus (claw foot) refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot (Fig. 69-6B). The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum of the foot. Charcot–Marie–Tooth disease (a peripheral neuromuscular disease associated with a familial degenerative disorder), diabetes mellitus, and tertiary syphilis are common causes of pes cavus. Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes. Orthotic devices alleviate pain and can protect the foot (Burns, Landorf, Ryan, et al., 2008). In severe cases, arthrodesis (fusion) is performed to reshape and stabilize the foot.

Morton’s Neuroma C Hallux valgus (bunion) Tibial nerve Medial plantar nerve Lateral plantar nerve Site of neurofibroma (Morton’s)

D Neurofibroma (Morton’s neuroma) FIGURE 69-6. Common foot deformities.

aspect of the first metatarsophalangeal joint. There is also osseous enlargement (exostosis) of the medial side of the first metatarsal head, over which a bursa may form (secondary to pressure and inflammation). Acute bursitis symptoms include a reddened area, edema, and tenderness. Factors contributing to bunion formation include heredity, ill-fitting shoes, and gradual lengthening and widening of the foot associated with aging. Osteoarthritis is frequently associated with hallux valgus. Treatment depends on the patient’s age, the degree of deformity, and the severity of symptoms. If a bunion deformity is uncomplicated, wearing a shoe that conforms to the shape of the foot or that is molded to the foot to prevent pressure on the protruding portions may be the only treatment needed. Corticosteroid injections control acute inflammation. Surgical removal of the bunion (exostosis) and osteotomies to realign the toe may be required to improve function, appearance, and symptoms (Wexler, Grosser, & Kile, 2008). Complications related to bunionectomy include limited range of motion, paresthesias, tendon injury, and recurrence of deformity. Postoperatively, the patient may have intense throbbing pain at the operative site, requiring opioid analgesia (e.g., morphine). The foot is elevated to the level of the heart to decrease edema and pain. The neurovascular sta-

Morton’s neuroma (plantar digital neuroma, neurofibroma) is a swelling of the third (lateral) branch of the median plantar nerve (Fig. 69-6D). The third digital nerve, which is located in the third intermetatarsal (web) space, is most commonly involved. Microscopically, digital artery changes cause an ischemia of the nerve. The result is a throbbing, burning pain in the foot that is usually relieved when the patient rests. Conservative treatment consists of inserting innersoles and metatarsal pads designed to spread the metatarsal heads and balance the foot posture. Local injections of a corticosteroid (e.g., hydrocortisone [Acticort]) and a local anesthetic agent may provide relief. If these fail, surgical excision of the neuroma is necessary. Pain relief and loss of sensation are immediate and permanent.

Flat Foot Flat foot (pes planus) is a common disorder in which the longitudinal arch of the foot is diminished. It may be caused by congenital abnormalities or associated with bone or ligament injury, muscle and posture imbalances, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis. Signs and symptoms include a burning sensation, fatigue, clumsy gait, edema, and pain. Exercises to strengthen the muscles and to improve posture and walking habits are helpful. A number of foot orthoses are available to give the foot additional support.

Nursing Management of the Patient Undergoing Foot Surgery Surgery of the foot may be necessary because of various conditions, including neuromas and foot deformities

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(bunion, hammer toe, claw foot). Generally, foot surgery is performed on an outpatient basis. Before surgery, the nurse assesses the patient’s ambulatory ability and balance and the neurovascular status of the foot. In addition, the nurse considers the availability of assistance at home and the structural characteristics of the home in planning for care during the first few days after surgery. After surgery, neurovascular assessment of the exposed toes every 1 to 2 hours for the first 24 hours is essential to monitor the function of the nerves and the perfusion of the tissues. If the patient is discharged within several hours after the surgery, the nurse teaches the patient and family how to assess for edema and neurovascular status (circulation, motion, sensation). Compromised neurovascular function can increase the patient’s pain (Chart 67-3 in Chapter 67). Pain experienced by patients who undergo foot surgery is related to inflammation and edema. Formation of a hematoma may contribute to the discomfort. To control the edema, the foot should be elevated on several pillows when the patient is sitting or lying. Ice packs applied intermittently to the surgical area during the first 24 to 48 hours may be prescribed to control edema and provide some pain relief. As activity increases, the patient may find that dependent positioning of the foot is uncomfortable. Simply elevating the foot often relieves the discomfort. Oral analgesic agents may be used to control the pain. The nurse instructs the patient and family about appropriate use of these medications. After surgery, the patient will have a bulky dressing on the foot, protected by a light cast or a special protective boot. Limits for weight bearing on the foot will be prescribed by the surgeon. Some patients are allowed to walk on the heel and progress to weight bearing as tolerated; other patients are restricted to non–weight-bearing activities. Assistive devices (e.g., crutches, walker) may be needed. The choice of the devices depends on the patient’s general condition and balance and on the weight-bearing prescription. Safe use of the assistive devices must be ensured through adequate patient education and practice before discharge. Strategies to move around the house safely while using assistive devices are discussed with the patient. As healing progresses, the patient gradually resumes ambulation within prescribed limits. The nurse emphasizes compliance with the therapeutic regimen. Any surgery carries a risk of infection. In addition, percutaneous pins may be used to hold bones in position, and these pins serve as potential sites for infection. Care must be taken to protect the surgical wound from dirt and moisture. When bathing, the patient can secure a plastic bag over the dressing to prevent it from getting wet. Patient instructions concerning aseptic wound care and pin care may be necessary. The nurse teaches the patient to monitor for temperature changes and infection. Drainage on the dressing, a foul odour, or increased pain and swelling could indicate infection. The nurse instructs the patient to promptly report any of these findings to the physician. If prophylactic antibiotics are prescribed, the nurse provides instruction about their correct use. The nurse plans patient teaching for home care, focusing on neurovascular status, pain management, mobility, and wound care (Chart 69-6).

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CHART 69-6

Patient Education: Self-Care After Foot Surgery Neurovascular Status The following signs and symptoms indicate impaired circulation and should be reported to your health care provider right away: • Change in sensation • Inability to move toes • Toes or foot cool to touch • Colour changes

Pain Management Methods to reduce pain include the following: • Elevate foot to heart level. • Apply ice as prescribed. • Use analgesic agents as prescribed. • Report pain that is not relieved.

Mobility • Use assistive devices safely. • Comply with prescribed weight-bearing limits. • Wear special protective shoe over the dressing.

Wound Care • Keep the dressing or cast clean and dry. • Report signs of wound infection (e.g., pain, drainage, fever) immediately.

• Follow the prescribed antibiotic regimen. • Keep your appointment with the surgeon for the initial dressing change.

METABOLIC BONE DISORDERS Osteoporosis Osteoporosis is the most prevalent bone disease in the world. More than 10 million Americans have osteoporosis and an additional 33.6 million have osteopenia, the precursor to osteoporosis. The consequence of osteoporosis is bone fracture. It is projected that one of every two Caucasian women and one of every five men will have an osteoporosis-related fracture at some point in their lives (National Osteoporosis Foundation [NOF], 2008; Osteoperosis Canada, 2014; Papaioannou, Morin, Cheung, et al., 2010).

Prevention Peak adult bone mass is achieved between the ages of 18 and 25 years in both females and males and is affected by genetic factors. Bone mass during these years is affected by nutrition, physical activity, medications, endocrine status, and general health (NOF, 2008; Osteoporosis Canada, 2014). Risk factors for osteoporosis and their effects on bone remodeling and maintenance are noted in Figure 69-7. Primary osteoporosis occurs in women after menopause (usually between the ages of 45 and 55 years) and in men later in life, but it is not merely a consequence of aging. Failure to develop optimal peak bone mass during

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Genetics • Caucasian or Asian • Female • Family history • Small frame

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Musculoskeletal Function

Predisposes to low bone mass

Age • Postmenopause • Advanced age • Low testosterone in men • Decreased calcitonin

Hormones (estrogen, calcitonin, and testosterone) inhibit bone loss

Nutrition • Low calcium intake • Low vitamin D intake • High phosphate intake (carbonated beverages) • Inadequate calories

Reduces nutrients needed for bone remodeling

Physical exercise • Sedentary • Lack of weight-bearing exercise • Low weight and body mass index

Bones need stress for bone maintenance

Lifestyle choices • Caffeine • Alcohol • Smoking • Lack of exposure to sunlight

Reduces osteogenesis in bone remodeling

Medications for example, corticosteroids, antiseizure medications, heparin, thyroid hormone Comorbidity for example, anorexia nervosa, hyperthyroidism, malabsorption syndrome, renal failure

Affects calcium absorption and metabolism

FIGURE 69-7. Risk factors for osteoporosis, and the effects of these

factors on bone.

childhood, adolescence, and young adulthood contributes to the development of osteoporosis. Early identification of at-risk teenagers and young adults, increased calcium intake, participation in regular weight-bearing exercise, and modification of lifestyle (e.g., reduced use of caffeine, cigarettes, carbonated soft drinks, and alcohol) are interventions that decrease the risk of osteoporosis, fractures, and associated disability later in life (NOF, 2008; Osteoporosis Canada, 2014). Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism. Specific disease states (e.g., celiac disease, hypogonadism) and medications (e.g., corticosteroids, antiseizure medications) that place patients at risk need to be identified and therapies instituted to reverse the development of osteoporosis (NOF, 2008; Osteoporosis Canada, 2014). The

degree of osteoporosis is related to the duration of medication therapy. When the therapy is discontinued or the metabolic problem is corrected, the progression of osteoporosis is halted, but restoration of lost bone mass usually does not occur.

Gerontologic Considerations The prevalence of osteoporosis in women older than 80 years is 50%. The average 75-year-old woman has lost 25% of her cortical bone and 40% of her trabecular bone. With the aging of the population, the incidence of fractures (more than 1.5 million osteoporotic fractures per year), pain, and disability associated with osteoporosis is increasing. Most residents of long-term care facilities have a low bone mineral density (BMD) and are at risk for bone fracture. Asymptomatic osteoporotic-related vertebral fractures are associated with loss of height, respiratory dysfunction, increased risk of mortality, and increased risk of subsequent fractures. Older men are also at heightened risk for osteoporosis and fractures. One-third of all hip fractures occur among men and these tend to be more lethal than those seen in women. Men are more likely than women to have secondary causes of osteoporosis that may lead to fractures, including use of corticosteroids (e.g., prednisone) and excessive alcohol intake (Ebeling, 2008). Older people absorb dietary calcium less efficiently and excrete it more readily through their kidneys; therefore, postmenopausal women and the older need to consume approximately 1,200 mg of daily calcium; quantities larger than this may place patients at heightened risk for renal calculi (i.e., kidney stones) or cardiovascular disease (NOF, 2008; Osteoporosis Canada, 2014).

Pathophysiology Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. Normal homeostatic bone turnover is altered; the rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass. The bones become progressively porous, brittle, and fragile; they fracture easily under stresses that would not break normal bone. These increase susceptibility to fracture, which occur most commonly as compression fractures (Fig. 69-8) of the thoracic and lumbar spine, hip fractures, and Colles’ fractures of the wrist. These fractures may be the first clinical manifestation of osteoporosis (McCance & Huether, 2014). The gradual collapse of a vertebra may be asymptomatic; it is observed as progressive kyphosis. With the development of kyphosis (i.e., “dowager’s hump”), there is an associated loss of height (Fig. 69-9). The postural changes result in relaxation of the abdominal muscles and a protruding abdomen. The deformity may also produce pulmonary insufficiency. Age-related loss begins soon after the peak bone mass is achieved (i.e., in the fourth decade). Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased. Estrogen, which inhibits bone breakdown, decreases with aging. On the other hand, parathyroid

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develop osteoporosis more frequently and more extensively than men because of lower peak bone mass and the effect of estrogen loss during menopause. More than half of all women older than 50 years show evidence of osteopenia.

Risk Factors

FIGURE 69-8. Progressive osteoporotic bone loss and compression fractures. From Rubin, E., Gorstein, F., Schwarting, R., et al. (2004). Pathology (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

hormone (PTH) increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. The withdrawal of estrogens at menopause or with oophorectomy causes an accelerated bone resorption that continues during the postmenopausal years. Women 5'6" 5'3" 5'0" 4'9"

Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis (Fig. 69-7). Also, Asian women of slight build are at risk for low peak BMD. African American women, who have a greater bone mass than Caucasian women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction. As a result, osteoporosis occurs in men at a lower rate and at an older age (about one decade later). It is believed that testosterone and estrogen are important in achieving and maintaining bone mass in men. Risk for osteoporosis increases with increasing age (Chart 69-7). Nutritional factors contribute to the development of osteoporosis. A diet that includes adequate calories and nutrients needed to maintain bone, calcium, and vitamin D must be consumed. Vitamin D is necessary for calcium absorption and for normal bone mineralization. Dietary calcium and vitamin D must be adequate to maintain bone remodeling and body functions. The best source of calcium and vitamin D is fortified milk. A cup of milk or calcium-fortified orange juice contains about 300 mg of calcium. The recommended adequate intake (RAI) level of calcium for all individuals is 1,000 to 1,200 mg daily (Osteoporosis Canada, 2014). The recommended vitamin D intake for adults of 50 years of age and older is 800 to 1,000 international units (IU) daily (NOF, 2008). Patients who have had bariatric surgery are at increased risk for osteoporosis as the duodenum is bypassed, which is the primary site for absorption of calcium (Hogan, 2005), as are patients who have gastrointestinal diseases that cause malabsorption (e.g., celiac disease). Bone formation is enhanced by the stress of weight and muscle activity. Resistance and impact exercises are most beneficial in developing and maintaining bone mass. Immobility contributes to the development of osteoporosis. When immobilized by casts, general inactivity, paralysis, or other disability, the bone is resorbed faster than it is formed, and osteoporosis results (Porth & Matfin, 2009).

Assessment and Diagnostic Findings

10 yrs. postmenopause

15 yrs. postmenopause height loss 1.5"

25 yrs. postmenopause height loss 3.5"

FIGURE 69-9. Typical loss of height associated with osteoporosis and

aging.

Osteoporosis may be undetectable on routine x-rays until there has been 25% to 40% demineralization, resulting in radiolucency of the bones. When the vertebrae collapse, the thoracic vertebrae become wedge shaped and the lumbar vertebrae become biconcave. Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DXA), which provides information about BMD at the spine and hip (see Chapter 67 for further discussion of tests for BMD). The DXA scan data are analyzed and reported as T-scores (the number of standard deviations [SDs] above or below the average BMD value for a young, healthy Caucasian woman). BMD testing is recommended for all women older than 65 years of age, for all men older than 70 years of age, for postmenopausal women and men older than 50 years of

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NURSING RESEARCH PROFILE

Chart 69-7. Beliefs of Osteoporosis Risks in Men and Women 50 Years of Age and Older Doheny, M. O., Sedlak, C. A., Estok, P. J., et al. (2007). Osteoporosis knowledge, health beliefs, and DXA T-scores in men and women 50 years of age and older. Orthopaedic Nursing, 26(4), 243–250. Purpose Osteoporosis is prevalent among older adults, particularly women older than 65 years of age. Although older men and postmenopausal women are at lesser risk for osteoporosis than older women, these populations of adults are nonetheless at risk. Yet, contemporary society seems to identify that osteoporosis is a disease of older women. The threefold purposes of this study were to determine if there was a difference in knowledge about osteoporosis, a difference in health beliefs related to osteoporosis, and a difference in bone density scores between men older than 50 years of age and women between 50 and 65 years of age. Design This study utilized a secondary analysis of data from a prior study of 218 healthy community-based women who were between 50 and 65 years of age and 226 healthy communitybased men who were at least 50 years of age. These study participants responded to the 24-item Osteoporosis Knowledge Test (OKT), the 42-item Osteoporosis Health Belief Scale (OHBS), and the 12-item Osteoporosis Self-Efficacy Scale (OSES). In addition, they had dual-energy x-ray

age with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis (Public Health Agency of Canada, 2009; osteoporosis Canada, 2014). BMD studies are useful in identifying osteopenic and osteoporotic bone and in assessing response to therapy. Through early screening (using both assessment of risk factors and BMD scans), promotion of adequate dietary intake of calcium and vitamin D, encouragement of lifestyle changes, and early institution of preventive medications, bone loss, and osteoporosis can be reduced, resulting in a reduced incidence of fracture. The WHO Fracture Risk Assessment Tool is a useful online questionnaire for determining the 10-year probability fracture risk (FRAX, 2014). Laboratory studies (e.g., serum calcium, serum phosphate, serum alkaline phosphatase, urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]) and x-ray studies are used to exclude other possible disorders (e.g., multiple myeloma, osteomalacia, hyperparathyroidism, malignancy) that contribute to bone loss.

Medical Management A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence, young adulthood, and the middle years, protects against skeletal demineralization. Such a diet includes three glasses of skim or whole vitamin D–enriched milk or other foods high in calcium (e.g., cheese and other dairy products,

absorptiometry (DXA) scans performed that yielded T-scores. Findings Neither the women nor men in the sample were knowledgeable about osteoporosis, although the women’s mean OKT scores were higher than the men’s scores. Men believed that they were less susceptible to osteoporosis, thought that it was less serious, had less faith in the efficacy of calcium in preventing and treating osteoporosis, and felt that there were fewer barriers to exercise to prevent osteoporosis than the sampled women. Less than half of the sampled men and women had normal DXA T-scores. Less than half of each group had T-scores that were consistent with osteopenia; approximately 10% of each sample had T-scores consistent with osteoporosis. Nursing Implications Both men and women are at risk for osteoporosis by the time they reach the age of 50, yet few of these adults believe that they are at risk. Results from this study suggest that as many as 10% of healthy men who are at least 50 years of age and healthy women who are between 50 and 65 years of age may already have osteoporosis. Nurses are in ideal positions to educate these adults about their risks and provide them with education aimed at preserving bone matrix and preventing fractures associated with osteoporosis.

steamed broccoli, canned salmon with bones) daily. Osteoporosis Canada has an extremely useful link for information on calcium supplementation (See “Calculate my Calcium”, Osteoporosis Canada, 2014). Regular weight-bearing exercise promotes bone formation. From 20 to 30 minutes of aerobic exercise (e.g., walking), 3 days or more a week, is recommended. Weight training stimulates an increase in BMD. In addition, exercise improves balance, reducing the incidence of falls and fractures (Chart 69-8).

Pharmacologic Therapy The first-line medications used to treat and prevent osteoporosis include calcium and vitamin D supplements and bisphosphonates. To ensure adequate calcium intake, a calcium supplement (e.g., Caltrate, Citracal) with vitamin D may be prescribed and taken with meals or with a beverage high in vitamin C to promote absorption. The recommended daily dose should be split and not taken as a single dose. Common side effects of calcium supplements are abdominal distention and constipation. Other medications that might be prescribed after these medications are tried include calcitonin, selective estrogen receptor modulators (SERMs), and anabolic agents (Johnson, Clifford & Smith, 2008). Bisphosphonates that include daily or weekly oral preparations of alendronate (Fosamax) or risedronate (Actonel), monthly oral preparations of ibandronate (Boniva), or yearly intravenous (IV) infusions of zoledronic acid (Reclast) increase bone mass and decrease bone loss by

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CHART 69-8

HOME CARE CHECKLIST •

Osteoporosis

At the completion of the home care instruction, the patient or caregiver will be able to:

Patient

Caregiver

Adolescents and Young Adults • List risk factors for osteoporosis.

✔

• Identify calcium- and vitamin D–rich foods.

✔

• Consume diet with adequate calcium (1000–1200 mg/day) and vitamin D.

✔

• Engage in weight-bearing exercise daily.

✔

• Modify lifestyle choices—avoid smoking, alcohol, caffeine, and carbonated beverages.

✔

✔

Menopausal and Postmenopausal Women • List risk factors for osteoporosis.

✔

• Identify calcium- and vitamin D–rich foods.

✔

• Consume diet with adequate calcium (1000–1200 mg/day) and vitamin D.

✔

• Discuss calcium supplements.

✔

• Engage in weight-bearing exercise at least three times weekly.

✔

• Engage in exercise that improves balance to reduce the incidence of falls.

✔

• Demonstrate good body mechanics.

✔

• Modify lifestyle choices—avoid smoking, alcohol, caffeine, and carbonated beverages.

✔

• Discuss pharmacologic agents to maintain and enhance bone mass.

✔

• Review concurrent medical conditions and medications with health care provider to identify

✔

✔

• Assess home environment for hazards contributing to falls.

✔

✔

• List risk factors associated with osteoporosis in men, including medications (e.g., corticoste-

✔

✔

• Modify lifestyle choices—avoid smoking, alcohol, caffeine, and carbonated beverages.

✔

• Engage in weight-bearing exercise daily, such as walking, weight lifting, and resistance exercise.

✔

• Consume diet with adequate calcium (1000–1200 mg/day) and vitamin D.

✔

• Participate in screening for osteoporosis.

✔

• Talk with health care provider about use of medications (e.g., alendronate) to enhance bone

✔

• Assess home environment for hazards contributing to falls.

✔

✔

factors that contribute to bone mass loss.

Men roids, antiseizure medications, aluminum-containing antacids); chronic diseases (e.g., kidney, lung, gastrointestinal); and undiagnosed low testosterone levels.

mass or to correct testosterone deficiency.

inhibiting osteoclast function (Johnson et al., 2008). These medications have demonstrated cost-effectiveness in preventing osteoporotic-related fractures in women of 65 years of age and older (Pfister, Welch, Lester, et al., 2006). In particular, alendronate is very effective therapy in preventing fractures in postmenopausal women with osteoporosis (Wells, Cranney, Peterson, et al., 2008). Adequate calcium and vitamin D intake is needed for maximum effect, but these supplements should not be taken at the same time of day as bisphosphonates. Side effects of bisphosphonates include gastrointestinal symp-

✔

toms (e.g., dyspepsia, nausea, flatulence, diarrhea, constipation). Some patients may develop esophageal ulcers, gastric ulcers, or osteonecrosis of the jaw related to bisphosphonate use (Johnson et al., 2008). Patients who take oral bisphosphonates must take these medications on an empty stomach on arising in the morning with a full glass of water and must sit upright for 30 to 60 minutes after their administration. Calcitonin (Miacalcin) directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD. Calcitonin is administered by nasal spray or by subcutaneous or

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intramuscular injection. Side effects include nasal irritation, flushing, gastrointestinal disturbances, and urinary frequency. It should not be prescribed for patients with seafood allergies (Johnson et al., 2008). SERMs such as raloxifene (Evista), reduce the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. They are indicated for both prevention and treatment of osteoporosis. They are contraindicated in women with a history of venous thromboembolism (Johnson et al., 2008). Teriparatide (Forteo) is a subcutaneously administered anabolic agent that is administered once daily. As a recombinant PTH, it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption (Johnson et al., 2008).

Fracture Management Fractures of the hip that occur as a consequence of osteoporosis are managed surgically by joint replacement or by closed or open reduction with internal fixation (e.g., hip pinning) as described in Chapters 68 and 70, respectively. Management of Colles’ fractures is also described in Chapter 70. Patients need to be evaluated for osteoporosis and treated, as indicated, in order to prevent additional fractures. Osteoporotic compression fractures of the vertebrae are managed conservatively. Additional vertebral fractures and progressive kyphosis are common. Pharmacologic and dietary treatments are aimed at increasing vertebral bone density. Most patients who experience these fractures are asymptomatic and do not require acute care management; for those who experience pain, acute care management is indicated as outlined in the following Nursing Process section. Percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra) can provide rapid relief of acute pain and improve quality of life (Pizzoli, Brivio, Caudana, et al., 2009). Patients who have not responded to first-line approaches to the treatment of vertebral compression fracture can be considered for the procedure. It is contraindicated in the presence of infection, old fractures, and certain coagulopathies.

!!"##

Nursing Process

The Patient With a Spontaneous Vertebral Fracture Related to Osteoporosis Assessment Health promotion, identification of people at risk for osteoporosis, and recognition of problems associated with osteoporosis form the basis for nursing assessment. The health history includes questions concerning the occurrence of osteopenia and osteoporosis and focuses on family history, previous fractures,

dietary consumption of calcium, exercise patterns, onset of menopause, and use of corticosteroids as well as alcohol, smoking, and caffeine intake. Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored. Physical examination may disclose a fracture, kyphosis of the thoracic spine, or shortened stature. Problems in mobility and breathing may exist as a result of changes in posture and weakened muscles.

Nursing Diagnoses Based on the assessment data, the major nursing diagnoses for the patient who experiences a spontaneous vertebral fracture related to osteoporosis may include the following: • Deficient knowledge about the osteoporotic process and treatment regimen • Acute pain related to fracture and muscle spasm • Risk for constipation related to immobility or development of ileus (intestinal obstruction) • Risk for injury: additional fractures related to osteoporosis

Planning and Goals The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures.

Nursing Interventions Promoting Understanding of Osteoporosis and the Treatment Regimen Patient teaching focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms. It is emphasized that all people continue to need sufficient calcium, vitamin D, and weightbearing exercise to slow the progression of osteoporosis. Patient teaching related to medication therapy as described previously is important.

Relieving Pain Relief of back pain resulting from compression fracture may be accomplished by resting in bed in a supine or side-lying position several times a day. The mattress should be firm and nonsagging. Knee flexion increases comfort by relaxing back muscles. Intermittent local heat and back rubs promote muscle relaxation. The nurse instructs the patient to move the trunk as a unit and to avoid twisting. The nurse encourages good posture and teaches body mechanics. When the patient is assisted out of bed, a trunk orthosis (e.g., lumbosacral corset) may be worn for temporary support and immobilization, although such a device is frequently uncomfortable and is poorly tolerated by many older patients. The patient gradually resumes activities as pain diminishes.

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Improving Bowel Elimination Constipation is a problem related to immobility and medications. Early institution of a high-fibre diet, increased fluids, and the use of prescribed stool softeners help prevent or minimize constipation. If the vertebral collapse involves the T10–L2 vertebrae, the patient may develop a paralytic ileus. The nurse therefore monitors the patient’s intake, bowel sounds, and bowel activity.

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4. Experiences no new fractures a. Maintains good posture b. Uses good body mechanics c. Consumes a diet high in calcium and vitamin D d. Engages in weight-bearing exercises (walks daily) e. Rests by lying down several times a day f. Participates in outdoor activities g. Creates a safe home environment h. Accepts assistance and supervision as needed

Preventing Injury Physical activity is essential to strengthen muscles, improve balance, prevent disuse atrophy, and retard progressive bone demineralization. Isometric exercises can strengthen trunk muscles. The nurse encourages walking, good body mechanics, and good posture. Daily weight-bearing activity, preferably outdoors in the sunshine to enhance the body’s ability to produce vitamin D, is encouraged. Sudden bending, jarring, and strenuous lifting are avoided.

Gerontologic Considerations Older people fall frequently as a result of environmental hazards, neuromuscular disorders, diminished senses and cardiovascular responses, and responses to medications. The patient and family need to be included in planning for care and preventive management regimens. For example, the home environment should be assessed for safety and elimination of potential hazards (e.g., scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (e.g., well-lighted staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear).

Evaluation Expected Patient Outcomes Expected patient outcomes may include: 1. Acquires knowledge about osteoporosis and the treatment regimen a. States relationship of calcium and vitamin D intake and exercise to bone mass b. Consumes adequate dietary calcium and vitamin D c. Increases level of exercise d. Takes prescribed medications, following instructions for administration e. Adheres to prescribed screening and monitoring procedures 2. Achieves pain relief a. Experiences pain relief at rest b. Experiences minimal discomfort during ADLs c. Demonstrates diminished tenderness at fracture site 3. Demonstrates normal bowel elimination a. Has active bowel sounds b. Reports regular pattern of bowel movements

Osteomalacia Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result of faulty mineralization, there is softening and weakening of the skeleton, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling or limping gait. These patients may be uncomfortable with their appearance. As a result of calcium deficiency, muscle weakness, and unsteadiness, there is an increased risk for falls and fractures, particularly pathologic fractures of the distal radius and the proximal femur (McCance & Huether, 2014).

Pathophysiology The primary defect in osteomalacia is a deficiency of activated vitamin D (calcitriol), which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. The supply of calcium and phosphate in the extracellular fluid is low. Without adequate vitamin D, calcium and phosphate are not moved to calcification sites in bones. Osteomalacia may result from failed calcium absorption (e.g., malabsorption syndrome) or from excessive loss of calcium from the body. Gastrointestinal disorders (e.g., celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel resection) in which fats are inadequately absorbed are likely to produce osteomalacia through loss of vitamin D (along with other fat-soluble vitamins) and calcium, the latter being excreted in the feces with fatty acids. In addition, liver and kidney diseases can produce a lack of vitamin D because these are the organs that convert vitamin D to its active form. Severe renal insufficiency results in acidosis. The body uses available calcium to combat the acidosis, and PTH stimulates the release of skeletal calcium in an attempt to re-establish a physiologic pH. During this continual drain of skeletal calcium, bony fibrosis occurs, and bony cysts form. Chronic glomerulonephritis, obstructive uropathies, and heavy metal poisoning result in a reduced serum phosphate level and demineralization of bone. Hyperparathyroidism leads to skeletal decalcification and thus to osteomalacia by increasing phosphate excretion in the urine. Prolonged use of antiseizure medication (e.g., phenytoin [Dilantin], phenobarbital) poses a risk of osteomalacia, as does insufficient vitamin D (dietary, sunlight).

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Osteomalacia that results from malnutrition (deficiency in vitamin D often associated with poor intake of calcium) is a result of poverty, poor dietary habits, and lack of knowledge about nutrition. It occurs most frequently in parts of the world where vitamin D is not added to food, where dietary deficiencies exist, and where sunlight is rare (Porth & Matfin, 2009).

Gerontologic Considerations A nutritious diet is particularly important in older people. Adequate intake of calcium and vitamin D is promoted. Because sunlight is necessary for synthesizing vitamin D, people should be encouraged to spend some time in the sun. Prevention, identification, and management of osteomalacia in the older are essential to reduce the incidence of fractures. When osteomalacia is combined with osteoporosis, the incidence of fracture increases.

Assessment and Diagnostic Findings On x-ray studies, generalized demineralization of bone is evident. Studies of the vertebrae may show a compression fracture with indistinct vertebral endplates. Laboratory studies show low serum calcium and phosphorus levels and a moderately elevated alkaline phosphatase concentration. Urine excretion of calcium and creatinine is low. Bone biopsy demonstrates an increased amount of osteoid, a demineralized, cartilaginous bone matrix that is sometimes referred to as “prebone.”

Medical Management Physical, psychological, and pharmaceutical measures are used to reduce the patient’s discomfort and pain. When assisting the patient to change positions, the nurse handles the patient gently, and pillows are used to support the body. As the patient responds to therapy, the skeletal discomfort diminishes. If possible, the underlying cause of osteomalacia is corrected. Frequently, skeletal problems associated with osteomalacia resolve themselves when the underlying nutritional deficiency or pathologic process is adequately treated. If osteomalacia is caused by malabsorption, increased doses of vitamin D, along with supplemental calcium, are usually prescribed (Binkley, Ramamurthy, & Krueger, 2012). Exposure to sunlight may be recommended; ultraviolet radiation transforms a cholesterol substance (7-dehydrocholesterol) present in the skin into vitamin D. If osteomalacia is dietary in origin, a diet with adequate protein and increased calcium and vitamin D is provided. The patient is instructed about dietary sources of calcium and vitamin D (e.g., fortified milk and cereals, eggs, chicken livers). The safe use of supplements is reviewed. Because high doses of vitamin D are toxic and increase the risk for hypercalcemia, the importance of monitoring serum calcium levels is stressed. Vitamin D raises the concentrations of calcium and phosphorus in the extracellular fluid and thus makes these ions available for mineralization of bone. Long-term monitoring of the patient is appropriate to ensure stabilization or reversal of osteomalacia. Some per-

sistent orthopedic deformities may need to be treated with braces or surgery (e.g., osteotomy may be performed to correct long bone deformity).

Paget’s Disease of the Bone Paget’s disease (osteitis deformans) is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. The disease occurs in about 2% to 3% of the population older than 50 years. The incidence is slightly greater in men than in women and increases with aging. A family history has been noted, with siblings often developing the disease. The cause of Paget’s disease is not known (Josse, Hanley, Kendler, et al., 2007).

Pathophysiology In Paget’s disease, there is a primary proliferation of osteoclasts, which induce bone resorption. This is followed by a compensatory increase in osteoblastic activity that replaces the bone. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the diseased bone is highly vascularized and structurally weak, pathologic fractures occur. Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain (Josse et al., 2007).

Clinical Manifestations Paget’s disease is insidious; most patients never experience symptoms. Some patients do not experience symptoms but have skeletal deformity; a few patients have symptomatic deformity and pain. The condition is most frequently identified on x-ray studies performed during a routine physical examination or during a workup for another problem. Sclerotic changes, skeletal deformities (e.g., bowing of the femur and tibia, enlargement of the skull, deformity of pelvic bones), and cortical thickening of the long bones occur. In most patients, skeletal deformity involves the skull or long bones. The skull may thicken, and the patient may report that a hat no longer fits. In some cases, the cranium, but not the face, is enlarged. This gives the face a small, triangular appearance. Most patients with skull involvement have impaired hearing from cranial nerve compression and dysfunction. Other cranial nerves may also be compressed. The femurs and tibiae tend to bow, producing a waddling gait. The spine is bent forward and is rigid; the chin rests on the chest. The thorax is compressed and immobile on respiration. The trunk is flexed on the legs to maintain balance and the arms are bent outward and forward and appear long in relation to the shortened trunk (McCance & Huether, 2014). Pain, tenderness, and warmth over the bones may be noted. The pain is mild to moderate, deep, and aching; it increases with weight bearing if the lower extremities are involved. Pain and discomfort may precede skeletal deformities of Paget’s disease by years and are often wrongly attributed by the patient to old age or arthritis.

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The temperature of the skin overlying the affected bone increases because of increased bone vascularity. Patients with large, highly vascular lesions may develop highoutput cardiac failure because of the increased vascular bed and metabolic demands.

Assessment and Diagnostic Findings Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect increased osteoblastic activity. Higher values suggest more active disease. Patients with Paget’s disease have normal blood calcium levels. X-rays confirm the diagnosis of Paget’s disease. Local areas of demineralization and bone overgrowth produce characteristic mosaic patterns and irregularities. Bone scans demonstrate the extent of the disease. Bone biopsy may aid in the differential diagnosis (McCance & Huether, 2014).

Medical Management Pain usually responds to NSAIDs. Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight is controlled to reduce stress on weakened bones and malaligned joints. Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring. Fractures, arthritis, and hearing loss are complications of Paget’s disease. Fractures are managed according to location. Healing occurs if fracture reduction, immobilization, and stability are adequate. Severe degenerative arthritis may require total joint replacement. Loss of hearing is managed with hearing aids and communication techniques used with hearing-impaired people (e.g., speech reading, body language) (see Chapter 60).

Pharmacologic Therapy Patients with moderate to severe disease may benefit from specific antiosteoclastic therapy. Several medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility. Calcitonin, a polypeptide hormone, retards bone resorption by decreasing the number and availability of osteoclasts. Calcitonin therapy facilitates remodeling of abnormal bone into normal lamellar bone, relieves bone pain, and helps alleviate neurologic and biochemical signs and symptoms. Calcitonin is administered subcutaneously or by nasal inhalation. Side effects include flushing of the face and nausea. The effect of calcitonin therapy is evident in 3 to 6 months through reduction of bone loss and pain. Bisphosphonates produce rapid reduction in bone turnover and relief of pain (Keating & Scott, 2007). They also reduce serum alkaline phosphatase and urinary hydroxyproline levels. Food inhibits absorption of these medications. Adequate daily intake of calcium and vitamin D is required during therapy. Plicamycin (Mithracin), a cytotoxic antibiotic, may be used to control the disease. This medication is reserved for severely affected patients with neurologic compromise and for those whose disease is resistant to other therapy. This medication has dramatic effects on pain reduction

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and on serum calcium, alkaline phosphatase, and urinary hydroxyproline levels. It is administered by IV infusion; hepatic, renal, and bone marrow function must be monitored during therapy. Clinical remissions may continue for months after the medication is discontinued.

Gerontologic Considerations Because Paget’s disease tends to affect older people, careful assessment of a patient’s pain and discomfort is necessary. Patient teaching helps the patient understand the treatment regimen, the need for a diet with adequate calcium and vitamin D, and how to compensate for altered musculoskeletal functioning. The home environment is assessed for safety to prevent falls and to reduce the risk of fracture. Strategies for coping with a chronic health problem and its effect on quality of life need to be developed.

MUSCULOSKELETAL INFECTIONS Osteomyelitis Osteomyelitis is an infection of the bone that results in inflammation, necrosis, and formation of new bone (Goswami, Johnson, & Chu, 2011)). Osteomyelitis is classified as: • Hematogenous osteomyelitis (i.e., due to bloodborne spread of infection) • Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound) • Osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet (Davis, 2005) Patients who are at high risk for osteomyelitis include those who are poorly nourished, older, or obese. Other patients at risk include those with impaired immune systems, those with chronic illnesses (e.g., diabetes, rheumatoid arthritis), and those receiving long-term corticosteroid therapy or other immunosuppressive agents. Postoperative surgical wound infections occur within 30 days after surgery. They are classified as incisional (superficial, located above the deep fascia layer) or deep (involving tissue beneath the deep fascia). If an implant has been used, deep postoperative infections may occur within a year. Deep sepsis after arthroplasty may be classified as follows: • Stage 1, acute fulminating: occurring during the first 3 months after orthopedic surgery; frequently associated with hematoma, drainage, or superficial infection • Stage 2, delayed onset: occurring between 4 and 24 months after surgery • Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread Bone infections are more difficult to eradicate than soft tissue infections because the infected bone is mostly avascular and not accessible to the body’s natural immune response. Also, there is decreased penetration by antibiotics.

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Osteomyelitis may become chronic and may affect the patient’s quality of life.

Pathophysiology Over 50% of bone infections are caused by Staphylococcus aureus. Other pathogens that are frequently found in osteomyelitis include gram-positive organisms that include streptococci and enterococci, followed by Gramnegative bacteria that include Pseudomonas species (Venugopalan & Martin, 2007). The initial response to infection is inflammation, increased vascularity, and edema. After 2 or 3 days, thrombosis of the local blood vessels occurs, resulting in ischemia with bone necrosis. The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains dead bone tissue (the sequestrum), which does not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as it does in soft tissue abscesses. New bone growth (the involucrum) forms and surrounds the sequestrum. Although healing appears to take place, a chronically infected sequestrum remains and produces recurring abscesses throughout the patient’s life. This is referred to as chronic osteomyelitis.

Clinical Manifestations When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no symptoms of sepsis. The area is swollen, warm, painful, and tender to touch (McCance & Huether, 2014). The patient with chronic osteomyelitis may present with a nonhealing ulcer that overlies the infected bone with a connecting sinus that will intermittently and spontaneously drain pus (Liu, Bayer, Cosgrove, et al., 2011).

Assessment and Diagnostic Findings In acute osteomyelitis, early x-ray findings demonstrate soft tissue edema. In about 2 to 3 weeks, areas of periosteal elevation and bone necrosis are evident. Radioisotope bone scans, particularly the isotope-labelled white blood cell (WBC) scan, and magnetic resonance imaging (MRI) help with early definitive diagnosis. Blood studies reveal leukocytosis and an elevated ESR. Wound and blood culture studies are performed, although they are only positive in 50% of cases. Therefore, treatment with antibiotics may be prescribed without definitively isolating the offending organism (Liu et al., 2011).

With chronic osteomyelitis, large, irregular cavities; raised periosteum; sequestra; or dense bone formations are seen on x-ray. Bone scans may be performed to identify areas of infection. The ESR and the WBC count are usually normal. Anemia, associated with chronic infection, may be evident. Blood cultures and drainage from the sinus tract are frequently unreliable. Imperical treatment with antibiotics is frequently prescribed without isolating the causative pathogen (Liu et al., 2011).

Prevention Prevention of osteomyelitis is the goal. Elective orthopedic surgery should be postponed if the patient has a current infection (e.g., urinary tract infection, sore throat) or a recent history of infection. During orthopedic surgery, careful attention is paid to the surgical environment and to techniques to decrease direct bone contamination. Prophylactic antibiotics, administered to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful. Urinary catheters and drains are removed as soon as possible to decrease the incidence of hematogenous spread of infection. Treatment of focal infections diminishes hematogenous spread. Aseptic postoperative wound care reduces the incidence of superficial infections and osteomyelitis. Prompt management of soft tissue infections reduces extension of infection to the bone. When patients who have had joint replacement surgery undergo dental procedures or other invasive procedures (e.g., cystoscopy), prophylactic antibiotics are frequently recommended.

Medical Management The initial goal of therapy is to control and halt the infective process. Antibiotic therapy depends on the results of blood and wound cultures. General supportive measures (e.g., hydration, diet high in vitamins and protein, correction of anemia) should be instituted. The area affected with osteomyelitis is immobilized to decrease discomfort and to prevent pathologic fracture of the weakened bone (McKay, Formby, Dickens, et al., 2010).

Pharmacologic Therapy As soon as the culture specimens are obtained, IV antibiotic therapy begins, based on the assumption that infection results from a staphylococcal organism that is sensitive to a penicillin or cephalosporin. The aim is to control the infection before the blood supply to the area diminishes as a result of thrombosis. Around-the-clock dosing is necessary to maintain a high therapeutic blood level of the antibiotic. After results of the culture and sensitivity studies are known, an antibiotic to which the causative organism is sensitive is prescribed. IV antibiotic therapy continues for 3 to 6 weeks. After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months. To enhance absorption of the orally administered medication, antibiotics should not be administered with food.

Surgical Management If the infection is chronic and does not respond to antibiotic therapy, surgical débridement is indicated. The

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infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution. Antibiotic-impregnated beads may be placed in the wound for direct application of antibiotics for 2 to 4 weeks (Kent, Rapp, & Smith, 2006). IV antibiotic therapy is continued. In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical débridement. A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer (saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile physiologic saline solution may be performed for 7 to 8 days. The wound is either closed tightly to obliterate the dead space or packed and closed later by granulation or possibly by grafting. The débrided cavity may be packed with cancellous bone graft to stimulate healing. With a large defect, the cavity may be filled with a vascularized bone transfer or muscle flap (in which a muscle is moved from an adjacent area with blood supply intact). These microsurgery techniques enhance the blood supply. The improved blood supply facilitates bone healing and eradication of the infection. These surgical procedures may be staged over time to ensure healing. Because surgical débridement weakens the bone, internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture (Davis, 2005).

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Nursing Diagnoses Based on the nursing assessment data, nursing diagnoses for the patient with osteomyelitis may include the following: • Acute pain related to inflammation and edema • Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitations • Risk for extension of infection: bone abscess formation • Deficient knowledge related to the treatment regimen

Planning and Goals The patient’s goals may include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of the treatment regimen.

Nursing Interventions Relieving Pain The affected part may be immobilized with a splint to decrease pain and muscle spasm. The nurse monitors the neurovascular status of the affected extremity. The wounds are frequently very painful, and the extremity must be handled with great care and gentleness. Elevation reduces swelling and associated discomfort. Pain is controlled with prescribed analgesic agents and other pain-reducing techniques.

Improving Physical Mobility !!"##

Nursing Process

The Patient With Osteomyelitis Assessment The patient reports an acute onset of signs and symptoms (e.g., localized pain, edema, erythema, fever) or recurrent drainage of an infected sinus with associated pain, edema, and low-grade fever. The nurse assesses the patient for risk factors (e.g., older age, diabetes, long-term corticosteroid therapy) and for a history of previous injury, infection, or orthopedic surgery. The patient avoids pressure and movement of the area. In acute hematogenous osteomyelitis, the patient exhibits generalized weakness due to the systemic reaction to the infection. Physical examination reveals an inflamed, markedly edematous, warm area that is tender. Purulent drainage may be noted. The patient has an elevated temperature. With chronic osteomyelitis, the temperature elevation may be minimal, occurring in the afternoon or evening.

Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. The patient must understand the rationale for the activity restrictions. The joints above and below the affected part should be gently moved through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to promote general well-being.

Controlling the Infectious Process The nurse monitors the patient’s response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration. With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of superinfection (e.g., oral or vaginal candidiasis, loose or foul-smelling stools). If surgery is necessary, the nurse takes measures to ensure adequate circulation to the affected area (wound suction to prevent fluid accumulation, elevation of the area to promote venous drainage, avoidance of pressure on the grafted area), to maintain needed immobility, and to ensure the patient’s adherence to weight-bearing restrictions. The nurse changes dressings using aseptic technique to promote healing and to prevent cross-contamination. The nurse continues to monitor the general health and nutrition of the patient. A diet high in protein

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CHART 69-9

HOME CARE CHECKLIST •

Osteomyelitis Patient

Caregiver

• Describe osteomyelitis.

✔

✔

• Relieve pain with pharmacologic and nonpharmacologic interventions.

✔

• State weight-bearing and activity restrictions.

✔

• Demonstrate safe use of ambulatory aids and assistive devices.

✔

• Describe use of prescribed medications.

✔

• Comply with antibiotic regimen.

✔

• Promote healing through aseptic dressing changes.

✔

✔

• Demonstrate proper wound care.

✔

✔

• Report signs and symptoms of continuing infection or superinfection.

✔

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

promotes a positive nitrogen balance and healing. The nurse encourages adequate hydration as well.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The patient and

family are taught about the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone fracture. They need to learn to maintain and manage the IV access and IV administration equipment in the home. Teaching includes medication name, dosage, frequency, administration rate, safe storage and handling, adverse reactions, and necessary laboratory monitoring. In addition, aseptic dressing and warm compress techniques are taught. The nurse carefully monitors the patient for the development of additional sites that are painful or sudden increases in body temperature. The nurse instructs the patient and family to observe for and report elevated temperature, drainage, odour, signs of increased inflammation, adverse reactions, and signs of superinfection. CONTINUING CARE. Management of osteomyelitis, including wound care and IV antibiotic therapy, is usually performed at home. The patient must be medically stable and physically able and motivated to adhere strictly to the therapeutic regimen of antibiotic therapy. The home care environment needs to be conducive to the promotion of health and to the requirements of the therapeutic regimen. If warranted, the nurse completes a home assessment to determine the patient’s and family’s abilities regarding continuation of the therapeutic regimen. If the patient’s support system is questionable or if the patient lives alone, a home care nurse may be needed to assist with IV administration of the antibiotics. The nurse monitors the patient for response to the treatment, signs and symptoms of superinfections, and adverse drug reactions. The nurse stresses the importance of follow-up health care appointments

✔

✔

and recommends age-appropriate health screening (Chart 69-9).

Evaluation Expected Patient Outcomes Expected patient outcomes may include: 1. Experiences pain relief a. Reports decreased pain b. Experiences no tenderness at site of previous infection c. Experiences no discomfort with movement 2. Increases physical mobility a. Participates in self-care activities b. Maintains full function of unimpaired extremities c. Demonstrates safe use of immobilizing and assistive devices d. Modifies environment to promote safety and to avoid falls 3. Shows absence of infection a. Takes antibiotic as prescribed b. Reports normal temperature c. Exhibits no edema d. Reports absence of drainage e. Laboratory results indicate normal WBC count and erythrocyte sedimentation rate f. Wound cultures are negative 4. Adheres to therapeutic plan a. Takes medications as prescribed b. Protects weakened bones c. Demonstrates proper wound care d. Reports signs and symptoms of complications promptly e. Consumes a diet high in protein f. Keeps follow-up health care appointments g. Reports increased strength h. Reports no elevation of temperature or recurrence of pain, edema, or other symptoms at the site

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Septic (Infectious) Arthritis Joints can become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation. Previous trauma to joints, joint replacement, coexisting arthritis, and diminished host resistance contribute to the development of an infected joint. S. aureus causes at least 50% of all joint infections, and 80% of cases of septic arthritis in patients with rheumatoid arthritis and diabetes. The knee is the joint that is most commonly infected (50% of cases), followed by the hip and the shoulder, respectively (McCance & Huether, 2014). Prompt recognition and treatment of an infected joint are important because accumulating purulent material results in chondrolysis (destruction of hyaline cartilage).

Clinical Manifestations The patient with acute septic arthritis usually presents with a warm, painful, swollen joint with decreased range of motion. Systemic chills, fever, and leukocytosis are present. Risk factors include advanced age, diabetes, rheumatoid arthritis, and pre-existing joint disease or joint replacement. Older patients and patients taking corticosteroids or immunosuppressive medications are at heightened risk; yet, these patients may not exhibit typical clinical manifestations of infection. Therefore, they require ongoing assessment to detect infection as early as possible in the infectious process (Gavet, Tournadre, Soubrier, et al., 2005).

Assessment and Diagnostic Findings An assessment for the source and cause of infection is performed. Diagnostic studies include aspiration, examination, and culture of the synovial fluid. Computed tomography (CT) and MRI may reveal damage to the joint lining. Radioisotope scanning may be useful in localizing the infectious process.

Medical Management Prompt treatment is essential and may save a prosthesis for patients who have had joint replacement surgery. Broad-spectrum IV antibiotics are started promptly and then changed to organism-specific antibiotics after culture results are available. The IV antibiotics are continued until symptoms resolve. The synovial fluid is aspirated and analyzed periodically for sterility and decrease in WBCs. In addition to prescribing antibiotics, the physician may aspirate the joint with a needle to remove excessive joint fluid, exudate, and debris. This promotes comfort and decreases joint destruction caused by the action of proteolytic enzymes in the purulent fluid. Occasionally, arthrotomy or arthroscopy is used to drain the joint and remove dead tissue (Kuo, Chang, Shen, et al., 2011). The inflamed joint is supported and immobilized in a functional position by a splint that increases the patient’s comfort. Analgesic agents, such as codeine, may be prescribed to relieve pain. After the infection has responded

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to antibiotic therapy, NSAIDs may be prescribed to limit joint damage. The patient’s nutrition and fluid status is monitored. Progressive range-of-motion exercises are prescribed as soon as the patient can begin movement without exacerbating symptoms of acute pain (Davis, 2005). If septic joints are treated promptly, recovery of normal function is expected. The patient is assessed periodically for recurrence. If the articular cartilage was damaged during the inflammatory reaction, joint fibrosis and diminished function may result.

Nursing Management The nurse describes the septic arthritis physiologic process to the patient and teaches the patient how to relieve pain using pharmacologic and nonpharmacologic interventions. The nurse also explains the importance of supporting the affected joint, adhering to the prescribed antibiotic regimen, and observing weight-bearing and activity restrictions. In addition, the nurse demonstrates and encourages the patient to practice safe use of ambulatory aids and assistive devices. The nurse teaches the patient strategies to promote healing through aseptic dressing changes and proper wound care. The patient is then encouraged to perform range-of-motion exercises after the infection subsides.

BONE TUMOURS Neoplasms of the musculoskeletal system are of various types, including osteogenic, chondrogenic, fibrogenic, muscle (rhabdomyogenic), and marrow (reticulum) cell tumours as well as nerve, vascular, and fatty cell tumours. They may be primary tumours or metastatic tumours from primary cancers elsewhere in the body (e.g., breast, lung, prostate, kidney). Metastatic bone tumours are more common than primary bone tumours (Polansky, 2013).

Types Benign Bone Tumours Benign tumours of the bone and soft tissue are more common than malignant primary bone tumours. Benign bone tumours generally are slow growing, well circumscribed, and encapsulated; present few symptoms; and are not a cause of death. Benign primary neoplasms of the musculoskeletal system include osteochondroma, enchondroma, bone cyst (e.g., aneurysmal bone cyst), osteoid osteoma, rhabdomyoma, and fibroma. Some benign tumours, such as giant cell tumours, have the potential to become malignant. Osteochondroma is the most common benign bone tumour. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder). It develops during growth and then becomes a static bony mass. In fewer than 1% of patients, the cartilage cap of the osteochondroma may undergo malignant transformation after trauma, and a chondrosarcoma or osteosarcoma may develop. Enchondroma is a common tumour of the hyaline cartilage that develops in the hand, femur, tibia, or humerus.

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Usually, the only symptom is a mild ache. Pathologic fractures may occur. Bone cysts are expanding lesions within the bone. Aneurysmal (widening) bone cysts are seen in young adults, who present with a painful, palpable mass of the long bones, vertebrae, or flat bone. Unicameral (single cavity) bone cysts occur in children and cause mild discomfort and possible pathologic fractures of the upper humerus and femur, which may heal spontaneously. Osteoid osteoma is a painful tumour that occurs in children and young adults. The neoplastic tissue is surrounded by reactive bone formation that can be identified by x-ray. Giant cell tumours (osteoclastomas) are benign for long periods but may invade local tissue and cause destruction. They occur in young adults and are soft and hemorrhagic. Eventually, giant cell tumours may undergo malignant transformation and metastasize (McCance & Huether, 2014).

Malignant Bone Tumours Primary malignant musculoskeletal tumours are relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements (multiple myeloma; see Chapter 33). Malignant primary musculoskeletal tumours include osteosarcoma, chondrosarcoma, Ewing’s sarcoma, and fibrosarcoma. Soft tissue sarcomas include liposarcoma, fibrosarcoma of soft tissue, and rhabdomyosarcoma. Bone tumour metastasis to the lungs is common. Osteosarcoma (i.e., osteogenic sarcoma) is the most common and most often fatal primary malignant bone tumour. Prognosis depends on whether the tumour has metastasized to the lungs at the time the patient seeks health care. Osteosarcoma appears most frequently in children, adolescents and young adults (in bones that grow rapidly), in older people with Paget’s disease of the bone, and in people with a prior history of radiation exposure. Clinical manifestations typically include localized bone pain that may be accompanied by a tender, palpable soft tissue mass. The primary lesion may involve any bone, but the most common sites are the distal femur, the proximal tibia, and the proximal humerus (Ottaviani & Jaffe, 2009; Skubitz & D’Adamo, 2007). Malignant tumours of the hyaline cartilage are called chondrosarcomas. These tumours are the second most common primary malignant bone tumour. They are large, bulky, tumours that may grow and metastasize slowly or very fast, depending on the characteristics of the tumour cells involved (i.e., grade). Patients with low-grade chondrosarcomas tend to have a much better prognosis than those with high-grade chondrosarcomas (see Chapter 16 for a discussion of tumour grades). The usual tumour sites include the pelvis, femur, humerus, spine, scapula, and tibia. Metastasis to the lungs occurs in less than half of patients. When these tumours are well differentiated, large bloc excision or amputation of the affected extremity results in increased survival rates. These tumours may recur, however (Gelderblom, Hogendoorn, Dijkstra, et al., 2008; Skubitz & D’Adamo, 2007).

Metastatic Bone Disease Metastatic bone disease (secondary bone tumour) is more common than primary bone tumours. Tumours arising from tissues elsewhere in the body may invade the bone

and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions). The most common primary sites of tumours that metastasize to bone are the kidney, prostate, lung, breast, ovary, and thyroid. Metastatic tumours most frequently attack the skull, spine, pelvis, femur, and humerus and often involve more than one bone (polyostotic) (McCance & Huether, 2014).

Pathophysiology A tumour in the bone causes the normal bone tissue to react by osteolytic response (bone destruction) or osteoblastic response (bone formation). Primary tumours cause bone destruction, which weakens the bone, resulting in bone fractures. Adjacent normal bone responds to the tumour by altering its normal pattern of remodeling. The bone’s surface changes and the contours enlarge in the tumour area. Malignant bone tumours invade and destroy adjacent bone tissue. Benign bone tumours, in contrast, have a symmetric, controlled growth pattern and place pressure on adjacent bone tissue. Malignant bone tumours invade and weaken the structure of the bone until it can no longer withstand the stress of ordinary use; pathologic fracture commonly results.

Clinical Manifestations Patients with metastatic bone tumour may have a wide range of associated clinical manifestations. They may be symptom-free or have pain that ranges from mild and occasional to constant and severe, varying degrees of disability, and, at times, obvious bone growth. Weight loss, malaise, and fever may be present. The tumour may be diagnosed only after pathologic fracture has occurred. With spinal metastasis, spinal cord compression may occur. It can progress rapidly or slowly. Neurologic deficits (e.g., progressive pain, weakness, gait abnormality, paresthesia, paraplegia, urinary retention, loss of bowel or bladder control) must be identified early and treated with decompressive laminectomy to prevent permanent spinal cord injury.

Assessment and Diagnostic Findings The differential diagnosis is based on the history, physical examination, and diagnostic studies, including CT, bone scans, myelography, arteriography, MRI, biopsy, and biochemical assays of the blood and urine. Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma. With metastatic carcinoma of the prostate, serum acid phosphatase levels are elevated. Hypercalcemia is present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly. A surgical biopsy is performed for histologic identification. Extreme care is taken during the biopsy to prevent seeding and resultant recurrence after excision of the tumour. Chest x-rays are performed to determine the presence of lung metastasis. Surgical staging of musculoskeletal

CHAPTER 69

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tumours is based on tumour grade and site (intracompartmental or extracompartmental), as well as on metastasis. Staging is used for planning treatment. During the diagnostic period, the nurse explains the diagnostic tests and provides psychological and emotional support to the patient and family. The nurse assesses coping behaviours and encourages use of support systems.

Medical Management Primary Bone Tumours The goal of primary bone tumour treatment is to destroy or remove the tumour. This may be accomplished by surgical excision (ranging from local excision to amputation and disarticulation), radiation therapy if the tumour is radiosensitive, and chemotherapy (preoperative, intraoperative [neoadjuvant], postoperative, and adjunctive for possible micrometastases). Chemotherapy may be delivered intra-arterially for patients with osteosarcoma; this mode of delivery is associated with improved limb preservation (Matthews, Snell, & Coats, 2006). Although limb salvage rates have improved since the 1970s, unfortunately overall osteosarcoma survival rates have not improved since 1980 (Allison, Carney, Ahlmann, et al., 2012). Survival and quality of life are important considerations in procedures that attempt to save the involved extremity. Limb-sparing (salvage) procedures are used to remove the tumour and adjacent tissue. A customized prosthesis, total joint arthroplasty, or bone tissue from the patient (autograft) or from a cadaver donor (allograft) replaces the resected tissue. Soft tissue and blood vessels may need grafting because of the extent of the excision. Complications may include infection, loosening or dislocation of the prosthesis, allograft nonunion, fracture, devitalization of the skin and soft tissues, joint fibrosis, and recurrence of the tumour. Function and rehabilitation after limb salvage depend on positive encouragement and reducing the risk of complications. Surgical removal of the tumour may require amputation of the affected extremity, with the amputation extending well above the tumour to achieve local control of the primary lesion (see Nursing Process: The Patient Undergoing an Amputation in Chapter 70). Because of the danger of metastasis with malignant bone tumours, chemotherapy is started before and continued after surgery in an effort to eradicate micrometastatic lesions. The goal of combined chemotherapy is greater therapeutic effect at a lower toxicity rate with reduced resistance to the medications. There is an improved longterm survival rate when a localized osteosarcoma is removed and chemotherapy is initiated. Soft tissue sarcomas are treated with radiation, limb-sparing excision, and adjuvant chemotherapy (see Chapter 17).

Secondary Bone Tumours The treatment of metastatic bone cancer is palliative. The therapeutic goal is to relieve the patient’s pain and discomfort while promoting quality of life. If metastatic disease weakens the bone, structural support and stabilization are needed to prevent pathologic fracture. At times, large bones with metastatic lesions are

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strengthened by prophylactic internal fixation. Internal fixation of pathologic fractures, arthroplasty, or methylmethacrylate (bone cement) reconstruction minimizes associated disability and pain. Patients with metastatic disease are at higher risk than other patients for postoperative pulmonary congestion, hypoxemia, deep vein thrombosis (DVT), and hemorrhage. Hypercalcemia results from breakdown of bone. It needs to be recognized promptly. Treatment includes hydration with IV administration of normal saline solution; diuresis; mobilization; and medications such as bisphosphonates, (e.g., pamidronate [Aredia]) and calcitonin. Because inactivity leads to loss of bone mass and increased calcium in the blood, the nurse assists the patient to increase activity and ambulation. Hematopoiesis is frequently disrupted by tumour invasion of the bone marrow or by treatment (chemotherapy or radiation). Blood component therapy restores hematologic factors. Pain can result from multiple factors, including the osseous metastasis, surgery, chemotherapy or radiation side effects, and arthritis. Pain must be assessed accurately and managed with adequate and appropriate opioid, nonopioid, and nonpharmaceutical interventions. External beam radiation to involved metastatic sites may be used. Patients with multiple bony metastases may achieve pain control with systemically administered “bone-seeking” isotopes (e.g., strontium 89). See Chapter 13 for more information about pain management. Additional therapies are used to treat the original cancer. Radiation and hormonal therapy may be effective in promoting healing of osteolytic lesions. Chemotherapy is used to control the primary disease (see Chapter17).

Nursing Management The nurse asks the patient about the onset and course of symptoms. During the interview, the nurse assesses the patient’s understanding of the disease process, how the patient and the family have been coping, and how the patient has managed the pain. On physical examination, the nurse gently palpates the mass and notes its size and associated soft tissue swelling, pain, and tenderness. Assessment of the neurovascular status and range of motion of the extremity provides baseline data for future comparisons. The nurse evaluates the patient’s mobility and ability to perform ADLs. The nursing care of a patient who has undergone excision of a bone tumour is similar in many respects to that of other patients who have had skeletal surgery. Vital signs are monitored; blood loss is assessed; and observations are made to assess for the development of complications such as DVT, pulmonary embolism, infection, contracture, and disuse atrophy. The affected part is elevated to reduce edema, and the neurovascular status of the extremity is assessed. Patient and family teaching about the disease process and diagnostic and management regimens is essential. Explanation of diagnostic tests, treatments (e.g., wound care), and expected results (e.g., decreased range of motion, numbness, change of body contours) helps the patient deal with the procedures and changes and comply with the therapeutic regimen. The nurse can most effectively reinforce and clarify information provided by the physician by being present during these discussions.

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Musculoskeletal Function

Accurate pain assessment and use of pharmacologic and nonpharmacologic pain management techniques are used to relieve pain and increase the patient’s comfort level. The nurse works with the patient in designing the most effective pain management regimen, thereby increasing the patient’s control over the pain. The nurse prepares the patient and gives support during painful procedures. Prescribed IV or epidural analgesic medications are used during the early postoperative period. Later, oral or transdermal opioid or nonopioid analgesic agents are indicated to alleviate pain. In addition, external radiation or systemic radioisotopes (e.g., strontium 89) may be prescribed to control pain (see Chapter 14 for further discussion of nursing management for patients in pain). Bone tumours weaken the bone to a point at which normal activities or even position changes can result in fracture. During nursing care, the affected extremities must be supported and handled gently. External supports (e.g., splints) may be used for additional protection. At times, the patient may elect to have surgery (e.g., open reduction with internal fixation, joint replacement) in an attempt to prevent pathologic fracture. Prescribed weight-bearing restrictions must be followed. The nurse and physical therapist teach the patient how to use assistive devices safely and how to strengthen unaffected extremities. The nurse encourages the patient and family to verbalize their fears, concerns, and feelings. They need to be supported as they deal with the impact of the malignant bone tumour. Feelings of shock, despair, and grief are expected. Referral to a psychiatric advanced practice nurse, psychologist, counsellor, or spiritual advisor may be indicated for specific psychological help and emotional support. Independence versus dependence is an issue for the patient who has a malignancy. Lifestyle is dramatically

changed, at least temporarily. It is important to support the family in working through the adjustments that must be made. The nurse assists the patient in dealing with changes in body image due to surgery and possible amputation (see Chapter 70 for nursing management of a patient with an amputation). It is helpful to provide realistic reassurance about the future and resumption of rolerelated activities and to encourage self-care and socialization. The patient participates in planning daily activities. The nurse encourages the patient to be as independent as possible. Involvement of the patient and family throughout treatment encourages confidence, restoration of self-concept, and a sense of being in control of one’s life.

Monitoring and Managing Potential Complications DELAYED WOUND HEALING. Wound healing may be delayed because of tissue trauma from surgery, previous radiation therapy, inadequate nutrition, or infection. The nurse minimizes pressure on the wound site to promote circulation to the tissues. An aseptic, nontraumatic wound dressing promotes healing. Monitoring and reporting of laboratory findings facilitate initiation of interventions to promote homeostasis and wound healing. Repositioning the patient at frequent intervals reduces the incidence of skin breakdown and pressure ulcers. Special therapeutic beds or mattresses may be needed to prevent skin breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting. INADEQUATE NUTRITION. Because loss of appetite, nausea, and vomiting are frequent side effects of chemotherapy and radiation therapy, it is necessary to provide adequate nutrition for healing and health promotion.

CHART 69-10

HOME CARE CHECKLIST •

Bone Tumour Patient

Caregiver

• Describe tumour growth process.

✔

✔

• Control pain with pharmacologic and nonpharmacologic interventions.

✔

✔

• Support affected musculoskeletal area.

✔

• Describe use of prescribed medications.

✔

• Comply with medication regimen.

✔

• Consume diet to promote healing and health.

✔

• State weight-bearing and activity restrictions.

✔

• Demonstrate safe use of ambulatory aids and assistive devices.

✔

• Protect affected bone from pathologic fracture.

✔

✔

• Identify complications of tumour and therapy.

✔

✔

• Report signs and symptoms of complications promptly.

✔

✔

• Use effective coping strategies.

✔

• Maintain role performance.

✔

At the completion of the home care instruction, the patient or caregiver will be able to:

✔

✔

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Antiemetics and relaxation techniques reduce the adverse gastrointestinal effects of chemotherapy. Stomatitis is controlled with anesthetic or antifungal mouthwash (see Chapter 17). Adequate hydration is essential. Nutritional supplements or parenteral nutrition may be prescribed to achieve adequate nutrition. OSTEOMYELITIS AND WOUND INFECTIONS. Prophylactic antibiotics and strict aseptic dressing techniques are used to diminish the occurrence of osteomyelitis and wound infections. During healing, other infections (e.g., upper respiratory infections) need to be prevented so that hematogenous spread does not result in osteomyelitis. If the patient is receiving chemotherapy, it is important to monitor the WBC count and to instruct the patient to avoid contact with people who have colds or other infections. HYPERCALCEMIA. Hypercalcemia is a dangerous complication of bone cancer. The symptoms must be recognized and treatment initiated promptly. Symptoms include muscular weakness, incoordination, anorexia, nausea and vomiting, constipation, electrocardiographic changes (e.g., shortened QT interval and ST segment, bradycardia, heart blocks), and altered mental states (e.g., confusion, lethargy, psychotic behaviour). See Chapter 15 for a discussion of hypercalcemia and its management.

Management of Patients With Musculoskeletal Disorders

taking his prescribed medications diligently. You note that this patient is obese. The patient tells you that he is getting frustrated that he continues to have significant low back pain that interferes with his ability to work. Identify other therapies or interventions that might be reasonable alternatives or adjuncts that might relieve this patient’s low back pain. What is the strength of the evidence for each of these potential therapies or interventions? 2 Your 30-year-old cousin tells you that she was diagnosed 3 months ago with impingement syndrome of her right shoulder. She was treated with intra-articular corticosteroids and physical therapy and has had a very good response to these interventions. She is a flight attendant and is concerned whether she is likely to have recurrent episodes or whether she is at risk for worse shoulder injuries. What is the likelihood that she may have either recurrence of her symptoms or worse rotator cuff injuries? What advice might you share with her so that she might continue her career as a flight attendant? 3

On the general medical unit where you are a staff nurse, a 74-year-old man is admitted with pneumonia and a history of chronic obstructive pulmonary disease (COPD). He also has a history of heavy cigarette smoking and alcohol consumption. You note during his screening process that he has lost 1 inch in height over the past year, and he has notable kyphosis of his lumbar vertebrae. What musculoskeletal condition is he at risk of developing? What specific questions would you ask him to determine the status of his bone health? Discuss the strength of the evidence that supports any risk factor reduction strategies you consider implementing.

4

At the orthopedic clinic where you work as a nurse, a 20-year-old college athlete presents for a workup because of persistent right shoulder pain with point tenderness at his proximal humerus and a palpable soft tissue mass. An extensive workup confirms an osteosarcoma. He is stunned with the diagnosis and tells you that he would rather die than have his right arm amputated (he is right-sided dominant and is his football team’s quarterback). What is the evidence that supports limb salvage over amputation in patients with osteosarcoma of an extremity? What can he expect in terms of quality of life after an amputation versus more conservative limb salvage interventions? What support systems would you mobilize for this patient?

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Preparation for and coordination of continuing health care are begun early as a multidisciplinary effort. Patient teaching addresses medication, dressing changes, treatment regimens, and the importance of physical and occupational therapy programs. The nurse teaches weight-bearing limitations and special handling to prevent pathologic fractures. It is important that the patient and family know the signs and symptoms of possible complications as well as resources available for continuing care (Chart 69-10). CONTINUING CARE. Frequently, arrangements are made with a home health care agency for home care supervision and follow-up. The home care nurse assesses the patient’s and family’s abilities to meet the patient’s needs and determines whether the services of other agencies are needed. The nurse advises the patient to have readily available the telephone numbers of people to contact in case concerns arise. The nurse emphasizes the need for long-term health supervision to ensure cure or to detect tumour recurrence or metastasis and the need for recommended health screening. If the patient has metastatic disease, end-of-life issues may need to be explored. Referral for hospice care is made if appropriate.

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REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

Critical Thinking Exercises 1

You are a staff nurse employed at a family practice clinic. A 52-year-old mechanic has been seeking treatment at the clinic for low back pain of 2 weeks’ duration. He has been prescribed a muscle relaxant and told to take over-the-counter NSAIDs. He is not reporting significant relief from his symptoms, though he reports

BOOKS McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th Ed.). St. Louis, MO: Mosby. National Association of Orthopaedic Nurses. (2007). Core curriculum for orthopae