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Medical Surgical

Huntington’s Disease

Huntington;s disease is a chronic, hereditary disease of the nervous system that results in progressive involuntary choreiform (dance-like) movements and dementia.  Researchers believe that glutamine abnormally collects in certain brain cell nuclei, causing cell death.  Huntington’s disease affects men and women of all races. It is transmitted as an autosomal dominant genetic disorder. Each child of a parent with Huntington’s has a 50% risk of inheriting the illness. Onset usually occurs between 35 and 45 years of age.

CLINICAL MANIFESTATIONS

  • The most prominent clinical features are abnormal involuntary movements (chorea), intellectual decline, ans emotional disturbance.
  • Constant writhing, twisting and uncontrollable movements of the entire body as the disease progresses.
  • Facial movements produce tics and grimaces; speech becomes slurred, hesitant, often explosive, and then eventually unintelligible.
  • Chewing and swallowing are difficult, and aspiration and choking are dangers.
  • Gait becomes disorganized, and ambulation is eventually impossible; patient is eventually confined to a wheelchair.
  • Bowel and bladder control is lost.
  • Progressive intellectual impairment occurs with eventual dementia.
  • Uncontrollable emotional changes occur but become less acute as the disease progresses. Patient may be nervous, irritable, impatient. During the early stages of illness: uncontrollable fits of anger; profound , often suicidal depression; apathy; or euphoria.
  • Hallucinations, delusions, and paranoid thinking may precede appearance of disjointed movements.
  • Patient dies in 10 to 15 years from heart failure, pneumonia, or infection or as a result of a fall or choking.

ASSESSMENT AND DIAGNOSTIC FINDINGS

  • Diagnosis is made on the basis of clinical presentation, positive family history, and exclusion of other causes.
  • Imaging studies, such as computed tomography (CT), and magnetic resonance imaging (MRI), may show atrophy of striatum.
  • A genetic marker for Huntington;s disease has been located. It offers no hope pf cure or even specific determination of onset.

MEDICAL MANAGEMENT

No treatment stops or reverse the process; palliative care is given.

  • Medications such as phenothiazines (haloperidol), butyrophenones, and thioxanthenes, which block dopamine receptors, and reserpine  and tetrabenazine. Anti-parkinsonism therapy (L-dopa) may improve chorea and temporarily decrease rigidity in some patients.
  • Motor signs are continually assessed and evaluated. Akathisia (motor restlessness) in the overmedicated patient is dangerous and should be reported.
  • Psychotherapy aimed at allaying anxiety and reducung stress may be beneficial; antidepressants are given for depression or suicidal ideation.
  • Patients needs and abilities are the focus of treatment.

NURSING MANAGEMENT

  • Reinforcing understanding that Huntington;s disease takes emotions, physical, social and financial tolls on every member of the patients family.
  • Encourage genetic counseling, long-term psychological counseling, marriage counseling, and financial and legal support.
  • Teach patient and family about medications, including signs indicating need for change in dosage and medication.
  • Address strategies to manage symptoms (chorea, swallowing problems, ambulation problems, or altered bowel or bladder function).
  • Arrange for consultation with a speech therapist, if needed.
  • emphasize the need for regular follow-up.
  • Refer for home care nursing assistance, respite care, day care centers, and eventually skilled long-term care to assist patient and family to cope.
  • Provide information about the Huntington’s Disease Foundation of America, which gives information, referrals, education, and support for research.

 

Reference:

Handbook for brunner & Suddarth’s textbook in Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.450-452

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Medical Surgical

Hodgkin’s Disease

Hodgkin’s disease is a rare cancer of unknown cause that is unicentric in origin and spreads along the lymphatic system. There is a familial pattern associated with Hodkin’s as well as an association with the Epstein-Barr virus (found 40% to 50% of patients). It is more common in men and tends to peak in the early 20s and after 50 years of age.  The Reed-Sternberg cell, a gigantic morphologically unique tumor cell that is thought to be  of immature lymphoid origin, is the pathologic hallmark and essential diagnostic criterion of Hodgkin’s disease. Most patients with Hodgkin’ disease have the types currently designated “nodular sclerosis” or “mixed cellularity”. The nodular sclerosis type tends to occur more often in young women ans at an earlier stage but has a worse prognosis than the  mixed cellularity subgroup. which occurs more commonly in men and causes more constitutional symptoms but has a better prognosis.

CLINICAL MANIFESTATIONS

  • Painless enlargement of the lymph nodes on one side of the neck. Individual nodes are firm and painless; common sites are the cervical, supraclavicular, and mediastinal nodes.
  • Mediastinal lymh nodes may be visible on x-ray films and large enough to cause severe pressure symptoms (eg. dyspnea from pressure against the trachea; dysphagia from pressure against the esophagus).
  • Symptoms may result from the tumor compressing other organs, causing cough and pulmonary effusion (from pulmonary infiltrates); jaundice (from hepatic involvement or bile duct obstruction); abdominal pain (from splenomegaly or retroperitoneal adenopathy); or bone pain (due to skeletal involvement).
  • Pruritus is common and can be distressing; unclear etiology Herpes zoster  infection is common.
  • Some patients (20%) experience brief but severe pain after drinking alcohol, usually at the site of the tumor.
  • Mild anemia develops; the white blood cell count may be elevated or decreased; and energy (an absence of or decreased response to skin sensitivity tests such as candidal infection, mumps) may be noted.
  • Constitutional symptoms for prognostic purpose referred to as B symptoms, include fever (without chills), drenching sweats (particularly at night), and unintentional loss of more than 10% of body weight (found in 40% of patients and more common in advanced disease).

ASSESSMENT AND DIAGNOSTIC METHODS

Diagnostic depends on identification of characteristic histologic features in an excised lymph node. After the diagnosis is confirmed, the total extent of tumor involvement is assessed and its distribution is defined.

  • Laboratory studies: complete blood count; platelet count, sedimentation rate, liver and renal function studies, RBC sedimentation rate and serum copper levels are used by some clinicians to assess disease activity.
  • Excisional  lymph node biopsy, bone marrow biopsy, characteristic presence of Reed-sternberg cell; staging of node.
  • Chest x-ray and computed tomography (CT) of chest, abdomen, and pelvis; positron emission tomography (PET) to detect residual disease.

MEDICAL MANAGEMENT

Treatment id determined by the stage of the disease instead of the histologic type.

  • Chemotherapy followed by radiation therapy is used in early-stage disease.
  • Combination chemotherapy alone is now the standard treatment for more advanced disease.
  • When Hodgkin;s does recur, the use of high doses of chemotherapeutic medications, followed by autologous bone marrow or stem-cell transplantation, can be very effective.

NURSING MANAGEMENT

  • Help patients to cope with undesirable effects of radiation therapy including esophagitis, anorexia, loss of taste, dry mouth, nausea and vomiting, diarrhea, skin reactions, and lethargy.
  • Serve bland, soft foods at mild temperature.
  • Teach patient about proper dental hygiene.
  • Administer antiemetics during peak times of nausea.
  • Teach patient that skin reactions are common; rubbing the area and applying heat, cold or lotion should be avoided.
  • Encourage patient to rest and sleep to maintain a  reasonable energy level; lethargy accompanies radiation.
  • Help patient to prepare for alopecia by encouraging him or her to purchase a wig before hair loss.
  • Encourage patient to report any sign of infection for immediate treatment.
  • Instruct patient to use contraception during chemotherapy to prevent cytotoxic effects on the fetus.
  • Encourage patient to keep all follow-up appointments.

 

Reference:

Handbook for Brunner & Suddarth’s textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.447-450

 

 

 

Categories
Medical Surgical

Hyperthyroidism (Grave’s disease)

Hyperthyroidism is the second most common endocrine disorder and Grave’s disease is the most common type. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland  by circulating immunoglobulins. Long-acting thyroid stimulator (LATS) is found significant in concentrations in the serum of many of these patients. The disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It may appear after an emotional shock, stress, or infection, but the exact significance of these relationships is not understood. Other common causes include thyroiditis and excessive ingestion of thyroid hormone (eg. from treatment of hypothyroidism)

CLINICAL MANIFESTATIONS

Hyperthyroidism presents a characteristic  group of signs and symptoms (thyrotoxicosis).

  • Nervousness (emotionally hyperexcitable), irritability, apprehensiveness; inability to sit quietly; palpitations, rapid  pulse on rest and exertion.
  • Poor tolerance of heat; excessive perspiration; skin that is flushed and likely to be warm, soft and moist
  • Dry skin and diffuse pruritus in the elderly
  • Fine tremor of the hands
  • Exophthalmos (bulging eyes) in some patients
  • Increased appetite and dietary intake, progressive loss of weight, abnormal muscle fatigability, weakness, amenorrhea, and changes in bowel function (constipation or diarrhea)
  • Pulse ranges between 90 and 160 beats/min with sinus tachycardia or dysrhythmias; systolic (but not diastolic) blood pressure elevation (increased pulse pressure).
  • Atrial fibrillation; cardiac decompensation in the form of congestive heart failure, especially in the elderly
  • Osteoporosis and fracture
  •  May include remissions and exacerbations, terminating with spontaneous recovery in a few months or years
  • May progress relentlessly; causing emaciation, intense nervousness, delirium, disorientation, and eventually myocardial hypertrophy and heart failure.

ASSESSMENT AND DIAGNOSTIC FINDINGS

  • Thyroid glands is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries
  • Laboratory tests show a decrease in serum TSH, an increase in serum thyroxine (T4) level and an increase in 123I or 125I uptake in excess of 50%.

Gerontologic Considerations

Elderly patients commonly presents with vague and nonspecific signs and symptoms. The major symptoms in the elderly patient may be depression and apathy, accompanied by significant weight loss and constipation in some. The patient may report cardiovascular symptoms and difficulty climbing stairs  or rising from a chair because of muscle weakness; congestive failure may be noted. Elderly patients may experience a single manifestation, such as atrial fibrillation, anorexia, or weight loss.  These general symptoms may mask underlying thyroid disease. Spontaneous remission of hyperthyroidism is rare in the elderly. Measurement of thyroid-stimulating hormone (TSH) uptake is indicated in elderly patients with unexplained physical or mental deterioration . Use of 123I or 131I is generally recommended for treatment of thyrotoxicosis rather than surgery unless an enlarged thyroid gland is pressing on the airway. Thyrotoxicosis must be controlled by antithyroid drugs before 131I is used because radiation may precipitate thyroid storm, which has a high mortality rate in the elderly.  Beta-blockers may be indicated. Use these agents with extreme caution ans monitor closely for granulocytopenia. Modify dosages of other medications because of the altered rate of metabolism in hyperthyroidism.

MEDICAL MANAGEMENT

Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. These forms of treatment are available:

  • Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland.
  • Pharmacotherapy with antithyroid medications.
  • Surgery with the removal of the most of the thyroid gland.

Radioactive Iodine (131 I)

  • 131 I is given to destroy the overactive thyroid cells (most common in the elderly).
  • 131 I is contraindicated in pregnancy and nursing mothers because radioiodine crosses the placenta and is secreted in breast milk.

Pharmacotherapy

  • The objective of pharmacotherapy is to inhibit hormone synthesis or release and reduce the amount of thyroid tissue.
  • The most commonly used medicatioins are propylthiouracil (Propacil, PTU) and methimazole (Tapazole) until patient is euthyroid.
  • Maintenance dose is established, followed by gradual withdrawal of the medication over the next several months.
  • Antithyroid drugs are contraindicated in late pregnancy because of the risk for goiter and cretinism in the fetus.
  • Thyroid hormone may be administered to put the thyroid to rest.

Adjunctive Therapy

  • Potassium iodide, Lugol’s solution, and saturated solution of potassium iodide (SSKI) may be added.
  • Beta-adrenergic agents may be used to control the sympathetic nervous system effects that occur in hyperthyroidism; for example; propanolol is used for nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Surgical Intervention

  • Surgical intervention (reserved for special circumstances)removes about five sixths of the thyroid tissue.
  • Before surgery, the patient is given propylthiouracil until signs of hyperthyroidism have disappeared.
  • Iodine is prescribed to reduce the thyroid size and vascularity and blood loss. Patient is monitored carefully for evidence of iodine toxicity (swelling buccal mucosa, excessive salivation, skin eruptions).
  • Risk for relapse and complications necessitates long-term follow-up of patient undergoing treatment of hyperthyroidism.
  • Surgery to treat hyperthyroidism is performed after thyroid function has returned to normal (4 to 6 weeks).

 

Reference:

Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams and Wilkins pp.461-464

Categories
Medical Surgical

Parkinson’s Disease

Parkinson’s disease is a slowly progressive degenerative  neurologic disorder affecting the brain center that are responsible for control and regulation of movement. 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. The cause of the disease is mostly unknown. The disease usually first appears in the fifth decade of life and is the fourth most common neurodegenerative disease.

PATHOPHYSIOLOGY

Stores of the neuotransmitter dopamine are lost in the substantia nigra ans the corpus striatum because of a degenerative process. The loss pf dopamine stores in this area of the brain results in excitatory neurotransmitter than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement . Other neurotransmitter pathways (responsible for cell metabolism, growth, nutrition, and so forth) may be involved as well. Cellular degeneration causes impairment of the extrapyramidal tracts that control semiautomatic functions and coordinated movements. Regional cerebral blood flow  is reduced, and there is a high prevalence of dementia. Biochemical and pathologic data suggest  that patients with Parkinson’s disease and dementia may have coexistent Alzheimer’s disease.

CLINICAL MANIFESTATIONS

The three cardinal signs of Parkinson’s disease are tremor, rigidity, and bradykinesia (abnormally slow movements).

  • Impatient movement: bradykinesia includes difficulty in initiating, maintaining, and performing motor activities, muscle stiffness or rigidity
  • Resting tremors: a slow unilateral turning of the forearm and hand and pill-rolling motion of the thumb against the fingers; tremors at rest and increasing with concentration and anxiety
  • Muscle weakness
  • Hypokinesia (abnormally diminished movement), gait disturbances, flexed posture, and postural instability (loss of postural reflexes, and the freezing phenomenon)

OTHER CHARACTERISTICS

Patients tend to develop micrographia (shrinking, slow hand-writing) as dexterity declines. Additional characteristics include:

  • Dysphonia (soft, slurred, low-pitched, and less audible speech)
  • Masklike facial expression
  • Loss of postural reflexes: patients stand with head bent forward and walks with propulsive gait ( shuffling gait); difficulty pivoting and loss of balance, resulting in risk for falls.
  • Depression and psychiatric manifestaitons (personality changes, psychosis, dementia, and confusion)
  • Sleep disorders, uncontrolled sweating, orthostatic hypotension, gastric and urinary retention, and constipation

ASSESSMENT AND DIAGNOSTIC METHODS

  • Patient’s history and presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia
  • Positron emission tomography (PET) scanning
  • Neurologic examination and response to pharmacologic management

MEDICAL MANAGEMENT

Goal of treatment is to control symptoms and maintain functional independence; no approach prevents disease progression.

Pharmacologic Therapy

  • Levodopa therapy ( converts to dopamine): most effective agent to relieve symptoms; usually given in combination with carbidopa (Sinemet), which prevents levodopa breakdown.
  • Budipine is a non-dopaminergic, antiparkinson medication that significantly reduce akinesia, rigidity, and tremor.
  • Antihistamine drugs to allay tremors.
  • Dopamine agonists (eg. pergolide [Permax], bromocriptine mesylate [Parlodel], ropinirole, and pramipexole are used to postpone the initiation of carbidopa and levodopa therapy.
  • Anticholinergic therapy to control the tremor and rigidity.
  • Amantadine hydrochloride  (Symmetrel), an antiviral agent, to reduce rigidity, tremor and bradykinesia.
  • Monoamine oxidase inhibitors (MAOI’s) to inhibit dopamine breakdown
  • Anntidepressant drugs
  • Trials of catechol-O-methyltransferase (COMT) inhibitors.

Surgical Management

  • Surgery to destory a part of the thalamus (stereotactic thalamotomy and pallidotomy) to interrupt nerve pathways and alleviate tremor or rigidity.
  • Transplantation of neural cells from fetal tissue of human or animal source to reestablish normal dopamine release.
  • Deep brain stimulation with pacemaker-like brain implants shows promise but is waiting for FDA approval.

 

 

Reference:

Handbook for Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp. 594-596

Categories
Medical Surgical

Cancer of the Cervix

              

Cancer of the cervix is predominantly (90%) squamous cell cancer and can include adenocarcinomas. It is less common than it once was because of early detection by the Pap test, but it remains the third most common reproductive cancer in women. it occurs most commonly between the ages of 35 and 45 years but can occur in women as young as 18 years. Risk factors vary from multiple sex partners to smoking to chronic cervical infection (exposure to HP virus).

 

CLINICAL MANIFESTATIONS:

  • Cervical cancer is most often asymptomatic. When discharge, irregular bleeding, or bleeding after sexual intercourse occurs, the disease may be advanced.
  • Vaginal discharge gradually increases in amount, becomes watery, and finally is dark ans foul-smelling because of necrosis of the tumor mass.
  • Bleeding occurs at irregular intervals between periods or after menopause, may be slight (enough to spot the undergarment), and is usually noted after mild trauma (intercourse, douching, or defecation). As disease continues, bleeding may persist and increase.
  • Nerve involvement, producing excruciating pain the back and legs, occurs as cancer advances and tissues outside the cervix are invaded, including the fundus and lymph glands anterior to the sacrum.
  • Extreme emaciation and anemia, often with fever due to secondary infection and abscesses in the ulcerating mass, and fistula formation may occur in the final stage.

ASSESSMENT AND DIAGNOSTIC FINDINGS

  • Pap smear and biopsy results show severe dysplasia, HGSIL, or carcinoma in situ.
  • Abnormal Pap test may be followed by biopsy, dilation and curettage (D & C), computed tomography (CT), magnetic resonance imaging (MRI), intravenous utrography (IVU), cystogram and barium radiopgraphs.

MEDICAL MANAGEMENT

Disease may be staged based on the International Classification staging system or TNM classification to determine treatment as well as progress of the cancer.

  • Conservative treatments include cryotherapy (freezing with nitrous oxide), laser therapy, loop electrosurgical excision procedure (LEEP), or conization (removing a cone shaped portion of the cervix).
  • Simle hysterectomy if invasion is less than 3 mm. Radical trachelectomy is an alternative to hysterectomy.
  • For invasive cancer , radical hysterectomy, radiation (external-beam or brachetherapy), or chemotherapy (cisplatin, carboplatin, and paclitaxel [Taxol] or a combination of these approaches may be used.
  • For recurrent cancer, pelvic exenteration is considered.
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Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.3 Superficial dissection, female pectoral region

  • On the specimen’s right side, the skin is removed; on the left side, the breast is sagittally sectioned.
  • The breast extends from the 2nd to the 6th ribs. The axillary process (tail) of the breast consists of glandular tissue projecting toward the axilla.
  • The region of loose connective tissue between the pectoral fascia and the deep surface of the breast, the retromammary bursa, permits the breast to move on the deep fascia.
  • Interference with the lymphatic drainage by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue), which in turn may result in deviation of the nipple and a leathery, thickened appearance of the breast skin. Prominent (puffy) skin between dimpled pores may develop, which gives the skin an orange-peel appearance (peau d’orange sign). Larger dimples may form if pulled by cancerous invasion of the suspensory ligaments of the breast.

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Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.2 Superficial dissection, male pectoral region

  • The platysma muscle, which descends to the 2nd or 3rd rib, is cut short on the right side of the specimen; together with the supraclavicular nerves, it is reflected on the left side.
  • The thin pectoral fascia covers the pectoralis major.
  • The clavicle lies deep to the subcutaneous tissue and the platysma muscle.
  • The cephalic vein passes deeply in the clavipectoral (deltopectoral) triangle to join the axillary vein.
  • Supraclavicular (C3 and C4) and upper thoracic nerves (T2 to T6) supply cutaneous innervation to the pectoral region.
  • The clavipectoral (deltopectoral) triangle, bounded by the clavicle superiorly, the deltoid muscle laterally, and the clavicular head of the pectoralis major muscle medially, underlies a surface depression called the infraclavicular fossa.
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Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.1 Surface anatomy of male pectoral region

  • The subject is adducting the shoulders against resistance to demonstrate the pectoralis major muscle.
  • The pectoralis major muscle has two parts, the sternocostal and clavicular heads.
  • The anterior axillary fold is formed by the inferior border of the sternocostal head of the pectoralis major muscle.
  • The axillary fossa (“armpit”) is a surface feature overlying a fat-filled space, the axilla.