Inflammation of theReproductive Organs

•Vaginitis
•inflammation of the vaginal mucosa & often asso. with irritation or infection of the vulva, usually cause by a change in the normal balance of vaginal bacteria, infection or reduced estrogen levels after menopause.
•Most Common Types of Vaginitis
•Bacterial vaginosis
–vaginitis results from overgrowth of one of several organisms normally present in the vagina, upsetting the natural balance of vaginal bacteria
•Yeast infections
–usually caused by Candida albicans (a naturally occurring fungus)
•Trichomoniasis
–caused by a parasite & is commonly transmitted by sexual intercourse.
•Atrophic vaginitis
–results from reduced estrogen levels after menopause. The vaginal tissues become thinner & drier, which may lead to itching, burning or pain.
•Causes & Forms of Vaginitis
•Infection
–Infectious vaginitis: accounts for 90% of all cases in reproductive age women & is represented by the triad:
–Candidiasis: vaginitis caused by C. albicans (a yeast)
–Trichomoniasis: vaginitis caused by T. vaginalis (a protozoan)
–Bacterial vaginosis: vaginitis caused by Gardnerella (a bacterium).
–Other less common infections are caused by gonorrhea, chlamydia, mycoplasma, herpes, campylobacter & some parasites
•Risk Factors for Vaginal Candida Infections
•Recent Course of Antibiotics
•Uncontrolled Diabetes
•Pregnancy
•High Estrogen Contraceptives
•Immunosuppression
•Thyroid or Endocrine Disorders
•Corticosteroid Therapy
•Causes & Forms of Vaginitis
•Hormonal vaginitis
–Hormonal vaginitis: includes atrophic vaginitis usually found in postmenopausal or postpartum women, sometimes occur in young girls before puberty. In these situations (due to i prodxn of estrogen)
•Irritation/allergy (non infectious vaginitis)
–Irritant vaginitis: caused by allergies to condoms, spermicides, soaps, perfumes, douches, lubricants & semen; can also be caused by hot tubs, abrasion, tissue, tampons or topical medications
•Causes & Forms of Vaginitis
•Foreign body
–Foreign Body Vaginitis: Foreign bodies (most commonly retained tampons or condoms) cause extremely malodorous vaginal discharges. Tx: removal, using ring forceps
•Organisms that are passed between sexual partners.
•Symptoms
•irritation &/or itching of the genital area
•inflammation (irritation, redness, & swelling caused by the presence of extra immune cells) of the labia majora, labia minora, or perineal area
•vaginal discharge
•foul vaginal odor
•discomfort or burning when urinating
•pain/irritation with sexual intercourse
•The color of the discharge may be predictive of the causative agent:
•Candida Vaginitis -Candidiasis - watery, white, cottage cheese like vaginal discharge; irritating to the vagina & the surrounding skin.
•Atrophic vaginitis (or "Senile Vaginitis") – scanty, dry, odorless vaginal discharge, usually causes painful intercourse (due to decreased hormones usually occurring during & after menopause)
•Bacterial Vaginitis - Gardnerella - fish-like odor, associated with itching & irritation
•The color of the discharge may be predictive of the causative agent:
•Trichonomas Vaginitis - profuse discharge with a fish-like odor, usually causes pain upon urination, painful intercourse, & inflammation of the external genitals.
**Women who have diabetes frequently develop vaginitis (often Candida Candida albicans) more often than women who do not.
•Diagnostic Procedures
•PAP smear
–Measurement of vaginal pH
- h w/ infxn
–C/S of vaginal discharge
•Complications
•Premature delivery & low birth wt baby
•persistent discomfort
•superficial skin infection (from scratching)
•complications of the causative condition (such as gonorrhea & candida infection)
•Treatment
•oral or topical antibiotics
•Antifungal/ antibacterial creams
–A cream containing cortisone may also be used to relieve some of the irritation
–a topical estrogen cream - for women who have irritation & inflammation caused by low levels of estrogen (postmenopausal)
•Prevention
Good hygiene may prevent some types of vaginitis from recurring & may relieve some symptoms:
•Avoid baths, hot tubs & whirlpool spas
–Rinse soap from outer genital area after a shower, & dry the area well to prevent irritation. Don't use scented or harsh soaps, such as those with deodorant or antibacterial action.
•Avoid irritants
–These include scented tampons & pads.
•Wipe from front to back after using the toilet
•Prevention
•Other things that may help prevent vaginitis:
–Don't douche :
•vagina doesn't require cleansing other than normal bathing
•Repetitive douching disrupts the normal organisms that live in the vagina & can actually h risk of vaginal infection
•Douching won't clear up a vaginal infection
–Use a male latex condom
–Wear cotton underwear & pantyhose with a cotton crotch: Don't wear underwear to bed. Yeast thrives in moist environments.
–Eat yogurt that contains active lactobacillus cultures.
•Lactobacillus is a type of "good" bacteria that's common in the vagina
•may sometimes help reduce recurrent vag. yeast infxns
•Cervicitis
•an inflammation of the cervix, the lower, narrow end of the uterus that opens into the vagina, caused by infection with STDs, including gonorrhea & chlamydia.
•Signs & Symptoms
•Asymptomatic (most often)
•Vaginal discharge that's grayish or yellow, possibly with an odor
•Frequent, painful urination
•Pain during intercourse
•Vaginal bleeding after intercourse, between menstrual periods or after menopause
•Causes
•Bacteria & viral infxn transmitted thru sexual contact
•Allergic rxn
•Bacterial overgrowth
•Risk Factors
•Engage in high-risk sexual behavior, such as unprotected sex or sex with multiple partners
•Began having sex at an early age
•Have a history of sexually transmitted diseases
•h risk if have sex with a partner who has engaged in high-risk sexual behavior or has had a sexually transmitted
•Diagnostic Procedures
•Pelvic exam
•PAP smear
Complications
•PID
•Treatment
•Antibiotic/ Antiviral
Prevention
•Practice safe sex
•Be monogamous
•Bartholinitis
•Inflammation of Bartholin's gland (bartholinitis) may be induced by Staphylococci, Streptococci, Escherichia coli, & Gonococci which have penetrated into the Bartholin's duct.
•The duct is occluded as a result of tissue edema & the retained secretion of the gland suppurates forming an abscess which not uncommonly ruptures spontaneously.
•The inflammatory process may subside without any suppuration & rupture
•Signs & Symptoms
•Severe pain in the labial area when sitting & walking
•General malaise
•Fever
•Elevated pulse rate
•Edema & hyperaemia in the area of the labia majora
•Suppurative lesions
•Development of a cyst in the labia majora (for recurrent Bartholinitis)
•Management
•Bed rest
•Cold applications (ice bags)
•Administration of antibiotics & sulphanilamides
•Surgery: Marsupialization - if the focus is suppurative
–suturing of the edges of the open cyst wall to the edges of the operative wound
–In cases of the spontaneous opening of an abscess, the involved area is treated with antiseptic solutions (3% solution of hydrogen peroxide) & then dressed with antibiotic ointment.
•Pelvic Inflammatory Disease
•infection of the female repro. organs, usually occurs when sexually transmitted bacteria spread from the vagina to the uterus & upper genital tract.
•may also develop when bacteria travel up a contraceptive device or when bacteria are introduced during gynecologic procedures.
•Pelvic Inflammatory Disease
•Many women who develop PID either experience no s/sx or don't seek tx
•PID may be detected only later when there is a problem getting pregnant or if there is chronic pelvic pain
•PID can result in infertility or complications during pregnancy
–Prompt tx of a STD can help prevent PID
•Signs & Symptoms
•Pain in your lower abdomen & pelvis
•Heavy vaginal discharge with an unpleasant odor
•Irregular menstrual bleeding
•Pain during intercourse
•Low back pain
•Fever, fatigue, diarrhea or vomiting
•Painful or difficult urination
WARNING signs & symptoms of PID:
•Severe pain low in your abdomen
•Vomiting
•Signs of shock, such as fainting
•Fever of higher than 101 F

•Causes
•Unsafe sexual practices - h likelihood of acquiring a STD,
h risk of PID
•Some forms of contraception may affect risk of developing PID
–Contraceptive IUDs may h risk of PID
–Barrier methods, such as condoms or diaphragms, i risk
–Use of the birth control pill alone offers no protection against acquiring STDs. But it may offer some protection against the dev’t of PID by causing the body to create thicker cervical mucus, making it more difficult for bacteria to reach the upper genital tract.
•Bacteria may also enter repro. tract as a result of an IUD insertion, childbirth, miscarriage, abortion or removing a small piece of tissue from uterine lining for lab analysis (endometrial biopsy)
•Risk Factors
•Sexually active woman younger than 25 y/o
•Multiple sexual partners
•Using nonbarrier contraceptives
–consistent use of barrier methods protects against PID, but not against other STDs, such as human papillomavirus (HPV) & herpes simplex virus (HSV)
•Recent IUD insertion
•Regular douching - may flush bacteria higher into the genital tract & mask symptoms that might cause to seek early treatment
•Having a history of PID or any STD

•Screening & Diagnosis
•Analysis of vaginal discharge & cervical cultures
•Pelvic laparoscopy - to confirm the diagnosis or to determine how widespread the infxn
–The doctor inserts a thin, lighted instrument through a small incision in abdomen to view the pelvic organs
•Complications
Abscesses in fallopian tubes & may damage reproductive organs.
•Ectopic pregnancy
–PID is a major cause of tubal (ectopic) pregnancy
•Infertility
–About one in eight women with PID becomes infertile after one year of unprotected sex
–Delay tx for PID h risk of infertility
•Chronic pelvic pain
–may last for mos. or yrs.
–Scarring in fallopian tubes & other pelvic organs can cause pain that commonly occurs during intercourse, exercise & ovulation
•Treatment
•Antibiotics - may prescribe a combination of antibiotics before receiving the results of the lab tests
•Analgesics
•Bed rest
•Avoid sexual intercourse until treatment is completed & tests indicate that the infection has cleared
•Prevention
•Safe sex practices
–Proper use of condoms i, but doesn't eliminate, the risk of contracting an STD
–Monogamous sexual relationships or abstinence
•Regular screenings for STDs
•Advise partner to be tested &, if necessary, be treated if a partner is (+) – to prevent the spread of STDs & possible recurrence of PID.
•Endometriosis
•Presence of endometrial tissue outside the lining of the uterine cavity
•Displaced endometrial tissue generally confined to the pelvic area (usually around the ovaries, uterovesical peritoneum, uterosacral ligaments & cul de sac) but can appear anywhere in the body
•It may occur in any age, including adolescence
•May be present in as many as 50% of infertility women
•Pathophysiology:Endometriosis
•implantation of the endometrium outside the uterus, most commonly on fallopian tubes, ovaries or the tissue lining of the pelvis
i
•Endometrium continues to act in its normal way: It thickens, breaks down & bleeds each month as the hormone levels rise & fall. Because there's nowhere for the blood from this displaced tissue to exit the body, it becomes trapped, & surrounding tissue can become irritated
i
•Trapped blood may lead to the growth of cysts g scar tissue formation & adhesions g pain in the area of misplaced tissue (often the pelvis) especially during menstruation. Scars & adhesions related to endometriosis also can cause fertility problems
•Causes
•Unknown
•Main theories
–Retrograde menstruation with implantation at ectopic sites
–Genetic predisposition & depressed immune system (may predispose to endometriosis)
–Coelomic metaplasia (repeated inflammation inducing metaplasia of mesothelial cells to the endometrial epithelium)
–Lymphatic or hematogenous spread (extraperitonel dse)
–Undifferentiated embryonic peritoneal tissue cells that remain dormant until hormones stimulate their response
•Signs & Symptoms
•Dysmenorrhea
•Abnormal uterine bleeding
•Infertility & profuse menses due to ectopic tissue in the uvaries & oviducts
•Pain that begins 5-7 days before menses peak & lasts for 2-3 days due to implantation of ectopic tissues & adhesions
•Dyspareunia
•Suprapubic pain, dysuria & hematuria due to ectopic tissue in the bladder
•Abdominal cramps, pain on defecation & constipation; bloody stools from bleeding of ectopic endometrium in the rectosigmoid musculature
•Complications
•Infertility
•Chronic pelvic pain
•Ovarian CA (rare)
•Diagnostic Tests
•Laparoscopy or laparotomy – the only definitive diagnostic
•Biopsy
•Empiric trial of GnRH agonist therapy confirms or refutes the impression of endometriosis
•Ultrasound
•Management
•Androgens such as Danazol, to inhibit the anterior PG
•Progestins & continuous combined hormonal contraceptives (pseudopregnancy regimen) to relieve symptoms by causing a regression of endometrial tissue
•GnRH agonists to induce pseudomenopause (medical oophorectomy), causing remission of the dse (commonly used)
•Laparoscopic removal of endometrial implants with conventional or laser
•Presacral neurectomy for central pelvic pain (50% effective)
•Laparoscopic uterosacral nerve ablation
•TAHBSO or TAH
•Analgesics
•Nursing Considerations
•Tell pt undergoing laparoscopy that they may experience pain in the shoulders from gas pumped into the abd. (to separate the organs & prevent accidental puncture) & some discomfort at the laparoscope insertion site
•Advise to avoid undergoing minor gynecological procedures immediately before & during menstruation (this may promote spread of endometrial tissue)
•Advise not to postpone childbearing for those who want to have children
•Recommend an annual pelvic exam & PAP smear
•Inform the pt taking Danazol that ovulation & menstruation will stop, resulting in pseudomenopause (tx lasts from 6-9 mos)
–Advise about expected adverse effects: acne, i breast size, edema. Flushing, sweating, voice deepening & wt. gain
–Inform pt that virilization effects may be irreversible
•Amenorrhea
•Abnormal absence or suppression of menstruation
•Primary amenorrhea: absence of menarche in an adolescent (age 16 & older)
•Secondary amenorrhea: cessation of menstruation for at least 3 mos. after the normal onset of menarche
•Pathophysiology
•In primary amenorrhea, the hypothalamic-pituitary-ovarian axis is dysfunctional:
–Caused by anatomic defects of the CNS
–Results in the ovary’s failure to receive hormonal signals that normally initiate the dev’t of secondary sex characteristics & menarche
•Secondary amenorrhea can result from:
–Hypogonadotropic-hypoestrogenic anovulation
–Uterine factors (as w/ Asherman’s syndrome: endometrium is sufficiently scarred that leads to nonfunctioning of the endometrium)
–Cervical stenosis
–Premature ovarian failure
•Causes
•Autoimmune disease
•Hormonal abnormalities
•Infection (mumps, oophoritis)
•Lack of ovarian response to gonadotropins
•Constant presence of progesterone or other endocrine abnormalities
•Absence of a uterus
•Endometrial damage
•Ovarian, adrenal or pituitary tumors
•Emotional disorders such as anorexia nervosa
•Malnutrition or obesity
•Excessive exercise
•Signs & Symptoms
•Absence of menstruation due to underlying cause
•Vasomotor flushes
•Vaginal atrophy
•Hirsutism
•Acne (secondary amenorrhea)
Complications
•Infertility
•Endometrial adenocarcinoma
•Diagnostic Tests
•Pregnancy test to rule out pregnancy
•Gonadotropin testing: reveals h or i pituitary gonadotropin levels
•Urine testing: h urinary 17-ketosteroids levels & excessive androgen secretion
•Vaginal cytologic examination, endometrial biopsy
•Plasma FSH analysis: level higher than 50 IU/L in primary ovarian failure; normal or low level in possible hypothalamic or pituitary abnormality
•Thyroid function test
•Laparoscopy, hysteroscopy
•CT, MRI
•Ultrasound
•Management
•Appropriate hormone replacement to reestablish menstruation
•Inducing ovulation using Clomiphene citrate (Clomid)
–For women with an intact PG
–May be successful for secondary amenorrhea due to gonadotropin deficiency, polycystic ovarian dse, or excessive wt. loss or gain
•FSH & human menopausal gonadotropins (Pergonal) for pituitary dse
•Improving nutritional status & normalizing wt.
•Modification exercise routine, if needed
•Treatment of emotional disorder, if needed
•Nursing Considerations
•Explain all diagnostic procedures & treatments to the pt
•Provide emotional support; psychiatric counseling if amenorrhea results from emotional disturbances or eating disorders
•After treatment: treat the pt how to keep an accurate record of menstrual cycles to aid in the early detection of recurrent amenorrhea
•Dysmenorrhea
•Painful menstruation associated with ovulation & unrelated to pelvic dse.
•Primary dysmenorrhea or secondary dysmenorrhea
–Primary dysmenorrhea - involves no physical abnormality & usually begins 6 mos-1year after began menstruating
•cramps tend to decrease in intensity as women get older & often disappear after pregnancy
–Secondary dysmenorrhea - involves an underlying physical cause, such as endometriosis or uterine fibroids.
•Pathophysiology
•Pain results from h prostaglandin secretion or sensitivity to prostaglandin in menstrual blood, which intensifies normal uterine contractions
•Prostaglandin intensify myometrial smooth muscle contraction & uterine bld vessel constriction thereby worsening the uterine hypoxia normally associated with menstruation
•A combination of intense muscle contractions & hypoxia causes the intense pain of dysmenorrhea
•Causes
•Primary dysmenorrhea
–Possible contributing factors:
•Hormonal imbalance
•Psychogenic factors such as depression
•Secondary dysmenorrhea
–Endometriosis
–Adenomyosis – tissue lining of the uterus begins to grow w/in the muscle walls of the uterus
–Cervical stenosis
–PID
–Pelvic tumors
–Use of IUD – may cause increased cramping during the 1st few months after insertion
–Uterine fibroids (leiomyoma) & uterine polyps (noncancerous) protrude from the lining of the uterus
•Signs & Symptoms
•Sharp, intermittent, cramping or throbbing pain in lower abdomen radiating to the lower back & thighs immediately w/ or before menstrual flow & peaks w/in 24 hrs
•Other signs & symptoms that can occur along with menstrual cramps include:
–Nausea and vomiting
–Loose stools
–Sweating
–Dizziness/ headache
–Painful breasts
–Irritability, depression
–Abdominal bloating
–Frequent urination
•Complications
•Primary dysmenorrhea
–Dehydration
•Secondary dysmenorrhea depend on the underlying cause:
–PID can cause scarring of the fallopian tubes that can lead to an ectopic pregnancy
–Endometriosis can lead to impaired fertility
Diagnostic Tests
•Pelvic exam
•Laparoscopy, hysteroscopy, or pelvic UTZ
•CT scan, MRI
•Management
•Nonsteroidal anti-inflammatory drug (NSAID), such as aspirin, ibuprofen (Advil, Motrin, etc.) or naproxen (Aleve)
•Ca to prevent & ameliorate uterine muscle spasms
•Apply hot compress on the lower abdomen to relieve discomfort
•Exercise (may i prostaglandin production by reducing endometrial hyperplasia)
•Primary dysmenorrhea
–Low-dose oral contraceptives to prevent ovulation, w/c may i the production of prostaglandins & i the severity of cramps
•Secondary dysmenorrhea: treat the underlying cause
–Antibiotics to treat infection or surgery to remove fibroids or polyps or to treat endometriosis
•Nursing Considerations
•Obtain a complete history, focusing on pt’s gynecological complaints
•Provide thorough pt teaching including normal female ana-physio as well as the nature of dysmenorrhea
•Encourage the pt to keep a detailed record of menstrual cycle & symptoms & to seek medical care if symptoms persist
•Encourage the pt to start a regular fitness program; stimulates endorphin release, helping to relieve discomfort
•Advise dietary modifications & vitamin therapy
–h dietary intake of whole grains & green, leafy vegetables
–i intake of caffeine, chocolate, alcohol, saturated fats & refined sugar products
–h intake of omega-3 polyunsaturated fatty acids, magnesium, Ca & B vitamins (help to i uterine spasms & cramping)
•Menorrhagia
•excessive or prolonged menstrual bleeding; losing 80 mL or more of blood during menstrual cycle
•Signs & Symptoms
•Menstrual flow that soaks through one or more sanitary pads every hour for several consecutive hours
•Menstrual periods last longer than 7 days
•Presence of large blood clots in menstrual flow
•Constant pain in lower abdomen during periods
•Tiredness, fatigue or shortness of breath (symptoms of anemia)
•Causes
•Hormonal imbalance
•Uterine fibroids
•Polyps
•Dysfunction of the ovaries - Lack of ovulation (anovulation) may cause hormonal imbalance & result in menorrhagia
•Adenomyosis (tissue lining of the uterus begins to grow w/in the muscle walls of the uterus)
•Intrauterine device (IUD)
•Pregnancy complications
–An ectopic pregnancy — may cause menorrhagia
•Cancer
•Medications: anti-inflammatory medications & anticoagulants can contribute to heavy or prolonged menstrual bleeding
•Other medical conditions: PID, thyroid problems, endometriosis, liver or kidney disease
•Diagnostic Tests
•Blood tests
–CBC – to check for blood loss
–Blood test for thyroid disorders or blood-clotting abnormalities
•Pap test
•Endometrial biopsy
•Ultrasound scan
•Sonohysterogram - This ultrasound scan is done after fluid is injected through a tube into the uterus via vagina & cervix. This allows the doctor to look for problems in the lining of the uterus.
•Hysteroscopy - A tiny tube with a light is inserted through vagina & cervix into the uterus
•Dilation & curettage (D and C) - to collect tissue from the uterine lining
•Complications
•Anemia
•Severe pain - requires prescription medication or a surgical procedure
•Management
•Drug therapy for menorrhagia may include:
–Iron supplements
–Nonsteroidal anti-inflammatory drugs (NSAIDs)
–Oral contraceptives - can help regulate ovulation & i episodes of excessive or prolonged menstrual bleeding.
•Progesterone - can help correct hormonal imbalance and reduce menorrhagia.
•Dilation & curettage (D & C), if drug tx is not successful
•Operative hysteroscopy - surgical removal of a polyp that may be causing excessive menstrual bleeding
•Management
•Endometrial ablation - permanently destroys the entire lining of the uterus.
–After endometrial ablation, most women have normal menstrual flow, some have little or no menstrual flow.
–Endometrial ablation reduces the ability to become pregnant.
•Endometrial resection
–This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus.
•Hysterectomy
–Surgical removal of the uterus & cervix
•Premenstrual Syndrome
•a tricky condition of a wide variety of signs & symptoms before the onset of menstrual period
•These problems are more likely to trouble women between their late 20s & early 40s, and they tend to recur in a predictable pattern.
•Signs & Symptoms
•Emotional & behavioral symptoms
–Tension or anxiety
–Depressed mood
–Crying spells
–Mood swings and irritability or anger
–Appetite changes and food cravings
–Trouble falling asleep (insomnia)
–Social withdrawal
–Poor concentration
•Physical signs and symptoms
–Joint or muscle pain
–Headache
–Fatigue
–Weight gain from fluid retention
–Abdominal bloating
–Breast tenderness
–Acne flare-ups
–Constipation or diarrhea
•Signs & Symptoms
•For most of these women, signs & symptoms disappear as the menstrual period begins.
•Premenstrual dysphoric disorder (PMDD) – a severe form of premenstrual syndrome with symptoms including:
–severe depression
–feelings of hopelessness
–Anger
–Anxiety
–low self-esteem
–difficulty concentrating
–Irritability & tension
**A number of women with severe PMS may have an underlying psychiatric disorder.
•Causes
•Unknown cause
•Contributing Factors:
–Cyclic changes in hormones
–Chemical changes in the brain - Fluctuations of serotonin, a brain chemical (neurotransmitter), play a crucial role in mood states could trigger the symptoms. Insufficient amounts of serotonin may contribute to premenstrual depression, fatigue, food cravings & sleep problems.
•Stress, depression
•Low levels of vitamins & minerals
•Eating a lot of salty foods (may cause fluid retention) & drinking alcohol & caffeinated beverages (may cause mood & energy level disturbances)
•Management
•Antidepressants
–use of antidepressants may be limited to the two weeks before menstruation begins.
•Nonsteroidal anti-inflammatory drugs (NSAIDs)
–Taken before or at the onset of mens. Period
•Diuretics
–to reduce the weight gain, swelling & bloating
–Spironolactone - a diuretic that can help ease some of the symptoms of PMS.
•Oral contraceptives
–To stop ovulation & stabilize hormonal swings
•Medroxyprogesterone acetate (Depo-Provera)
–It is used to temporarily stop ovulation. However, Depo-Provera may cause an increase in some s/sx of PMS, such as increased appetite, weight gain, headache & depressed mood.
•Management
•Modify your diet
•Eat smaller, more frequent meals each day to reduce bloating & the sensation of fullness.
•Limit salt & salty foods to reduce bloating & fluid retention
•Choose foods high in complex carbohydrates, such as fruits, vegetables & whole grains.
•Ca-rich foods or calcium supplement.
•Daily multivitamin supplement.
•Avoid caffeine & alcohol.
•Incorporate exercise into regular routine
•Reduce stress
–Get plenty of sleep.
–Muscle relaxation or deep-breathing exercises to help i headaches, anxiety or insomnia
–Yoga or massage - to relax & relieve stress
•Record symptoms for a few months
–to identify the triggers & timing of symptoms – to develop strategies that may help to lessen them.
•Uterine Prolapse
•Stages of uterine prolapse are described by the degree of descent of the uterus.
•Dyspareunia, backache, pressure in the pelvis, bowel or bladder problems
•Pessaries (an appliance inserted into the vagina, usually as an aid toward maintaining the normal positions of the uterus and bladder)
•Surgery
•Cystocele
•Protrusion of the bladder through the vaginal wall due to weakened pelvic structures
•Difficulty in emptying bladder, urinary frequency and urgency, urinary tract infection, stress urinary incontinence
•Kegel exercises
•Surgery
•Rectocele
•Protrusion of the rectum through a weakened vaginal wall
•Constipation, hemorrhoids, fecal impaction, feelings of rectal or vaginal fullness
•High-fiber diet, stool softeners, laxatives
•Surgery
•Male Reproductive Disorders
•Congenital Disorders
•Hypospadia
–A birth deformity in which the urethra ends before it reaches the tip of the penis.
•Cryptorchidism
–Congenital disorder in w/c one or both testes fail to descend into the scrotum, remaining in the abdomen or inguinal canal or at the external ring of the inguinal canal
–Most commonly affects the right testis, although it may be bilateral
–True undescended testes – testes remain along the path of normal descent
–Ectopic testes – testes deviate from the path of normal descent
•Pathophysiology
•A prevalent but still unsubstantiated theory links undescended testes to dev’t of the gubernaculum (a fibromuscular band that connects the testes to the scrotal floor)
•It may result from inadequate testosterone levels or a defect in the testes or the gubernaculum
•Because the testes are maintained at a higher temp. by being w/in the body, spermatogenesis is impaired, leading to reduced fertility
•Causes
•Hormonal factors (testosterone deficiency)
•Structural factors
•Genetic predisposition
•Prematurity (premature neonates are most commonly affected bec.testes normally descend into the scrotum around 28 wks’ gestation)
•Prenatal exposure to diethylstillbestrol
•Signs & Symptoms
•Nonpalpable testis on affected side
•Enlarged scrotum on the affected side due to compensatory hypertrophy (occasionally)
•Infertility after puberty due to absence of spermatogenesis (uncorrectedbilateral cryptorchidism) despite normal testosterone levels
•Complications
•Sterility
•Risk of testicular CA
•Increased vulnerability to trauma if bilateral cryptorchidism isn’t treated by early adolescence
•Diagnostic Tests
•Surgical: Orchiopexy
–Indicated if the testes don’t descend spontaneously by age 1
–Usually performed before age 4; optimum age is 1-2 yrs bec. about 40% of undescended testes can no longer produce viale sperm by age 2
•Human chorionic gonadotropin (hCG) – to stimulate descent (rarely used); ineffective for testes located in the abdomen
•Nursing Considerations
•Provide info. on causes, available treatments & possible effect on reproduction; emphasize that the testes may descend spontaneously (esp. in premature infants)
•Prepare the child for surgery using age-appropriate explanations & terms the child understands
–Tell the child that a rubber band may be taped to his thigh for about 1 week after surgery to keep the testis in place
–Explain that his scrotum may swell but shouldn’t be painful
–Reassure the child that he won’t feel pain during surgery
•Nursing Considerations
•Provide appropriate care after orchiopexy
–Monitor VS, I & O, check dressings, encourage deep breathing & coughing & watch out for urine retention
–Keep the operative site clean, & teach the child to wipe from front to back after defecation
–Maintain tension on the applied rubber band to keep the testis in place & make sure that it isn’t too tight
–Encourage parent to participate in post-op care, such as bathing, feeding the child; urge the child to do as much for himself as possible (age-appropriate
•Orchitis (Mumps)
•Acute testicular inflammation resulting from trauma or infection
•Treatment: bedrest with scrotal elevation, application of ice, and administration of analgesics and antibiotics
•Mumps orchitis
•Hydrocele
•Cystic mass is usually filled with straw-colored fluid that forms around the testis resulting from impaired lymphatic drainage of the scrotum, causing a swelling of the tissue surrounding the testes.
•Hydrocele may be drained via needle and syringe or it may be removed surgically.
•Spermatocele
•A sperm-containing cyst develops on the epididymis alongside the testicle.
•Normally, spermatoceles are small and asymptomatic, and require no interventions.
•If they become large enough to cause discomfort, a spermatocelectomy is performed.
•Epididymitis
•Inflammation of the epididymis resulting from an infection or noninfectious source such as trauma
•Treatment: bedrest with scrotum elevated on a towel, scrotal support when ambulating
•Comfort measures
•Epididymectomy
•Varicocele
•A cluster of dilated veins occur behind and above the testis.
•Varicoceles can also cause infertility.
•Varicocelectomy is performed through an inguinal incision in which the spermatic veins are ligated in the cord.
•Phimosis & Paraphimosis
•Phimosis- constricted prepuce that cannot be retracted over the glans
•Paraphimosis- prepuce remains down around the tip of the penis
•Emergency requiring immediate tx
•Circumcision
•Warm bath to allow dressing to loosen
•Barbiturate sleeping medications
•Priapism
•Uncontrolled and long-maintained erection without sexual desire; causes the penis to become large and painful
•Can occur from:
–Thrombosis of veins of corpora cavernosa
–Leukemia
–Sickle cell disease
–Diabetes mellitus
–Malignancies
–Abnormal reflex
–Some drug effects
–Recreational drugs
–Prolonged sexual activity
•Collaborative Management
•Urologic emergency
•Goal of intervention: to improve the venous drainage of the corpora cavernosa
•Meperidine
•Warm enemas
•Urinary or suprapubic catheterization
•Large-bore needle or Sx intervention
•Bacterial Prostatitis
•Often occurs with urethritis or an infection of the lower urinary tract
•Fever, chills, dysuria, urethral discharge, and boggy, tender prostate
•Urethral discharge with white blood cells in the prostatic secretions
•Chronic bacterial prostatitis
•Nonbacterial/Chronic Pelvic Pain Syndrome
•Can occur after viral illness or may be associated with sexually transmitted diseases
•Other causes: autoimmune, neuromuscular etiologies, allergy-mediated reactions, psychosexual problems
•Prostatodynia or pelvic floor pain
•Treatment
•Benign Prostatic Hyperplasia
•Enlargement of the prostate sufficient to compress the urethra & cause urinary obstruction
Causes
•Aging
•Arteriosclerosis
•Inflammation
•Metabolic or nutritional disturbances
•Family history
•Clinical Manifestations
•Due to enlarged prostate gland:
–Reduced urinary stream
–Urinary hesitancy
–Difficulty starting micturition
•Due to increased obstruction:
–Nocturia
–Polyuria
–Urine retention & incontinence
–Possible hematuria
•Visible midline mass due to incompletely emptied bladder
COMPLICATIONS
•Complete urinary obstruction
•Infection
•Hydronephrosis
•Renal insufficiency
•Renal failure
•Renal calculi
•Hemorrhage
•Shock
•Diagnostic Test
•Digital rectal exam
•Prostate specific antigen: slightly elevated
•Cystourethroscopy
•Transrectal ultrasound
•Management
•Even spacing of fluid intake throughout the day to prevent bladder distention
•Limit nighttime fluid to prevent nocturia
•Antibiotics to treat UTI
•Alpha-adrenergic blockers (terazosin, doxazosin, tamsulosin, to improve urine flow rates and relieve bladder outlet obstruction by relaxing the smooth muscle of the prostate and bladder neck
•Administer Finasteride (Proscar) or Dutasteride (Avodart) to reduce prostate size
•Insert Indwelling catheter to alleviate urine retention
•Alternative Treatment for Mild Symptoms
•Gentle prostate massage to decrease prostatic congestion
•Cold Sitz bath for 3-8 minutes to stimulate blood flow to the prostate and bladder
•Regular ejaculation to help relieve prostatic congestion
•Surgical Management
•Transurethral resection of the prostate (TURP)
•Transurethral needle ablation (TUNA) to burn away well-defined regions of the prostate to improve urine flow
•Transurethral microwave treatment to destroy portions of the prostate w/ heat
•Transurethral laser excision to reduce prostate size
•Open surgery:
–Suprapubic (transvesical) resection: most common; useful for prostatic enlargement causing pouching w/in the gallbladder
–Retropubic (extravesical) resection: allows direct visualization; potency & continence are usually maintained
•Nursing Considerations
•Monitor VS, I & O & daily weigh
•Monitor for signs of post operative diuresis that may lead to serious dehydration, reduced blood volume, electrolyte loss, shock & anuria
•Maintain patent catheter
•Provide appropriate post operative care

Care of the Death & Dying

ØOverview: Death & Dying
ØDeath when lungs and heart cease to function
ØMultiple organ dysfunction syndrome (MODS)
ØClinical death: the short interval after the cessation of heartbeat and breathing when no evidence of brain function is present
ØFocus on death as a natural process
ØPalliative Care
ØA philosophy that provides a compassionate & supportive approach to clients & families who are living with life-threatening illnesses
ØA holistic approach that does not hasten or postpone death, but provides relief of symptoms experienced by the dying client while providing emotional & spiritual support to improve the quality of care at the end of life
ØPalliative Care
ØProvides relief from pain & other distressing symptoms
ØAffirms life & regards dying as a normal process
ØIntends neither to hasten nor postpone death
ØIntegrates the psychosocial & spiritual aspects of pt care
ØOffers a support system to help pts live as actively as possible until death
ØOffers a support system to help the family cope during the pt’s illness & in their own bereavement
ØPalliative Care
ØUses a team approach to address the needs of pts & their families, including bereavement counseling, if indicated
ØWill enhance quality of life, & may also positively influence the course of illness
ØIs applicable early in the course of illness, in conjunction w/ other therapies that are intended to prolong life (chemo or radiation tx)
ØInformed Consent & Communication
ØConfidentiality
ØAdvance Directives:
lLiving Will
lDurable Power of Attorney for Health Care
ØMedical Futility
ØDNR/DNAR Orders
ØResearch
ØInformed Consent
ØInformed consent entails right to refuse
ØIt should be given by patient or surrogate
lBut there are exceptions….
lIn the ICU, “blanket consent” covers many situations
ØDocumentation
ØCommunication
ØClear communication is part of good care
ØView self as an “educator” of patient & family (but not just raw data)
ØProvide adequate time for family to talk
ØListen for the underlying values & goals
ØGet comfortable with occasional silences
ØWhat is impact of family interests?
ØURGENT INDICATIONS FOR DISCUSSING END-OF-LIFE CARE
ØImminent death
ØTalk about wanting to die
ØInquiries about hospice or palliative care
ØRecent hospitalization for severe progressive illness
ØSevere suffering & poor prognosis
ØCommunicating w/ Pt’s Family
ØValue what the family members say.
ØAcknowledge their emotions.
ØListen.
ØUnderstand the pt as a person thru asking questions.
ØElicit questions from family members.
ROUTINE INDICATIONS
ØDiscussing prognosis
ØDiscussing tx with low probability of success
ØDiscussing hopes & fears
ØPhysician would not be surprised if the pt died in 6–12 mos
ØCommunication Bloopers
ØDo you want us to do everything?
ØShould we stop everything?
ØThere is nothing more we can do.
ØHe failed all the treatments we’ve tried.
ØWhat do you want us to do if she/he stops breathing?
ØOthers???
ØStereotyping of Patients/Families
ØGeneralizations are rarely useful.
ØIndividuals vary greatly.
ØFind a balance.
ØAvoid nick-names/jokes
lCan impact patient care
•May impact other MDs/RNs
•Patient/family overhears
ØConfidentiality
ØPatient’s reputation could be at stake.
ØEstablish to whom you are giving information.
ØRarely should patient information be withheld from the patient
ØAdvance Directives
ØOral or written expressions by an adult with decision making capacity conveying wishes related to medical care in anticipation of being unable to communicate wishes.
ØPatient, not family, can revoke at any time (document in medical record)
lVerbal or written revocation
lShould have a witness
lExplicit documentation
ØQuestions to ask to a pt about AD
ØIf you were to get so sick that you could not talk to me directly, who should I talk to help me make decisions about your care?
ØDoes this person know about this responsibility?
ØDoes he or she know what you want?
ØWhat would you want?
ØHave you written down what you want?
ØLiving Will
ØTerminal illness & patient lacks decision-making capacity.
ØAllows specific instructions: to receive or withhold/withdraw treatments
ØIt requires compliance
ØInvolvement of surrogate is not necessary.
ØDurable Power of Attorney for Health Care
ØActivated when decision making incapacity occurs
ØNames agent empowered to make medical decisions
ØApplies to any medical decision with limited exceptions
ØAllows specific instructions
ØProcedures for Handling ADs
ØInquire about existence of AD
ØSocial worker/EPIC maintains copies
ØPlace newly acquired copies of AD on chart and inform Social Worker
ØSocial Worker ( and Pastoral Care) can assist patient in completing an AD
ØDecision Makers
ØLegal guardian
ØMedical Power of Attorney
ØSpouse
ØMajority of adult children
ØParents
ØMajority of adult siblings
ØNearest adult related by blood or adoption who is reasonably available
ØPortable DNAR (DNR)
ØState-wide logo for Identification & Orders
ØProvides immunity for compliance with law
ØFor patients arriving with portable DNR, rewrite on DNAR/DNR order form
ØA DNAR/DNR is an Attending Physician’s order
ØDNR Comfort Care
ØYou will:
lSuction the airway
lAdminister oxygen
lPosition for comfort
lSplint or immobilize
lControl bleeding
lProvide pain medication
lContact other appropriate health care providers such as hospice, home health, AP/CNP
lProvide emotional support
ØDNR Comfort Care Protocol
ØYou will not:
lAdminister chest compressions
lInsert an artificial airway
lAdminister resuscitative drugs
lDefibrillate or cardiovert
lProvide respiratory assistance (other than suctioning the airway & administering oxygen)
lInitiate resuscitative IV, or initiate cardiac monitoring
ØActivation of DNAR Protocol
ØDNAR Comfort Care:
lAt time order is given
ØDNAR Comfort Care – Arrest:
lAt time of cardiac or respiratory arrest
•Cardiac arrest – absence of palpable pulse
•Respiratory arrest – absence of spontaneous respirations/presence of agonal breathing
ØDNAR - Specified
ØAppropriate for patients that might not want CPR, but would like other medical interventions
ØRaises questions about partial/limited CPR attempts
ØShould make “medical sense”
ØConsent for DNAR Orders
ØInformed consent of patient or surrogate
ØNo obligation to initiate CPR if resuscitation would be futile, i.e.,:
lIf resuscitation would not achieve its physiological objective
lwould offer no benefit to the patient
lwould violate reasonable medical standards
ØDNAR in the OR
ØPrior to any invasive procedure any existing DNAR order should be reviewed with patient or patient’s surrogate
ØChanges should be documented in the patient’s medical record with a notation indicating when & if the original DNAR order should be reinstated
ØWhen does a surgical procedure end?
ØGoals for End-of-Life Care
ØControl symptoms
ØIdentify client needs
ØPromote meaningful interactions between the client & significant others
ØFacilitate a peaceful death
ØHospice Care
ØAn interdisciplinary approach facilitates both quality of life & a “good” death for clients who are nearing the end of their lives.
ØHospice programs are often affiliated with home care agencies, providing services to families at home or in an extended care facility.
ØHospice Care Team
ØThe family
ØA physician
ØA nurse, who usually serves as a case manager and coordinates care with other disciplines
ØCounselors, including psychologists and clergy
ØA social worker
ØHome health aides
ØTrained volunteers
ØPsychosocial Assessment
ØFear
ØAnxiety
ØCultural considerations & bereavement
ØFeelings of client & significant others
ØFatigue Management
ØAspiration precautions
ØMouth care & moisture for lips
ØAltered routes of medication administration if needed—choose the least invasive route of medication administration with the most effective treatment
ØPain Management
ØPain is the symptom that dying clients fear most.
ØPain medications should be scheduled to prevent any recurrence of pain.
ØConsider alternative route of pain medication administration as needed.
ØWHO 3-Step Dosing Model For Pain Management
ØStep 1: Mild pain
lAnalgesics include aspirin, acetaminophen, & nonsteroidal anti-inflammatory drugs (NSAIDs)
•NSAIDs can cause GI bleeding
•Acetaminophen can be toxic at doses exceeding 4 gm in 24 hours, particularly in pts w/ compromised liver function.
ØStep 2: Moderate pain
lOpioids such as codeine, fentanyl, hydrocodone, hydromorphone, morphine, & oxycodone
lOpioid is combined with either acetaminophen or aspirin
ØWHO 3-Step Dosing Model For Pain Management
ØStep 3: Severe pain
lOpioid & a NSAID are combined with adjuvant drugs such as antidepressants
•Many opioids are available in sustained-release form as tablets & granules
•Fentanyl is also available in a skin patch that will last up to 72 hours
ØDyspnea Management
ØTreatment of the primary cause & relieve the psychological distress that accompanies the symptom
ØMorphine sulfate
ØDiuretics
ØBronchodilators
ØAntibiotics
ØAnticholinergics
ØSedatives
ØOxygen
ØNausea & Vomiting Management
ØAntiemetic agents
ØEspecially evident in persons with AIDS or breast, stomach, or gynecologic causes
ØRestlessness & Agitation Management
ØTreat the underlying cause.
ØAdminister sedatives.
ØConsult with a spiritual and/or bereavement counselor.
ØPhysical & Emotional Support
ØBeing realistic about the facts of death & dying
ØEncouraging reminiscence of client’s life memories & stories of events
ØPromoting spirituality including religion
ØFostering hope for clients & their families
ØAvoiding explanations of the loss
ØCommunicating with the client
ØProviding referrals to bereavement specialists
ØGRIEF AND LOSS
ØLOSS is a universal experience that occurs throughout life span; something valuable is gone
ØGRIEF is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement; total response to emotional experience related to loss
ØBEREAVEMENT= Subjective response by loved-ones
ØMOURNING= behavioral response
ØResponses to loss are strongly influenced by one’s cultural background
ØThe grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss.
ØSTAGES OF GRIEVING (Kubbler-Ross)
ØDenial- refuses to believe that the loss has occurred
ØAnger- the individual resists the loss & may “act out” feelings
ØBargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss
ØDepression- overwhelming feeling of loneliness & withdrawal from others
ØAcceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, & the interaction to other people resumed
ØLoss & Death RESPONSIBILITIES
ØProvide Relief from loneliness, fear & depression
ØHelp clients maintain sense of security
ØHelp clients accept losses
ØProvide physical comfort
ØDeath & Dying (Kozier)
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØSymptomatology of Dying
ØOne to three months prior to death:-Anorexia-Spiritual Distress
-Nausea & Vomiting-Fatigue/increased need for sleep-withdrawal from the world and from people ( h introspection / talking less)-malodorous wounds
ØOne to two weeks prior to death:- Confusion
- Picking at Clothes / Tubing
- Seeing / Talking to the Deceased
- Terminal Restlessness/Agitation
- i blood pressure- h or i pulse- skin color changes – pale or blue- h perspiration / body temp. changes- sleeping most of the time
ØDays or Hours prior to death:-Fixed stare (Eyes glassy, tearing, half or fully open) - Wavering level of consciousness
- surge of energy / restlessness or no activity- irregular breathing / periods of apnea- weak pulses / cool extremities- i urine output & incontinence- cannot be awakened
ØCare During the Last Hours
ØWhen it is apparent that death is imminent, health professionals need to alert the family and confirm the goals of care. It should be documented in the patient's chart, including the observation that the patient is dying.
ØSigns that death has occurred include:
·Lack of respiration or pulse
·Eyes open but do not move or blink; pupils dilated
·Jaw relaxed; mouth slightly open
·Bowel and bladder contents expelled
·Patient does not respond to touch or speech
ØWhen death has occurred, nurses or other clinicians need to express their sympathy to the family. It is enough to say "I am sorry for your loss."
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØNursing Responsibilities In Death & Dying
ØNurses need to take time to analyze their own feelings about death before they can effectively help others with terminal illness
ØThe major goals for the dying clients are:
l1. To maintain PHYSIOLOGIC and
l2. PSYCHOLOGIC support
l3. To achieve a dignified & peaceful death
l4. To maintain personal control
ØThe Dying Person’s Bill of Rights
ØCreated by Amelia J. Barbus (Associate Prof. of Nursing at Wayne State University)
lI have the right to be treated as a living human being until I die.
lI have the right to maintain a sense of hopefulness however changing its focus may be.
lI have the right to be cared for by those who can maintain a sense of hopefulness, however challenging this might be.
lI have the right to express my feelings & emotions about my approaching death in my own way.
lI have the right to participate in decisions concerning my care.
ØThe Dying Person’s Bill of Rights
lI have the right to expect continuing medical & nursing attention even though "cure" goals must be changed to "comfort" goals.
lI have the right not to die alone.
lI have the right to be free from pain.
lI have the right to have my questions answered honestly.
lI have the right not to be deceived.
lI have the right to have help from & for my family in accepting my death.
lI have the right to die in peace & dignity.
ØThe Dying Person’s Bill of Rights
lI have the right to retain my individuality & not be judged for my decisions w/c may be contrary to beliefs of others.
lI have the right to discuss & enlarge my religious &/or spiritual experiences, whatever these may mean to others.
lI have the right to expect that the sanctity of the human body will be respected after death.
lI have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs & will be able to gain some satisfaction in helping me face my death.
ØPOSTMORTEM CARE
ØDeath must be certified by a physician—in a formal process called pronouncement
ØAll equipment and supplies need to be removed from the bedside and any soiled linen removed from the room.
ØAgency policy may differ on how to deal with tubes that were in place at the time of death.
ØPostmortem Care
ØLegal considerations, such as death certificate
ØDetermination of the need for an autopsy
ØTransfer of the body
ØPOSTMORTEM CARE
ØHow the body is cared for after death is influenced by religion or culture- health professionals should be aware of any preferences or limitations and comply with them.
ØPlace the body in a supine position with a pillow under the head and shoulders avoids discoloration of the face.
ØEyelids are closed; holding them closed for a few seconds helps them to remain closed.
ØIf the person wore dentures, those are inserted to give the face a more natural appearance.
ØPlacing a rolled towel under the chin will hold the mouth closed.
ØPOSTMORTEM CARE
ØThe arms are positioned either at the sides of the body or across the abdomen.
ØThe identifying wristband is left on unless it has become too tight due to fluid retention.
ØAny soiled areas of the body are washed and absorbent pads are placed under the buttocks.
ØA clean gown is placed on the body and the hair is brushed or combed.
ØAny jewelry is removed, except for a wedding band, which is taped to the finger.
ØPOSTMORTEM CARE
ØThe body is carefully covered up to the shoulders with clean bed linens.
ØAll belongings of the deceased are listed and placed in a safe storage area for the family.
ØSoft lighting is preferred and chairs are made available for family members. Clinicians need to reassure family members that they should take as much time as they need to say their last goodbyes. Only when the family leaves the room should final preparations for removal of the body be initiated.
ØPOSTMORTEM CARE
ØAfter the family has viewed the body, the care provider attaches additional ID tags, one to the ankle and another to the wrist (if the deceased person's wristband has been removed).
ØThe entire body is then wrapped in a shroud, either plastic or cotton, and another ID tag affixed to the outside of the shroud. Then the body is either picked up by the responsible mortician (undertaker) or sent to the morgue until arrangements are made with a mortician.
ØSome hospitals or other agencies close the doors to all patient rooms before transporting a body through the corridors and service elevators and require the use of service elevators rather than public elevators during this transfer.
ØAUTOPSY
ØIt contributes to medical education, aids in the characterization of newly emerging diseases, and advances the understanding of disease-related changes. It can also reveal errors in clinical diagnosis.
ØHealth professionals need to determine whether the family has any religious or cultural concerns about autopsy procedure.
ØFamilies also need to know that autopsy does not disfigure the body and would not interfere with having an open-casket service.
ØORGAN DONATION
ØIdeally, questions about organ donation are discussed with the patient in the context of advance directives. This relieves the family of making the decision during the stressful time immediately after death. Unless the patient has documented the wish to become an organ donor, the family must decide.
ØFederal law requires that only a designated representative of an organ procurement organization (OPO) or a "designated requestor" may approach the family about organ donation.
ØCARING FOR THE FAMILY DURING BEREAVEMENT
ØBegins when a loved one is diagnosed with terminal illness, initiating a period of anticipatory grieving for both patient and family.
ØAfter the patient dies, family members continue to grieve until they become resolved to live without the deceased.
ØIt may take weeks, months; for others, grieving may take a year or longer.
ØThe way in which a person will grieve depends on the personality of the grieving individual, his/her relationship with the person who died, the situation surrounding the loss, and the attachment to the person.
ØCARING FOR THE FAMILY DURING BEREAVEMENT
ØGrief reactions can be:
lPsychological & emotional: anger, guilt, anxiety, sadness, and despair
lPhysical: difficulties, appetite changes, somatic complaints, or illness
lSocial: feelings about taking care of others in the family, the desire to see or not see family or friends, or the desire to return to work
Ø3 Tasks Of Grief Work (Lindemann)
1.Freedom from ties to the deceased
2.Readjustment to the environment from which the deceased is missing
3.Formation of new relationships

NURSING CARE OF CLIENTS WITH DISTURBANCES OF THE ENDOCRINE SYSTEM

•PITUITARY GLAND (HYPOPHYSIS)
•Located at the base of the brain
•Directly affects the function of the other endocrine glands
Parts of the Pituitary Gland
(1)Anterior Pituitary Gland (Adenohypophysis)
(2)Posterior Pituitary Gland (Neurohypophysis)

•SECRETIONS OF THE ANTERIOR PITUITARY GLAND
GROWTH HORMONE (SOMATOTROPIN)
•responsible for growth of body tissues and bone
PROLACTIN (MAMMOTROPIC/LACTOTROPIC HORMONE)
•responsible for tissue growth and lactation
ACTH (ADRENOCORTICOTROPIC HORMONE)
•stimulates adrenal cortex to secrete CORTISOL and ALDOSTERONE
TSH (THYROID-STIMULATING HORMONE)
•stimulates the thyroid gland to secrete T3 and T4
GONADOTROPINS (LH AND FSH)
•influence the ovaries to secrete ESTROGENS and PROGESTERONE; testes to secrete TESTOSTERONE
MSH (MELANOCYTE-STIMULATING HORMONE)
•Stimulates melanocytes to produce pigment MELANIN
•SECRETIONS OF THE POSTERIOR PITUITARY GLAND
ADH (ANTI-DIURETIC HORMONE/VASOPRESSIN)
•causes RENAL RETENTION OF WATER (excluding sodium) and VASOCONSTRICTION
OXYTOCIN
•hormone released during childbirth to cause UTERINE CONTRACTION and during breastfeeding to cause “let-down reflex”
•HYPERPITUITARISM
•Chronic, progressive HYPERFUNCTION of the pituitary gland resulting to OVERSECRETION of the anterior pituitary hormones
ETIOLOGY
•Tumor
•Hyperplasia
ASSESSMENT
•ACROMEGALY – gradual, marked enlargement of the bones of the face, jaw, hands and feet. It may be accompanied by diaphoresis, hyperglycemia, oily skin and hirsutism
•GIGANTISM – proportional overgrowth of all body tissues with remarkable height
•Galactorrhea
•Cushing’s Disease
•Hyperthyroidism
•Precocious puberty
•“Eternal tan”
•SIADH
DIAGNOSTIC TESTS
•Skull x-ray, CT Scan and MRI would reveal TUMOUR OR PITUITARY ENLARGEMENT
•Serum Analysis would reveal ELEVATED GROWTH HORMONES
MEDICAL MANAGEMENT
•Administration of BROMOCRIPTINE (PARLODEL) to inhibit synthesis of growth hormone
•Radiation therapy
NURSING INTERVENTIONS
•Provide EMOTIONAL SUPPORT if there is altered body image
•Provide ROM if there is muscle weakness
•Apply OILY LOTION if there is dry skin
SURGICAL MANAGEMENT
•TRANSPHENOIDAL HYPOPHYSECTOMY to remove the pituitary gland
PREPARING THE PATIENT FOR HYPOPHYSECTOMY
•Explain the procedure to the patient
•Insert INDWELLING CATHETER since DIURESIS (SIGN OF DIABETES INSIPIDUS) may be a complication of the surgery
NURSING CARE AFTER HYPOPHYSECTOMY
•Place patient on HIGH-FOWLER’S position to avoid tension on the suture line and avoid increased ICP
•Place patient on BED REST on the first 24 hours and encourage ambulation on DAY 2
•Remind the patient to AVOID SNEEZING, COUGHING, BENDING OVER and BLOWING THE NOSE to avoid injury to the suture line
•Administer analgesics if there is pain
•Monitor for signs and symptoms of DIABETES INSIPIDUS (COMMON COMPLICATION)
MANAGEMENT IF THERE IS DIABETES INSIPIDUS
•Watch out for CARDINAL SIGNS (thirst, urine output of 900ml/2 hours, increased urine specific gravity of 1.004)
•Provide fluid replacement and administer VASOPRESSIN as ordered
•Expect DIABETES INSIPIDUS to resolve within 72 hours
•If there is rhinorrhea, check for glucose since it may be indicative of CSF LEAKAGE
DISCHARGE INSTRUCTIONS AFTER HYPOPHYSECTOMY
•Instruct patient to REPORT PROGRESSIVE VISUAL CHANGES and DIURESIS
•Advise patient NOT TO BRUSH TEETH for 2 weeks to avoid injury to suture line
•Advise patient AVOID USE OF COMMERCIAL MOUTHWASHES to avoid irritation of the suture line
•HYPOPITUITARISM
•HYPOFUNCTION of the pituitary gland resulting to DEFICIENT SECRETION of the pituitary hormones
•Results to MARKED METABOLIC DYSFUNCTION, SEXUAL IMMATURITY AND GROWTH RETARDATION
ETIOLOGY
•Trauma
•Tumor
•Vascular lesion
•Surgery or radiation of the pituitary gland
•congenital
ASSESSMENT
•Dwarfism
•Absence of milk during lactation (women)
•Addisonian symptoms
•Symptoms of hypothyroidism
•Underdeveloped genitals
•No growth of body hair
•Amenorrhea and infertility
•Decreased libido, impotence, and aspermia
•Symptoms of diabetes insipidus
DIAGNOSTIC TESTS
•Skull x-ray, CT scan may reveal PITUITARY TUMOUR
•Serum analysis may reveal LOW LEVELS OF HORMONES
MEDICAL MANAGEMENT
•Hormone replacement therapy
•Radiation therapy
SURGICAL MANAGEMENT
•Surgical removal of the tumor
•SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMONE (SIADH)
•EXCESSIVE anti-diuretic hormone (ADH) secretion by the posterior pituitary gland
•Characterized by IMPAIRED WATER EXCRETION with NORMAL SODIUM EXCRETION
ETIOLOGY
•CNS disorders interfering with hypothalamic-pituitary mechanisms such as BRAIN TUMOUR, STROKE, HEAD INJURY AND GUILLAIN-BARRE SYNDROME
•Pulmonary disorders such as PNEUMONIA, TUBERCULOSIS, BRONCHIECTASIS
•DRUGS that increase ADH production such as ANTIDEPRESSANTS, NSAIDs, CHLORPROPRAMIDE (Diabinase), VINCRISTINE (Oncovin), CYCLOPHOSPHAMIDE (Cytoxan), CARBAMAZEPINE (Tegretol), METOCLOPRAMIDE (Reglan), MORPHINE
PATHOPHYSIOLOGY
ASSESSMENT
COMPLICATIONS
•Cerebral edema
•Brain herniation
DIAGNOSTIC TESTS
MEDICAL MANAGEMENT
NURSING INTERVENTIONS
•Monitor weight, intake and output, vital signs and serum sodium levels
•Observe for restlessness, irritability, seizures, heart failure, and unresponsiveness (SIGNS OF HYPONATREMIA AND WATER INTOXICATION)
SURGICAL MANAGEMENT
•Removal of tumour causing hypersecretion of ADH
•DIABETES INSIPIDUS
•DEFICIENCY in VASOPRESSIN or anti-diuretic hormone (ADH) secretion by the posterior pituitary gland
•Characterized by EXCESSIVE WATER EXCRETION
ETIOLOGY
•Hereditary
•Tumors or injury to hypothalamus or pituitary gland
•Removal of the pituitary gland (HYPOPHYSECTOMY)
•Drugs that interfere with response of the kidney to ADH such as LITHIUM CARBONATE, DEMECLOCYCLINE
PATHOPHYSIOLOGY
ASSESSMENT
DIAGNOSTIC TESTS
MEDICAL MANAGEMENT
NURSING INTERVENTIONS
•Monitor weight, intake and output, vital signs and electrolyte levels
•Monitor for signs of dehydration
•Increase fluid intake by oral or intravenous route
•Encourage client to drink fluids in equal amount to urine output
•THYROID GLAND
•Located anterior part of the neck Controls rate of body metabolism and growth
HORMONES SECRETED BY THE THYROID GLAND
•DIAGNOSTIC TESTS FOR THYROID FUNCTION
•GOITER
•enlargement of the thyroid gland
•result from increased TSH
•may occur with HYPERTHYROIDISM, HYPOTHYROIDISM OR EUTHYROIDISM
TYPES OF GOITER
(1)TOXIC GOITER – hyperthyroid goiter
(2)NON-TOXIC OR SIMPLE GOITER – euthyroid goiter
•HYPERTHYROIDISM
•Other names include THYROTOXICOSIS, GRAVE’S DISEASE, EXOPHTHALMIC GOITER OR TOXIC DIFFUSE GOITER
•Common to females below 40 years old
ETIOLOGY
•Severe emotional stress
•Autoimmune disorder
•Thyroid inflammation
PATHOPHYSIOLOGY
ASSESSMENT
•Due to increased amounts of thyroid hormone
–Enlarged thyroid
–Nervousness
–Heat intolerance
–Sweating
–Weight loss
–Increased appetite
–Frequent bowel movements
–Tremor
–Palpitations
–Hypertension
•Due to activation of cytokine-mediated activation of orbital tissue fibroblasts
–Exopthalmus (may not be present in other patients)
•Due to increased activity in spinal cord area that controls muscle tone
–Fine tremor
–Shaky handwriting
–Clumsiness
•signs and symptoms of THYROID STORM due to hyperthyroid state
–Tachycardia
–Vomiting
–High fever
–Vomiting
–Shock
–Coma
COMPLICATIONS
•Muscle wasting, atrophy, and paralysis
•Heart failure
•Hypoparathyroidism (after thyroidectomy)
•Hypothyroidism (after radioactive iodine treatment)
DIAGNOSTIC TESTS
•Radioimmunoassay: increased serum T3 and T4 levels
•Blood testing: decreased TSH level
•Thyroid Scan: increased uptake
MEDICAL MANAGEMENT
•Thalidomides
–Propylthiouracil (PTU) and Methimazole (Tapazole)
–Blocks synthesis of thyroid hormones
–Should be takin with meals
–Side Effects: unexplained fever, sore throat, skin rashes
•Radioactive Iodine (I131) treatment
–Treatment of choice for patients not planning to have children
–Produces effects after 6-8 weeks
–May cause hypothyroidism
•Lugol’s Solution (Saturated Solution of Potassium Iodide)
–Inhibits release of thyroid hormone
–Mix with fruit juice or glass of water to improve the taste
–Provide drinking straw to prevent staining
–Side effects: allergic reaction, increased salivation, colds
•Dexamethasone
–Inhibit action of thyroid hormones
–Prevents conversion of T3 and T4
•Beta-Blockers: Propanolol (Inderal)
–Controls hypertension and tachycardia
–Blocks conversion of T4 to active T3
–May cause hypotension
EMERGENCY TREATMENT OF THYROID STORM
•Thalidomide
•Dexamethasone
•Supportive Measures: nutrients, vitamins, oxygen, hypothermia blankets and sedatives
NURSING INTERVENTIONS
•Provide NON-STIMULATING ENVIRONMENT cool environment
•Provide diet that is HIGH-CALORIE, HIGH-PROTEIN, VITAMINS AND MINERALS
•Increase fluid intake (if with diarrhea)
•Avoid stimulants like coffee, tea and nicotine
•Administer artificial tears at regular intervals
•Instruct client to wear artificial tears when going out under the sun
•AVOID EXCESSIVE PALPATION OF THE THYROID to prevent thyroid storm
SURGICAL MANAGEMENT
•Subtotal Thyroidectomy – removal of about 5/6 of the gland
NURSING CARE AFTER THYROIDECTOMY
•Monitor for respiratory distress; keep tracheostomy tray at the bedside
•Monitor for signs of hemorrhage
•Monitor for signs of hypocalcemia (tetany and numbness) indicative of accidental removal of the parathyroid gland
•Monitor for dysphagia or hoarseness (indicative of laryngeal nerve injury)
•Change dressing as ordered
•Place patient on SEMI-FOWLER’S position and support neck with sandbags to ease tension on the incision
•Inform client that HYPOTHYROIDISM may develop 2-4 weeks after the surgery
NURSING CARE AFTER RADIOACTIVE IODINE (I131) TREATMENT
•Instruct patient to AVOID EXPECTORATING since saliva will be radioactive for 24 hours after treatment
•Instruct to avoid taking OTC COUGH medications because it contains iodine
•Instruct that iodine may remain the body for 1 week
•Instruct to avoid breastfeeding

•HYPOTHYROIDISM
•Also called MYXEDEMA in adults or CRETINISM in children
•Results from deficiency of thyroid hormones
ETIOLOGY
•Autoimmune disorder (Hashimoto’s Disease)
•Removal of the thyroid (Thyroidectomy)
•Radiation therapy with radioactive iodine
•Intake of thalidomides
TYPES OF HYPOTHYROIDISM
(1)Primary – if the cause is thyroid hypofunction
(2)Secondary – if the cause is pituitary hyposecretion of TSH
(3)Tertiary – if the cause is hypothalamic hyposecretion of TRH
PATHOPHYSIOLOGY
ASSESSMENT
•Effects of decreased basal metabolic rate (Typical Signs)
–Weakness
–Fatigue
–Forgetfulness
–Sensitivity to cold
–Unexplained weight gain
–Constipation
•Effects of fluid accumulation
–Decreasing mental state (sign of myxedema coma)
–Coarse, dry, flaky, inelastic skin
–Puffy face, hands, and feet
–Hoarseness
–Periorbital edema
–Upper eyelid droop
–Dry, sparse hair
–Thick, brittle nails
•Signs of cardiovascular involvement
–Decreased cardiac output
–Slow pulse rate
–Signs of poor peripheral circulation
–Heart enlargement (cardiomegaly)
•Late signs indicating disease progression
–Progressive stupor
–Hypoventilation
–Hypoglycemia
–Hyponatremia
–Hypotension
–Hypothermia
•Signs of MYXEDEMA COMA (severe stage of hypothyroidism)
–Hypothermia
–Unconscious

COMPLICATIONS
•Heart failure
•Myxedema coma
•Infection
•Megacolon
•Organic psychosis
•Infertility
•Hyperlipidemia
DIAGNOSTIC TESTS
•Radioimmunoassay reveals low T3 and T4 levels
•Increased TSH levels (if cause is thyroid dysfunction)
•Decreased TSH levels (if cause is pituitary and hypothalamic dysfunction)
•Elevated serum cholesterol, alkaline phosphatase and triglyceride level
•Low serum sodium level
•ABG analysis reveal decreased pH and increased carbon dioxide (RESPIRATORY ACIDOSIS)
MEDICAL MANAGEMENT
•Hormone replacement with synthetic thyroid hormones
–Proloid (Thyroglobulin)
–Synthroid (Levothyroxine)
–Dessicated Thyroid Extract
–Cytomel
•Surgery excision, chemotherapy, or radiation if there is tumour
NURSING INTERVENTIONS
•Provide high-bulk, low-calorie diet and encourage activity to manage constipation and weight loss; administer laxatives or cathartics as needed
•After thyroid replacement begins, watch out for signs and symptoms of hyperthyroidism such as restlessness, sweating and excessive weight loss
•Check frequently for signs of decreasing cardiac output
•Provide warm environment during cold climate
•PARATHYROID GLANDS
•Gland located near the thyroid gland
•Produces PARATHORMONE which regulates calcium and phosphorous levels
•HYPERPARATHYROIDISM
•Results from EXCESSIVE PARATHORMONE secretion
CLASSIFICATION
(1)PRIMARY
–Results when secretion of PTH and serum calcium levels increase DUE TO PRESENCE OF TUMOUR
(2)SECONDARY
–Results when secretion of PTH increase DUE TO OVERCOMPENSATION to decreased calcium resulting from decreased intestinal absorption of calcium and vitamin D

ETIOLOGY
•Parathyroid adenoma
•Congenital hyperparathyroidism
•Multiple endocrine neoplasia
•Rickets
•Vitamin D deficiency
•Chronic renal failure
•Phenytoin and laxative use
PATHOPHYSIOLOGY
ASSESSMENT
•Due to hypercalcemia
–Renal insufficiency
–Nephrolithiasis
–Dehydration
–Pseudogout
–Psychomotor and personality disturbances
•Due to bone degeneration
–Chronic low back pain
–Bone tenderness
–Fractures
DIAGNOSTIC TESTS
•Radioimmunoassay: increased serum PTH (CONFIRMATIVE)
•Blood Test: increased calcium and decreased phosphate
•Urine Test: increased calcium
•X-ray: demineralization of bones
MEDICAL MANAGEMENT
•Promote urinary excretion of excess calcium
–Increase fluid intake to p
–Diuretic such as furosemine (Lasix)
–Oral sodium or potassium phosphate
–SQ or IM calcitonin
•Vitamin D to promote bone absorption of calcium
•Aluminum hydroxide to correct hyperphosphatemia
•Dialysis to decrease phosphorus levels
NURSING INTERVENTIONS
•Strain urine to check for calculi
•Provide at least 3L of fluid per day including cranberry or prune juice to increase urine acidity and prevent stones formation
•Limit dietary intake of calcium
•Avoid administration of calcium-containing drugs like some antacids and thiazide diuretics
•Auscultate for signs of pulmonary edema
SURGICAL MANAGEMENT
•Parathyroidectomy – removal of the parathyroid gland
PREPARING PATIENT FOR SURGERY
•Administer IV magnesium and phosphate or sodium phosphate solution by mouth or retention enema to prevent postoperative magnesium and phosphate deficiencies
•Administer calcium, vitamin D to prevent hypocalcemia 4-5 days after the surgery
NURSING CARE AFTER PARATHYROIDECTOMY
•Check frequently for respiratory distress
•Keep tracheostomy set at bedside
•Watch for signs of laryngeal nerve damage and hemorrhage
•Check for swelling at the operative site
•Place patient in SEMI-FOWLER’S position and support head and neck with SANDBAGS to decrease edema
•Watch for TETANY (tingling in the hands and around the mouth) indicative of hypocalcemia
•Administer calcium gluconate or calcium chloride if there is TETANY
•Encourage early ambulation to speed up bone recalcification
•HYPOPARATHYROIDISM
•Disorder characterized by DEFICIENCY OF PTH
ETIOLOGY
•Congenital absence of parathyroid gland
•Autoimmune disease
•Parathyroidectomy
•Massive radiation therapy
PATHOPHYSIOLOGY
ASSESSMENT
•Neuromuscular irritability
•Seizures
•Increased deep tendon reflexes
•POSITIVE CHVOSTEK’S SIGN
•POSITIVE TROSSEAU’S SIGN
•Dysphagia
•Paresthesia
•Psychosis
•Arrhythmias
•Hair loss
•Brittle nails
•Weakened tooth enamel
DIAGNOSTIC TEST
•Radioimmunoassay: decreased serum PTH
•Blood Test: decreased calcium and elevated phosphate
•X-ray: increased bone density
•ECG: prolonged QT intervals and QRS complex and ST segment changes
MEDICAL MANAGEMENT
•Supplementation with vitamin D and calcium
•IV calcium gluconate in emergency conditions
•Sedatives and anti-convulsants to prevent seizures
NURSING INTERVENTIONS
•Maintain patent IV line and keep IV calcium gluconate 10% solution available
•Institute seizure precautions
•Keep tracheostomy and endotracheal set available
•Watch out for cardiac arrhythmias and decreased cardiac output
•Offer HIGH CALCIUM AND LOW PHOSPHATE diet
•ADRENAL GLANDS
•Small structures which cap the kidney
2 PARTS OF THE ADRENAL GLAND
(1)MEDULLA – secretes EPINEPHRINE (adrenalin) and NOREPINEPHRINE
(2)CORTEX – secretes ALDOSTERONE (mineralocorticoid), CORTISOL (glucocorticoid) and ANDROGEN (adrenocorticoid)
FUNCTION OF ADRENAL GLAND HORMONES
•CUSHING’S DISEASE
•Hypersecretion of adrenal cortex leading to INCREASED CORTISOL (MAIN REASON), ALDOSTERONE, ANDROGEN and ESTROGEN
ETIOLOGY
•Tumour of the adrenal gland or the pituitary gland
•Prolonged steroid therapy
PATHOPHYSIOLOGY
ASSESSMENT
COMPLICATIONS
•Osteoporosis
•Infections
•Ureteral calculi
•Metastasis of malignant tumors
DIAGNOSTIC TESTS
•Urinalysis: free cortisol levels above 150 μg/24 hours
•Dexamethasone suppression test: failure to suppress plasma cortisol levels
•Blood Test: elevated serum cortisol, decreased potassium and calcium; elevated glucose and sodium levels
MEDICAL MANAGEMENT
•Radiation therapy for tumour
•Ketoconazole (Nizoral) and aminoglutethimide (Cytadren) to inhibit cortisol synthesis
•Mitotane (Lysodren) to destroy adrenocortical cells that secrete cortisol
•Bromocriptine (Parlodel) to inhibit prolactin secretion from pituitary gland
NURSING INTERVENTIONS
•Provide a diet that is HIGH IN PROTEIN AND POTASSIUM, LOW IN CALORIES, CARBOHYDRATES AND SODIUM
•Monitor for side effects of mitotane, aminoglutethimide and metyrapone (slowed mentation and physical weakness)
•Watch for signs of infection
•Perform passive ROM to minimize risk of fractures
•Maintain therapeutic communication for emotional lability
SURGICAL MANAGEMENT
•Bilateral adrenalectomy or Pituitary Surgery to remove tumors
NURSING CARE AFTER SURGERY
•Watch for signs of shock; give vasopressor and increase rate of IV fluids as needed
•Administer analgesics and replacement steroids
•Watch for and report signs of INCREASED ICP (Intracranial Pressure) such as confusion, agitation, change in level of consciousness, nausea and vomiting
NURSING CARE FOR PATIENTS IN STEROID REPLACEMENT THERAPY
•Check for signs of adrenal hypofunction (suggesting inadequate steroid replacement) such as orthostatic hypotension, apathy, weakness and fatigue
•Advise patient to take steroids with antacids or meals to minimize gastric irritation
•Tell patient to report stressful situations that may need increased steroid dosage
•Discourage abrupt discontinuation of steroids to prevent adrenal crisis
•ADDISON’S DISEASE
•Hyposecretion of adrenal cortex leading to DECREASED CORTISOL, ALDOSTERONE AND ANDROGEN
ETIOLOGY
•Autoimmune disorder
•Abrupt withdrawal of steroid therapy
•Hyposecreting tumour of the adrenal gland
•Infections
PATHOPHYSIOLOGY
ASSESSMENT
COMPLICATIONS
•Hyperpyrexia (extreme elevation in temperature)
•Psychotic reactions
•Shock
•Profound hypoglycemia
•Ultimate vascular collapse, renal shutdown, coma and death
DIAGNOSTIC TESTS
•PLASMA CORTISOL LEVEL: DECREASED (LESS THAN 5MCG/DL)
•BLOOD CHEMISTRY: decreased glucose, sodium and increased potassium; increased creatinine and blood urea nitrogen (BUN)
•COMPLETE BLOOD COUNT: elevated hematocrit
•RAPID CORTICOTROPIN STIMULATION TEST: FAILURE OF THE CORTISOL AND ALDOSTERONE LEVELS TO RISE
•CT SCAN: ADRENAL CALCIFICATION AND ENLARGEMENT OR ATROPHY
MEDICAL MANAGEMENT
•Lifelong corticosteroid replacement with cortisone or hydrocortisone to replace deficiency of cortisol
•Oral aldosterone replacement with fludrocortisone (Florinef) to prevent dehydration, hypotension, hyponatremia, and hyperkalemia
NURSING INTERVENTIONS
•Assess for signs of shock, hyperkalemia and cardiac arrhythmia
•Monitor weight, intake and output
•Increase fluid intake with oral fluids and IVF
•If patient has diabetes, check blood glucose regularly
NURSING CARE IF THE PATIENT IS RECEIVING STEROIDS
•Offer diet that is SODIUM AND POTASSIUM BALANCED
•If patient is anorexic, suggest 6 SMALL FREQUENT FEEDINGS
•Watch for FLUID AND ELECTROLYTE IMBALANCE if patient is receiving MINERALOCORTICOID; and ORTHOSTATIC HYPOTENSION OR ELECTROLYTE ABNORMALITY if patient is receiving GLUCOCORTICOID
•Teach patient about signs of STEROID OVERDOSE (SWELLING, WEIGHT GAIN) and UNDERDOSE (LETHARGY AND WEAKNESS)
•OFFER ANTACID while on steroid to prevent GI irritation
ADDISONIAN CRISIS – critical DEFICIENCY OF MINERALOCORTICOIDS AND GLUCOCORTICOIDS
TRIGGERS OF ADDISONIAN CRISIS: acute stress, sepsis, trauma, surgery or omission of steroid therapy
MANAGEMENT FOR ADDISONIAN CRISIS
•Assess for sig
•IV bolus of hydrocortisone
•3-5 L of IV normal saline and glucose solution
•MAINTENANCE DOSE: hydrocortisone
•DIABETES MELLITUS
•Metabolic disorder characterized by HYPERGLYCEMIA (elevated serum glucose) from LACK OF INSULIN (TYPE I) or INCREASED RESISTANCE TO INSULIN (TYPE II) or both
CLASSIFICATIONS
(1)TYPE 1 – Insulin Dependent Diabetes Mellitus (IDDM)
(2)TYPE 2 – Non-Insulin Dependent Diabetes Mellitus (NIDDM)
(3)Gestational Diabetes Mellitus
PREDISPOSING FACTORS
•Stress
•Heredity
•Obesity
•Viral infection
•Autoimmune disorders
•Women
PATHOPHYSIOLOGY
ASSESSMENT
CARDINAL SIGNS OF DIABETES MELLITUS (3PsW)
•P - olyuria
•P - olydipsia
•P - olyphagia
•W - eight loss
COMPLICATIONS
•Microvascular disease (retinopathy, neuropathy, nephropathy)
•Macrovascular disease (coronary artery disease, stroke)
•Diabetic ketoacidosis (if type 1)
•Hyperosmolar hyperglycemic non-ketotic coma (if type 2)
DIAGNOSTIC TESTS
MEDICAL MANAGEMENT
•Insulin administration
•Use of Oral hypoglycemic agents (OHAs)
•Proper diet
•Regular Exercise
INSULIN THERAPY FOR A DIABETIC PATIENT
NURSING INTERVENTIONS DURING INSULIN THERAPY
•Administer insulin using the SUBCUTANEOUS route because it offers slow absorption, less pain and tissue damage
•Administer insulin through INTRAVENOUS only during emergency such as DKA
•Administer insulin at ROOM TEMPERATURE; cold administration may cause LIPODYSTROPHY
•ROTATE INJECTION SITE to prevent lipodystrophy which can inhibit insulin absorption
•GENTLY ROLL VIAL IN BETWEEN THE PALMS to redistribute insulin particles
•DO NOT SHAKE! Bubbles can cause inaccurate measurement
•If mixing insulin, draw up CLEAR INSULIN BEFORE CLOUDY INSULIN
•Observe for side effects of insulin therapy
SIDE EFFECTS OF INSULIN
ORAL HYPOGLYCEMIC AGENTS
PROVIDING DIABETIC FOOT CARE
•INSPECT FEET DAILY, use mirror to inspect bottom of the feet
•Wash feet with WARM WATER AND MILD SOAP
•PAT DRY the feet – do not rub
•Wear COMFORTABLE PROPERLY-FITTED PAIR OF SHOES (leather or canvass)
•Use cotton socks and AVOID SYNTHETIC FIBERS
•Do not go barefooted
•Trim the toenails STRAIGHT ACROSS; use nail file instead
MANAGING COMPLICATIONS OF DIABETES
LIST OF SIMPLE SUGARS
•3-4 oz regular softdrink
•8 0z fruit juice
•5-7 pcs. lifesaver’s candies
•1 tbsp sugar
•5 ml pure honey or karo soup
•10-15 mg carbohydrate