Human Needs Neuro and Reproductive

Seizure

Health History -Birth defects or injuries at birth -Anoxic episodes -CNS trauma or infections -Stroke -Metabolic disorders -Alcoholism Data related to a specific seizure episode can be obtained from a witness Exposure to metals or carbon monoxide Hepatic or renal failure Compliance with antiseizure medications, barbiturate or alcohol withdrawal, cocaine/amphetamines Medications: Adherence to antiseizure medication regimen; barbiturate or alcohol withdrawal; use and overdose of cocaine, amphetamines, lidocaine, theophylline, penicillin, lithium, phenothiazines, tricyclic antidepressants, benzodiazepines. Family history Headaches, aura, mood or behavioral changes before seizure Anxiety, depression, loss of self-esteem, social isolation Decreased sexual drive, erectile dysfunction Precipitating Factors -Metabolic acidosis or alkalosis -Hyperkalemia -Hypoglycemia -Dehydration -Water intoxication Bitten tongue, soft tissue damage, cyanosis Abnormal respiratory rate Apnea (ictal) Absent or abnormal breath sounds Airway occlusion Hypertension, tachy/bradycardia Bowel/urinary incontinence, excessive salivation Weakness, paralysis, ataxia (postictal) Abnormal CT, MRI, EEG Generalized Seizures: -Tonic-clonic: loss of consciousness, muscle tightening then jerking, dilated pupils, hyperventilation then apnea, postictal somnolence -Absence: altered consciousness, minor facial motor activity Focal Seizures: Simple -Aura -Focal sensory, motor, cognitive, or emotional phenomena -Unilateral "marching" -Motor seizure Complex -Altered consciousness with inappropriate behaviors, automatisms -Amnesia of event Nursing Diagnoses: -Ineffective breathing pattern -Ineffective self-health management -Risk for injury Overall goals are that patient will -Be free from injury during seizure. -Have optimal mental and physical functioning while taking antiseizure medications. -Have satisfactory psychosocial functioning. Promote safety measures. -Wear helmet if risk for head injury. -General health habits (diet, exercise) -Assist to identify events or situations precipitating seizures and avoid if possible. -Instruct to avoid excessive alcohol, fatigue, and loss of sleep. Improved approaches to perinatal, labor, and delivery care have reduced fetal trauma and hypoxia and thereby have reduced brain damage leading to seizure disorders. Help the patient to handle stress constructively. Observe, treat, and document seizure. -Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor. -Do not restrain patient or place any objects in their mouth. -May require positioning, suctioning, or oxygen after seizure. When a seizure occurs, the nurse should carefully observe and record details of the event because the diagnosis and subsequent treatment often rest solely on the seizure description. Note all aspects of the seizure. What events preceded the seizure? When did the seizure occur? How long did each phase (aural [if any], ictal, postictal) last? What occurred during each phase? Both subjective data (usually the only type of data in the aural phase) and objective data are important. Note the exact onset of the seizure (which body part was affected first and how); the course and nature of the seizure activity (loss of consciousness, tongue biting, automatisms, stiffening, jerking, total lack of muscle tone); the body parts involved and their sequence of involvement; and the presence of autonomic signs, such as dilated pupils, excessive salivation, altered breathing, cyanosis, flushing, diaphoresis, or incontinence. Assessment of the postictal period should include a detailed description of the level of consciousness, vital signs, pupil size and position of the eyes, memory loss, muscle soreness, speech disorders (aphasia, dysarthria), weakness or paralysis, sleep period, and the duration of each sign or symptom. A seizure can be a frightening experience for the patient and for others who may witness it. Assess the level of their understanding and provide information about how and why the event occurred. This is an excellent opportunity for you to dispel many common misconceptions about seizures. Seizure response dogs receive special training to assist those in distress. -They can find help if owner is in trouble. -They can pull away objects that pose danger. -Can carry information about their handler for emergency response teams. -Provide emotional support. Do you know what to tell someone if they are interested in buying a seizure response dog? 1. Contact Canine Assistants - one of the largest nonprofits that provide seizure response dogs; they actually specialize in seizure dogs. 2. Understand the process. Although the cost to train a seizure response dog is up to $20,000+, they provide the dogs free of charge to recipients. The cost is covered by private donations to Canine Assistants. However, your patient will need to fill out an application and get on the waiting list. 3. Complete the application. The application and medical form needed is located on the Canine Assistants website. Mail to the address provided on the form. 4. Consider getting on a wait list with a few organizations. If your patient is anxious about getting a dog, you can suggest they fill out applications for a few organizations. This will give you a better chance of finding a dog sooner. Paws With a Cause offers a program, and you can check the American Dog Trainers Network's listing for programs in your state. 5. Be patient while waiting for a dog. The wait list for seizure dogs can be a couple of years. Ambulatory and Home Care: Prevention of recurring seizures is the major goal in treatment. -Instruct on importance of adherence to medication, not to adjust dose without physician. -Keep regular appointments. -Teach family members emergency management. If a dose is missed, usually the dose should be made up if the omission is remembered within 24 hours. Remind family, caregivers, and significant others that it is not necessary to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Emotional support and identification of coping mechanisms to adjust to personal limitations imposed by the disease -Medical alert bracelets -Referrals to agencies and organizations Patients with a seizure disorder also experience concerns or fears related to recurrent seizures, incontinence, or loss of self-control. For issues relating to job discrimination, refer patients to the state human rights commission or the state department of vocational rehabilitation. Assist the patient who has specific problems in finding appropriate resources - local chapter of the Epilepsy Foundation, Department of Veterans Affairs for veterans, community mental health center for intensive psychologic counseling, social workers and welfare agencies for those with financial problems and living arrangement needs, vocational rehabilitation services for job placement when seizures are not well-controlled, etc. Driving laws related to patients who have had a seizure vary from state to state. For example, some states require a 3-month seizure-free period before issuing or reissuing a driver's license, whereas others require up to 1 year. The EF provides current information on driving laws for each state. Inform the patient that medical alert bracelets, necklaces, and identification cards are available through the EF, local pharmacies, or companies specializing in identification devices (e.g., Medic Alert). However, the use of these medical identification tags is optional. Some patients have found them beneficial, but others have found them to be more a burden than a help because these individuals prefer not to be identified as having a seizure disorder. Encourage the patient to learn more about epilepsy through self-education Evaluation: Expected Outcomes -Experience breathing pattern adequate to meet oxygen needs. -Experience no seizure-related injury. -Express acceptance of seizure disorder by admitting presence of epilepsy and maintaining compliant behavior -Acceptance of disorder -Acknowledgment seizure has occurred -Therapeutic drug levels -Compliance with therapeutic regimen

Endometrial Cancer

Cancer of the endometrium is the most common gynecologic malignancy. Has a relatively low mortality rate, since most cases are diagnosed early. The survival rate is over 95% if the cancer has not spread at the time of diagnosis. The major risk factor for endometrial cancer is estrogen, especially unopposed estrogen. Additional risk factors include increasing age, nulliparity, late menopause, obesity, smoking, diabetes mellitus, and a personal or family history of hereditary nonpolyposis colorectal cancer (HNPCC) Endometrial cancer arises from the lining of the endometrium. Most tumors are adenocarcinomas. The precursor may be a hyperplastic state that progresses to invasive carcinoma. Hyperplasia occurs when estrogen is not counteracted by progesterone. The cancer directly extends into the cervix and through the uterine serosa. As invasion of the myometrium occurs, regional lymph nodes, including the paravaginal and para-aortic, become involved. Hematogenous metastases develop concurrently. The usual sites of metastases are lung, bone, liver, and eventually the brain. Malignant cells can be found in the peritoneal cavity, probably after transport through the fallopian tubes. The first sign of endometrial cancer is abnormal uterine bleeding, usually in postmenopausal women. Because perimenopausal women have sporadic periods for a time, it is important that this sign not be ignored or attributed to menopause. Pain occurs late in the disease process. Other manifestations that may arise are related to metastasis to other organs. Metastatic spread occurs in a characteristic pattern. Spread to the pelvic and para-aortic nodes is common. When distant metastasis occurs, it most commonly involves the lungs, liver, bones, brain, and vagina. Assess for Clinical Manifestations -abnormal uterine bleeding, usually in postmenopausal women -Pain in later stages -symptoms r/t metastasis Nursing Management -Pre and post op care for Total Hysterectomy with BSO with lymph node biopsies -Care of the patient receiving Radiation or chemotherapy, or Hormonal therapy Most cases of endometrial cancer are diagnosed at an early stage when surgery alone may result in cure. Treatment of endometrial cancer is a total hysterectomy and bilateral salpingo-oophorectomy with lymph node biopsies. The lack of estrogen and progesterone receptors is a poor prognostic indicator. Surgery may be followed by radiation, either to the pelvis or the abdomen externally or intravaginally, to decrease local recurrence. No tumor markers with high sensitivity and high specificity for endometrial cancer are known at present, although CA-125 is often used in clinical practice. CA-125 has been used in surveillance of advanced endometrial cancer. In patients who have increased CA-125 values pretreatment, this test might prove useful in posttreatment surveillance. Treatment of advanced or recurrent disease is difficult. Progesterone HT (e.g., megestrol [Megace]) can be used when the progesterone receptor status is positive and the tumor is well differentiated. Tamoxifen (Nolvadex), either alone or in combination with progesterone therapy, is also effective in women with advanced or recurrent endometrial cancer. Chemotherapy is considered when progesterone therapy is unsuccessful. Agents used include doxorubicin (Adriamycin), cisplatin (Platinol), 5-fluorouracil (5-FU), carboplatin (Paraplatin), and paclitaxel (Taxol).

Breast Cancer

Did you know? White women have a higher incidence of breast cancer than nonwhites African American women have lower survival rates from breast cancer than white women, even when diagnosed at an early state Hispanic and Asian/Pacific Islander women have lower mortality rates than whites and African Americans. Hispanic women have the lowest screening rates Hispanic and African American women are more likely to be diagnosed at a later stage than white women Cultural values strongly influence how women respond to and cope with breast cancer and treatment. Health beliefs and behaviors are influenced by diverse cultural norms. Breast cancer screening, diagnosis, and treatment are affected by the cultural values and meanings (body image, sexuality, modesty, motherhood) attached to the breasts. Women may delay screening or treatment for varying reasons, including an acceptance of disease as inevitable fate or "God's will," a mistrust of Western medicine, lack of health care benefits, fear, modesty, or the stigma of a cancer diagnosis. Subjective data Past health history -Atypical changes in benign breast disease -Previous breast cancer -Early menarche -Nulliparity or 1st pregnancy after age 30 -Hx endometrial, ovarian, or colon cancer -Hx hyperestrogenism and testicular atrophy in men Carefully document the size and location of the lump or lumps. Assess the physical characteristics of the lesion, such as consistency, mobility, and shape. Medications: -Use of hormones, especially HRT after menopause and use of oral contraceptives -History of infertility treatments Surgery or other treatments: -Exposure to therapeutic radiation such as for Hodgkin's lymphoma or thyroid radiation Family history, alcohol use, changes felt on BSE, sedentary lifestyle Possible indicators of metastasis including reports of unexplained weight loss, changes in cognition, bone pain, headache Psychological stress, anxiety Objective data -Axillary and supraclavicular lymphadenopathy -Hard, irregular discrete nodular, non-painful, immobile lump -Nipple fixation or retraction, erosion, edema, peu'd orange, erythema, induration, infiltration or dimpling -Possible indicators of metastasis: nodule at mastectomy site, hepatomegally, jaundice,ascites Initial Nursing Diagnosis -Decisional conflict related to knowledge about treatment options and their effects -Fear and or anxiety related to diagnosis of breast cancer -Disturbed body image related to anticipated physical and emotional effects of treatment modalities Initial Planning The patient diagnosed with breast cancer will: -Actively participate in the decision-making process related to treatment options -Comply with the therapeutic plan -Manage the side effects of adjuvant therapy -Be supported to access and benefit from the support provided by significant others and health care providers Psychologic Care -Assist in developing positive but realistic attitude -Help identify sources of support -Encourage verbalization of anger and fears -Promote open communication of thoughts and feelings between patient and family -Provide accurate and complete answers to treatment and disease related questions -Offer information on community resources and support groups Diagnosis of breast cancer has significant psychologic impact. It is estimated that 20-60% of cancer patients experience symptoms of depression Reminded of own mortality Hassles with insurance/health care system Surgery/Radiation therapy/Chemotherapy can all negatively impact relationship with spouse or partner (loss of breast, scarring, alopecia, pain, side-effects of treatments) Some patients may just give up & withdraw or self-medicate with drugs/alcohol Assist in developing positive but realistic attitude Help identify sources of support Encourage verbalization of anger and fears Promote open communication of thoughts and feelings between patient and family Provide accurate and complete answers to treatment and disease related questions Offer information on community resources and support groups In a study by Stephens et al. (2008) major concerns of women newly diagnosed with breast cancer (after mastectomy) included: -Fear of recurrence (PRIMARY CONCERN) -Anxiety regarding postoperative treatments -Anxiety regarding the future -Impact of diagnosis and performance -Impact of cancer on finances and loved ones -Depression Care for Mastectomy/ Lumpectomy or Mammoplasty Preoperative teaching -Turn, cough, deep breathing -Post-operative exercises -Pain management Post-operative -Semi-Fowler's with arm on affected side elevated on a pillow -Flexing & extending fingers &/or arm -Teach measures to prevent lymphedema -Care of drains if present -No procedures on affected side!!! The difficulty and pain encountered by the woman in performing what used to be simple tasks that are included in the exercise program may cause frustration and depression. The goal of all exercise is a gradual return to full range of motion within 4 to 6 weeks. Teach measures to prevent lymphedema: -Frequent & sustained elevation of arm -Perform exercised daily -No venipunctures or blood pressures to affected arm -Avoid tight clothing or jewelry on affected arm -Carry purse, luggage with other arm -Use electric razor when shaving underarm -Careful manicures, avoid cutting cuticles -Avoid burns or sunburns to affected arm/hand -May use elastic sleeve, or sequential compression device Monitor for Radiation Side Effects Skin changes similar to sunburn Teach: -Use mild, unscented soap or nondrying antipruitic soap if dryness & itchiness persist -Pat the area dry, avoid rubbing -Avoid applying deodorant to affected area -Avoid tight tops or underwire bra -Avoid extremes in temperature -Protect area from ultraviolet light for at least 1 year post therapy -Report worsening pain/discomfort to HCP Skin changes are a common adverse affect - similar result as a sunburn, erythema, itching, soreness, burning & peeling Ambulatory & Home Care -Self-care techniques -BSE & annual mammography -Referral to mental health provider/support group -Symptoms to report to HCP -Prosthesis fitting -Loose-fitting clothing for drains Once the client is ready to go home, you need to ensure that you have spent time teaching self-care Emphasize importance of BSE and annual mammography Refer to mental health provider for support and coping needs Symptoms to report to HCP after surgery: -Fever -Inflammation at surgical site -Erythema -Constipation -Unusual swelling Report changes after discharge: New back pain Weakness SOB Confusion Stress importance of wearing well-fitting prosthesis (some insurance companies will pay for this so ensure client has a prescription Preoperative sexual assessment for baseline data If client has drains, encourage wearing loose fitting clothing until they are removed.

Stroke

occurs when there is (1) ischemia (inadequate blood flow) to a part of the brain or (2) hemorrhage into the brain that results in death of brain cells. Functions such as movement, sensation, or emotions that were controlled by the affected area of the brain are lost or impaired. The severity of the loss of function varies according to the location and extent of the brain damage. Primary assessment is focused on -Cardiac status -Respiratory status -Neurologic assessment If the patient is stable, obtain -Description of the current illness -Pay special attention to symptom onset and duration, nature, and changes. Pay special attention to initial symptoms including whether they were intermittent or continuous. Obtain information from patient, family members, significant others, and/or caregiver. Pay attention to hypertension, history of stroke, a fib, cad, pad, respiratory status (make sure expansion is occurring on both sides Neuro assessment: pupils, awake, alert oriented, oriented x4, person place, time, situation, If the patient is stable, obtain -History of similar symptoms previously experienced -Current medications -History of risk factors and other illnesses --Hypertension, etc. -Family history of stroke or cardiovascular disease Secondary assessment includes a comprehensive neurologic examination. -Level of consciousness --Include NIH Stroke Scale -Cognition -Motor abilities Comprehensive neurologic examination -Cranial nerve function -Sensation -Proprioception -Cerebellar function -Deep tendon reflexes Nursing Diagnoses: -Risk for ineffective cerebral tissue perfusion -Ineffective airway clearance -Impaired physical mobility -Impaired verbal communication Diagnoses include but are not limited to -Unilateral neglect -Impaired urinary elimination -Impaired swallowing -Situational low self-esteem Goals are developed collaboratively with patient, caregiver, and family. Goals include that the patient will -Maintain stable or improved level of consciousness. -Attain maximum physical functioning. -Maximize self-care abilities and skills. Goals include that the patient will -Maintain stable body functions. -Maximize communication abilities . -Maintain adequate nutrition. -Avoid complications of stroke. -Maintain effective personal and family coping. Health Promotion -You have an important role in the promotion of a healthy lifestyle. To help reduce the incidence of stroke -Focus on stroke prevention. -Teach how to reduce modifiable risk factors. Nursing measures to reduce risk factors for stroke are similar to those for coronary artery disease. Uncontrolled or undiagnosed hypertension is the primary cause of stroke. Therefore you need to be involved in blood pressure screening and ensuring that patients adhere to the use of their antihypertensive medications. If a person is a diabetic, it is very important that the diabetes is well-controlled. If an individual has atrial fibrillation, an anticoagulant or aspirin may be used to prevent the risk of stroke. Because smoking is a major risk factor for stroke, you need to be actively involved in helping patients to stop smoking Another very important aspect of health promotion is teaching patients and families about early symptoms associated with stroke or TIA. presents information on when to seek health care for these symptoms Respiratory system Management of the respiratory system is a nursing priority. -Risk for atelectasis -Risk for aspiration pneumonia -Risks for airway obstruction -May require endotracheal intubation and mechanical ventilation Advancing age and immobility increase the risk for atelectasis and pneumonia. Risk for aspiration pneumonia is high because of impaired consciousness or dysphagia. All patients should be effectively screened for their ability to swallow and kept NPO until dysphagia has been ruled out. Nursing interventions to support adequate respiratory function are individualized to meet the needs of the patient (include frequent assessment of airway patency and function, oxygenation, suctioning, patient mobility, positioning of the patient to prevent aspiration, and encouraging deep breathing). Oral care at least every 2 hours for patients on mechanical ventilation reduces the occurrence of ventilator-assisted pneumonia. Neurologic system Monitor closely to detect changes suggesting -Extension of the stroke -↑ ICP -Vasospasm -Recovery from stroke symptoms The primary clinical assessment tool to evaluate and document neurological status in acute stroke patients is the NIH Stroke Scale (NIHSS). It can serve as a measure of stroke severity and is a predictor of both short- and long-term outcomes of stroke patients. It serves as a data collection tool for planning patient care and provides a common language for exchanging information among health care providers. Additional neurologic assessment includes mental status, pupillary responses, and extremity movement and strength. Also closely monitor vital signs. A decreasing level of consciousness may indicate increasing ICP. Monitor ICP and cerebral perfusion pressure as well if the patient is in a critical care environment. Record your nursing assessment on flow sheets to communicate the patient's neurologic status to the stroke team. Cardiovascular system -Goals aimed at maintaining homeostasis -Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease. -Cardiac efficiency may be compromised. -Monitoring vital signs frequently -Monitoring cardiac rhythms -Calculating intake and output, noting imbalances -Regulating IV infusions -Adjusting fluid intake to the individual needs of the patient -Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) -Monitoring heart sounds for murmurs or for S3 or S4 heart sounds -Watch for orthostatic hypotension before ambulating patient for 1st time In addition to decreased cardiac reserves secondary to cardiac disease, cardiac efficiency may be further compromised by fluid retention, overhydration, dehydration, and/or blood pressure variations. Central venous pressure, pulmonary artery pressure, or hemodynamic monitoring may be used as indicators of fluid balance or cardiac function in the critical care unit. Bedside monitors or telemetry may record cardiac rhythms. Hypertension is sometimes seen following a stroke as the body attempts to increase cerebral blood flow. It is important to monitor for orthostatic hypotension before ambulating the patient for the first time. Neurologic changes can occur with a sudden decrease in BP. After stroke, patient is at risk for venous thromboembolism (VTE). -Weak or paralyzed lower extremities are particularly vulnerable. -Related to immobility, loss of venous tone, and decreased muscle pumping in leg -Most effective prevention is keeping the patient moving. Teach the patient active range-of-motion exercises if the patient has voluntary movement in the affected extremity. For the patient with hemiplegia, passive range-of-motion exercises should be done several times a day. Additional measures to prevent VTE include positioning to minimize the effects of dependent edema and the use of elastic compression gradient stockings or support hose. Musculoskeletal system -Goal is to maintain optimal function. -Accomplished by the prevention of joint contractures and muscular atrophy -In the acute phase, range-of-motion exercises and positioning are important. --Paralyzed or weak side needs special attention when positioned. Passive range-of-motion exercise is begun on the first day of hospitalization. If the stroke is due to subarachnoid hemorrhage, the movement is limited to the extremities. Position each joint higher than the joint proximal to it to prevent dependent edema. Specific deformities on the weak or paralyzed side that may be present in patients with stroke include internal rotation of the shoulder; flexion contractures of the hand, wrist, and elbow; external rotation of the hip; and plantar flexion of the foot. Optimize musculoskeletal function. -Trochanter roll at hip to prevent external rotation -Hand cones to prevent hand contractures -Arm supports with slings and lap boards to prevent shoulder displacement Do not use rolled washcloths in place of hand cones Avoidance of pulling the patient by the arm to avoid shoulder displacement Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop Hand splints to reduce spasticity There is disagreement on whether hand splints facilitate or diminish spasticity. The decision regarding the use of footboards or hand splints is made on an individual patient basis. Integumentary system Susceptible to skin breakdown related to -Loss of sensation -Decreased circulation -Immobility Compounded by patient age, poor nutrition, dehydration, edema, and incontinence Prevention of skin breakdown Pressure relief by position changes, special mattresses, wheelchair cushions -Position patient on the weak or paralyzed side for only 30 minutes. Good skin hygiene Emollients applied to dry skin Early mobility An example of a position change schedule is side-backside, with a maximum duration of 2 hours for any position. If an area of redness develops and does not return to normal color within 15 minutes of pressure relief, the epidermis and dermis are damaged. Do not massage the damaged area because this may cause additional damage. Gastrointestinal system Stress of illness contributes to a catabolic state that can interfere with recovery. Constipation is the most common bowel problem. -Prophylactic stool softeners or fiber -Physical activity promotes bowel function. If the patient does not have a daily or every-other-day bowel movement, check the patient for impaction. The patient who has liquid stools should also be checked for stool impaction. Depending on the patient's fluid balance status and swallowing ability, fluid intake should be at least 1800 to 2000 mL/day and fiber intake up to 25 g/day. Bowel retraining may need to occur, and this training will continue into the rehabilitation phase. A bowel management program consists of placing the patient on the bedpan or bedside commode or taking the patient to the bathroom at a regular time daily to reestablish bowel regularity. A good time for the bowel program is 30 minutes after breakfast because eating stimulates the gastrocolic reflex and peristalsis but may need to be adjusted as individual bowel habits may vary. Urinary system -In the acute stage, poor bladder control results in incontinence. -Efforts should be made to promote normal bladder function. -Avoid the use of indwelling catheters. If an indwelling catheter must be used initially, it should be removed as soon as the patient is medically and neurologically stable. A bladder retraining program consists of (1) adequate fluid intake with most of it given between 7:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours using bedpan, commode, or bathroom; (3) noting signs of restlessness, which may indicate the need for urination, and (4) assessment for bladder distention by palpation. Assessment of postvoid residual volume is often done using bladder ultrasound. The ultrasound measures how much urine is in the bladder following voiding. If urine remains in the bladder, incomplete emptying is a problem and may cause urinary tract infections. A coordinated program by the entire nursing staff is needed to achieve urinary continence. Nutrition -Nutritional needs require quick assessment and treatment. -May initially receive IV infusions to maintain fluid and electrolyte balance -May require nutrition support Patients should have their nutritional needs addressed in the first 72 hours of admission to the hospital, as nutrition is important for recovery and healing. First feeding should be approached carefully. -Test the swallowing, chewing, gag reflex, and pocketing before beginning oral feeding. Feedings must be followed by scrupulous oral hygiene. Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and exercises to stimulate swallowing should be started. The speech therapist or occupational therapist is usually responsible for designing this program. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following. Various dietary items may be recommended by the speech therapist. Foods should be easy to swallow and provide enough texture, temperature (warm or cold), and flavor to stimulate a swallow reflex. Crushed ice can be used as a stimulant. Instruct the patient to swallow and then swallow again. Pureed foods are not usually the best choice because they are often bland and too smooth. Thin liquids are often difficult to swallow and may promote coughing. Thin liquids can be thickened with the use of a commercially available thickening agent (e.g., Thick-It). Avoid milk products because they tend to increase the viscosity of mucus and increase salivation. Place food on the unaffected side of the mouth. The inability to feed oneself can be frustrating and may result in malnutrition and dehydration. Interventions to promote self-feeding include using the unaffected upper extremity to eat; employing assistive devices such as rocker knives, plate guards, and nonslip pads for dishes; removing unnecessary items from the tray or table, which can reduce spills; and providing a nondistracting environment to decrease sensory overload and distraction. The effectiveness of the dietary program is evaluated in terms of maintenance of weight, adequate hydration, and patient satisfaction. These interventions should be introduced in the acute care setting. Communication Your role in meeting psychologic needs of the patient is primarily supportive. Assess the patient for both the ability to speak and the ability to understand. -Speak slowly and calmly, using simple words or sentences. -Gestures may be used to support verbal cues. An alert patient is usually anxious because of lack of understanding about what has happened and because of difficulty with communicating or inability to communicate. The stroke patient with aphasia may easily be overwhelmed by verbal stimuli. Nursing interventions that support communication include (1) frequent, meaningful communication; (2) allowing time for the patient to comprehend and answer; (3) using simple, short sentences; (4) using visual cues; (5) structuring conversation so that it permits simple answers by the patient; and (6) praising the patient honestly for improvements with speech. A picture board may be helpful for communicating with the stroke patient. Speech, comprehension, and language deficits are the most difficult problem for the patient and family. Speech therapists can assess and formulate a plan to support communication. Sensory-perceptual alterations Related to the hemisphere of the brain in which the stroke occurred Visual problems may include -Diplopia (double vision) -Loss of the corneal reflex -Ptosis (drooping eyelid) -Homonymous hemianopsia Sensory-perceptual problems are common in stroke patients. Vision problems influence safety and ability to be independent. Diplopia is often treated with an eye patch. If the corneal reflex is absent, the patient is at risk for corneal abrasion and should be observed closely and protected against eye injuries. Patients with stroke on right side of brain -Difficulty in judging position, distance, and movement -Impulsive, impatient, and deny problems related to stroke -Respond best to directions given verbally The patient with a right-brain stroke (left hemiplegia) is at higher risk for injury because of mobility difficulties. The task should be broken down to simple steps for ease of understanding. Environmental control, such as removing clutter and obstacles and using good lighting, aids in concentration and safer mobility. Patients with a stroke on the right side of the brain usually have difficulty in judging position, distance, and rate of movement. These patients are often impulsive and impatient and tend to deny problems related to strokes. They may fail to correlate spatial-perceptual problems with the inability to perform activities, such as guiding a wheelchair through the doorway. The patient with a right-brain stroke (left hemiplegia) is at higher risk for injury because of mobility difficulties. Directions for activities are best given verbally for comprehension. The task should be broken down to simple steps for ease of understanding. Environmental control, such as removing clutter and obstacles and using good lighting, aids in concentration and safer mobility. Provide nonslip socks at all times. One-sided neglect is common for people with right-brain stroke, so you may assist or remind the patient to dress the weak or paralyzed side or shave the forgotten side of the face. Patients with stroke on left side of brain -Slower in organization and performance of tasks -Impaired spatial discrimination -Have fearful, anxious response to stroke -Respond well to nonverbal cues Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks. They tend to have impaired spatial discrimination. These patients usually admit to deficits and have a fearful, anxious response to a stroke. Their behaviors are slow and cautious. Nonverbal cues and instructions are helpful for comprehension with patients who have had a left-brain stroke. Coping Often a family disease Affects family -Emotionally -Socially -Financially Changing roles and responsibilities A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Reactions to this threat vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow. During the acute phase of caring for the stroke patient and the family, nursing interventions designed to facilitate coping involve providing information and emotional support. Explain -What has happened -Diagnosis -Therapeutic procedures --Should be clear and understood by patient Explanations to the patient about what has happened and about diagnostic and therapeutic procedures should be clear and understandable. Decision making and upholding the patient's wishes during this challenging time are of upmost importance. Advance directives should be honored, and family meetings or updates should be held daily about feeding tube placement or tracheostomy. Patient's family should be given a careful, detailed explanation of what has happened to the patient. Family members usually have not had time to prepare for the illness. Social services referral is often helpful. If the family is extremely anxious and upset during the acute phase, explanations may need to be repeated at a later time. Patient is usually discharged from the acute care setting to -Home -Intermediate or long-term care facility -Rehabilitation facility --Critical factor: independence in ADLs Ongoing rehabilitation is essential to maximize patient's abilities. Ideally, discharge planning with the patient and caregiver starts early in the hospitalization and promotes a smooth transition from one care setting to another. Rehabilitation requires a team approach so the patient and family can benefit from the combined, expert care of a stroke team. A critical factor in discharge planning is the patient's level of independence in performing ADLs. Ambulatory and Home Care: Nurses have an excellent opportunity to prepare the patient and family for discharge through -Teaching -Demonstration/return demonstration -Practice -Evaluation of self-care skills Total care is considered in discharge planning: medications, nutrition, mobility, exercises, hygiene, and toileting. Follow-up care is carefully planned to permit continuing nursing; physical, occupational, and speech therapy; as well as medical care. Community resources should be identified to provide recreational activities, group support, spiritual assistance, respite care, adult day care, and home assistance based on the individual patient's needs. Rehabilitation is the process of maximizing the patient's capabilities and resources to promote optimal functioning. -Physical, mental, and social well-being -Goals are set mutually by patient, family, nurse, stroke/rehab team. The goals of rehabilitation are to prevent deformity and maintain and improve function. Most patients will see the maximum benefit in the first year of recovery following a stroke. The stroke team is composed of many members, including nurses, physicians, psychiatrist, physical therapist, occupational therapist, speech therapist, registered dietitian, respiratory therapist, vocational therapist, recreational therapist, social worker, psychologist, pharmacist, and chaplain. Physical therapy focuses on mobility, progressive ambulation, transfer techniques, and equipment needed for mobility. Occupational therapy emphasizes retraining for skills of daily living such as eating, dressing, hygiene, and cooking. Occupational therapists are also skilled in cognitive and perceptual evaluation and training. Speech therapy focuses on speech, communication, cognition, and eating abilities. The rehabilitation nurse assesses the patient and family with -Rehabilitation potential of the patient -Physical status of all body systems -Presence of complications caused by the stroke or other chronic conditions -Cognitive status of the patient Many of the nursing interventions outlined in the nursing care plan for the patient with a stroke (see NCP 58-1) are initiated in the acute phase of care and continue throughout rehabilitation. Some of the interventions are independent nursing actions, whereas others involve the entire rehabilitation team. The rehabilitation nurse assesses the patient and family. -Family resources and support -Expectations of patient and family related to the rehabilitation program Musculoskeletal Function Initially emphasize musculoskeletal functions of -Walking -Eating -Toileting Interventions advance in a manner of progressive activity If muscles are still flaccid several weeks after the stroke, prognosis for regaining function is poor. -Focus of care is on preventing additional loss. Most patients begin to show signs of spasticity with exaggerated reflexes within 48 hours following the stroke. Spasticity at this phase of stroke denotes progress toward recovery. As improvement continues, small voluntary movements of the hip or shoulder may be accompanied by involuntary movements in the rest of the extremity (synergy). The final stage of recovery occurs when the patient has voluntary control of isolated muscle groups. Loss of postural stability is common after stroke. When the nondominant hemisphere is involved, walking apraxia and loss of postural control are usually apparent. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided. Musculoskeletal interventions Balance training Transferring from bed to chair -Bobath method or constraint-induced movement therapy may be used in musculoskeletal rehabilitation. -CIMT is a more recent approach. The goal of the Bobath approach is to help the patient gain control over patterns of spasticity by inhibiting abnormal reflex patterns. Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal movement, and promotion of bilateral function of the body. An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and the stronger side to facilitate more bilateral functioning. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity. The ability of patients to comply with this approach is challenging and may limit its use. Supportive or assistive equipment, such as canes, walkers, and leg braces, may be needed on a short- or long-term basis for mobility. The physical therapist usually selects the most appropriate supportive device(s) to meet individual needs and instructs the patient regarding use. Incorporate physical therapy activities into the patient's daily routine for additional practice and repetition of rehabilitation efforts. Assistive Devices for Eating -The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. -Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other -Plate guards help keep food on the plate -Cup with special handle. After the acute phase, a dietician can assist in determining the appropriate daily caloric intake based on the patient's size, weight, and activity level. Interventions to promote self-feeding include using the unaffected upper extremity to eat; employing assistive devices such as rocker knives, plate guards, and nonslip pads for dishes; removing unnecessary items from tray or table, reducing spills; providing a nondistracting environment to reduce sensory overload with distraction. Toileting interventions Implement a bowel management program for problems with -Bowel control -Constipation -Incontinence High-fiber diet and adequate fluid intake Patients with stroke frequently have constipation, which responds to the following dietary management: -Fluid intake of 2500 to 3000 mL daily unless contraindicated -Prune juice (120 mL) or stewed prunes daily -Cooked fruit 3 times daily -Cooked vegetables 3 times daily -Whole-grain cereal or bread 3 to 5 times daily Nursing measures are also focused on promoting urinary continence. Interventions for atypical emotional response -Distract the patient. -Explain to patient and family that emotional outbursts may occur. -Maintain a calm environment. -Avoid shaming or scolding patient. Patients who have had strokes often exhibit emotional responses that are not appropriate or typical for the situation. Patients may appear apathetic, depressed, fearful, anxious, weepy, frustrated, and angry. Some patients exhibit exaggerated mood swings, especially those with a stroke on the left side of the brain (right hemiplegia). The patient may be unable to control emotions and may suddenly burst into tears or laughter. This behavior is out of context and often is unrelated to the underlying emotional state of the patient. Patients with a stroke may be coping with many losses. -Often go through the process of grief -Some patients experience long-term depression. -You have a role in supporting coping. The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. The patient, caregiver, and family often go through the process of grief and mourning associated with the losses. Some patients experience long-term depression with symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. In addition, the time and energy required to perform previously simple tasks can result in anger and frustration. Assist coping process. -Support communication between the patient and family. -Discuss lifestyle changes from deficits. -Discuss changing roles and responsibilities within the family. -Being an active listener to allow expression of fear, frustration, and anxiety -Include family in goal planning and patient care. -Support family conferences. Maladjusted dependence with inadequate coping occurs when the patient does not maintain optimal functioning for self-care, family responsibilities, decision making, or socialization. This situation can cause resentment from both the patient and family with a negative cycle of interpersonal dependency and control. Family members must cope with three aspects of patient's behavior: 1. Recognition of behavioral changes resulting from neurologic deficits that are not changeable 2. Responses to multiple losses both by the patient and the family 3. Behaviors that may have been reinforced during the early stages of stroke as continued dependency Stroke support groups within rehab facilities and community are helpful. -Mutual sharing -Teaching -Coping -Understanding Family therapy is a helpful adjunct to rehabilitation. Open communication, information regarding the total effects of stroke, education regarding stroke treatment, and therapy are helpful. Sexual function -Person who has had a stroke may be concerned about the loss of sexual function. -Common concerns about sexual activity are impotence and the occurrence of another stroke during sex. Many patients are comfortable talking about their anxieties and fears regarding sexual function if the nurse is comfortable and open to the topic. You may initiate the topic with the patient and spouse or significant other. Nursing interventions for sexual activity include teaching about (1) optional positioning of partners, (2) timing for peak energy times, and (3) patient and partner counseling. Community Integration -Resources can be a valuable asset to patients and families after stroke. -Nurse case managers, home health nurses, discharge planners, clinical nurse specialists can all identify resources. -National and local help is available. Traditionally, successful community integration following stroke has been difficult for the patient because of persistent problems with cognition, coping, physical deficits, and emotional liability that interfere with functioning. Older patients who have had a stroke often have more severe deficits and frequently experience multiple health problems. Failure to continue the rehabilitation regimen at home may result in deterioration and further complications. Community resources can be an asset to patients and their families. The National Stroke Association provides information, resources, referral services, and quarterly newsletters on stroke. The American Stroke Association, a division of the American Heart Association, has information regarding stroke, hypertension, diet, exercise, and assistive devices. This association sponsors self-help groups in many areas. The Easter Seal Society provides wheelchairs and other assistive devices for stroke patients. Local groups can offer more daily assistance such as meals and transportation. Gerontologic Considerations: Stroke is a significant cause of death and disability among older adults. -You have the opportunity to assist through acute hospitalization, rehab, long-term care, home care. -Patient, caregiver, and family require ongoing assessment and adaptation to changing needs. Stroke can result in a profound disruption in the life of an older person. The magnitude of disability and changes in total function can leave patients wondering if they can ever return to their "old self," and loss of independence may be a major concern. The ability to perform ADLs may require many adaptive changes because of physical, emotional, perceptual, and cognitive deficits. Home management may be a particular challenge if the patient has an older spouse caregiver who also has health problems. There may be limited family members (including adult children) living in close proximity to provide help. The rehabilitative phase and assisting the older patient to deal with the residual deficits of stroke, as well as aging, can provide a challenging nursing experience. Patients may become fearful and depressed because they think they may have another attack or die. The fear can become immobilizing and interfere with effective rehabilitation. Changes may occur in the patient-spouse relationship. The dependency resulting from a stroke may be threatening to the relationship. The spouse may also have chronic medical problems that can affect the ability to take care of the stroke survivor. The patient may not want anyone other than the spouse to provide care, thus putting a significant burden on the spouse. Optimizing quality of life is the ultimate goal.

Penile Cancer

Assess for -Clinical Manifestations - a superficial ulceration or a pimple like nodule which can be mistaken for an STD -History of HPV Nursing Care of the patient Treated with: -Lazer removal -Radiation -Chemotherapy

Bacterial Meningitis

an acute inflammation of the meningeal tissues surrounding the brain and spinal cord. Meningitis usually occurs in fall, winter, or early spring and is often secondary to viral respiratory disease. Older adults and persons who are debilitated are affected more frequently than the general population. College students living in dormitories and individuals living in institutions (e.g., prisoners) are also at a high risk for contracting meningitis. Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial meningitis. Haemophilus influenzae was once the most common cause of bacterial meningitis. However, the use of H. influenzae vaccine has resulted in a significant decrease in meningitis related to this organism The organisms usually gain entry to the CNS through the upper respiratory tract or the bloodstream. However, they may enter by direct extension from penetrating wounds of the skull or through fractured sinuses in basilar skull fractures. Fever, severe headache, nausea, vomiting, and nuchal rigidity (neck stiffness) are key signs of meningitis. Photophobia, a decreased LOC, and signs of increased ICP may also be present. Coma is associated with a poor prognosis and occurs in 5% to 10% of patients with bacterial meningitis. Seizures occur in one third of all cases. The headache becomes progressively worse and may be accompanied by vomiting and irritability. If the infecting organism is a meningococcus, a skin rash is common and petechiae may be seen. Initial assessment should include -Vital signs -Neurologic evaluation -Fluid intake and output -Evaluation of lungs and skin Nursing Diagnoses: -Decreased intracranial adaptive capacity -Risk for ineffective cerebral tissue perfusion -Hyperthermia -Acute pain Overall Goals -Return to maximal neurologic functioning -Resolve the infection -Control pain and discomfort Health Promotion -Vaccination against respiratory infections Meningococcal vaccines -MPSV4 - Licensed for people > 55 -MCV4 - Preferred for people < 55 Prophylactic antibiotics for anyone exposed to bacterial meningitis Prevention of respiratory infections through vaccination programs for pneumococcal pneumonia and influenza is very important. There are two meningococcal vaccines available in the United States: meningococcal polysaccharide vaccine (MPSV4) and meningococcal conjugate vaccine (MCV4). -MPSV4 has been available since the 1970s. -Two doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16. Early and vigorous treatment of respiratory and ear infections is important. Acute Interventions -Revolve around the nursing diagnoses of -↓ Intracranial adaptive capacity -Risk for ineffective cerebral perfusion -↑ Fever -Acute pain -Close observation and assessment -Provide relief for head and neck pain -Position for comfort -Darkened room and cool cloth over the eyes for photophobia The patient with bacterial meningitis is usually acutely ill. The fever is high, and head pain is severe. Irritation of the cerebral cortex may result in seizures. The changes in mental status and LOC depend on the degree of increased ICP. Assess and record vital signs, neurologic status, fluid intake and output, skin, and lung fields at regular intervals based on the patient's condition. Assist the patient to a position of comfort, often curled up with the head slightly extended. The head of the bed should be slightly elevated, when permitted after lumbar puncture. The presence of a familiar person at the bedside may have a calming effect. The patient with bacterial meningitis is usually acutely ill. The fever is high, and head pain is severe. Irritation of the cerebral cortex may result in seizures. The changes in mental status and LOC depend on the degree of increased ICP. Assess and record vital signs, neurologic status, fluid intake and output, skin, and lung fields at regular intervals based on the patient's condition. Assist the patient to a position of comfort, often curled up with the head slightly extended. The head of the bed should be slightly elevated, when permitted after lumbar puncture. The presence of a familiar person at the bedside may have a calming effect. Minimize environmental stimuli. -Mental distortion and hypersensitivity are typical. -Convey caring and unhurried gentleness while providing efficient care. Provide safety. Observe and record seizures. -Prevent injury. -Administer antiseizure medications. Vigorously manage fever. -Fever increases cerebral edema and the frequency of seizures. -Neurologic damage may result from high, prolonged fever. If the fever is resistant to aspirin or acetaminophen, more vigorous means are necessary, such as a cooling blanket. Care should be taken not to reduce the temperature too rapidly because shivering may result, causing a rebound effect and increasing the temperature. Wrap the extremities in soft towels or a blanket covered with a sheet to reduce the occurrence of shivering, which can raise ICP. If a cooling blanket is not available or desirable, tepid sponge baths with water may be effective in lowering the temperature. Protect the skin from excessive drying and injury and prevent breaks in the skin. Assess for dehydration. -Evaluate fluid intake and output. -Compensate for diaphoresis in replacement fluids. Maintain therapeutic blood levels of antibiotics. Respiratory isolation until cultures are negative Calculate replacement fluids as 800 mL/day for respiratory losses and 100 mL for each degree of temperature above 100.4°F (38°C). Supplemental feeding (e.g., enteral nutrition) to maintain adequate nutritional intake may be necessary. Meningococcal meningitis is highly contagious, whereas other causes of meningitis may pose minimal to no infection risk with patient contact. However, standard precautions are essential to protect the patient and the nurse. Ambulatory and Home Care: Provide for several weeks of convalescence. Increase activity as tolerated. -Stress adequate nutrition. -Encourage adequate rest and sleep. Residual effects can result in sequelae such as dementia, seizures, deafness, hemiplegia, and hydrocephalus. Assess vision, hearing, cognitive skills, and motor and sensory abilities after recovery, with appropriate referrals as indicated. Progressive ROM exercises and warm baths for muscle rigidity Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities Tend to signs of anxiety and stress of family and caregivers Emphasize a high-protein, high-calorie diet in small, frequent feedings. Residual effects can result in sequelae such as dementia, seizures, deafness, hemiplegia, and hydrocephalus. Assess vision, hearing, cognitive skills, and motor and sensory abilities after recovery, with appropriate referrals as indicated. Evaluation: Patient will -Demonstrate appropriate cognitive function. -Be oriented to person, place, and time. -Maintain body temperature within normal range. -Report satisfaction with pain control. The most common acute complication of bacterial meningitis is increased ICP. Most patients have increased ICP, and it is the major cause of an altered mental status. Another complication of bacterial meningitis is residual neurologic dysfunction. Dysfunction often occurs involving many cranial nerves. Cranial nerve irritation can have serious sequelae. The optic nerve (CN II) is compressed by increased ICP. Papilledema is often present, and blindness may occur. When the oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) nerves are irritated, ocular movements are affected. Ptosis, unequal pupils, and diplopia are common. Irritation of the trigeminal nerve (CN V) results in sensory losses and loss of the corneal reflex. Irritation of the facial nerve (CN VII) results in facial paresis. Irritation of the vestibulocochlear nerve (CN VIII) causes tinnitus, vertigo, and deafness. The dysfunction usually disappears within a few weeks. However, hearing loss may be permanent after bacterial meningitis. Hemiparesis, dysphasia, and hemianopsia may also occur. These signs usually resolve over time. If they do not, a cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis is suspected. Acute cerebral edema may cause seizures, CN III palsy, bradycardia, hypertensive coma, and death. Headaches may occur for months after the diagnosis of meningitis until the irritation and inflammation have completely resolved. It is important to implement pain management for chronic headaches. A noncommunicating hydrocephalus may occur if the exudate causes adhesions that prevent the normal flow of CSF from the ventricles. CSF reabsorption by the arachnoid villi may also be obstructed by the exudate. In this situation, surgical implantation of a shunt is the only treatment. Waterhouse-Friderichsen syndrome is a complication of meningococcal meningitis. The syndrome is manifested by petechiae, disseminated intravascular coagulation (DIC), adrenal hemorrhage, and circulatory collapse. DIC and shock, which are some of the most serious complications of meningitis, are associated with meningococcemia. a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after the collection of specimens for cultures, even before the diagnosis is confirmed Ampicillin, penicillin, vancomycin, cefuroxime (Ceftin), cefotaxime (Claforan), ceftriaxone (Rocephin), ceftizoxime (Cefizox), and ceftazidime (Ceptaz) are some commonly prescribed drugs for treating bacterial meningitis. Dexamethasone (a corticosteroid) may also be prescribed before or with the first

Mastitis

Breast Infection Assess for clinical manifestations -Warm to touch, indurated, painful, often unilateral, cracked nipple Nursing Interventions Teach continuation of breast feeding unless abscess or purulent drainage Teach hand expression of breast milk and use of breast shield Pre and Post op care if surgical excision and drainage is needed

Menopause

ASSESS FOR CLINICAL MANIFESTATIONS OF PERIMENOPAUSE -Irregular menses -Vasomotor instability (hot flashes and night sweats) -Atrophy of genitourinary tissue (e.g., vaginal epithelium) -Stress and urge incontinence -Breast tenderness -Mood changes ASSESS FOR CLINICAL MANIFESTATIONS OF POSTMENOPAUSE -Cessation of menses -Occasional vasomotor symptoms -Atrophy of genitourinary tissue with decreased support -Stress and urge incontinence -Osteoporosis Loss of estrogen: risk for osteoporosis, may need calcium supplement to help build back bone density Assess for Signs and Symptoms of Estrogen deficiency -Vasomotor - Hot flashes, Night sweats -Psychologic - Emotional lability, Change in sleep pattern, Decreased REM sleep -Skeletal, Increased fracture rate, particularly of vertebral bodies but also of humerus, distal radius, and upper femur -Cardiovascular, Decreased high-density lipoproteins (HDLs), Increased low-density lipoproteins (LDLs) -Genitourinary - Atrophic vaginitis, Dyspareunia secondary to poor lubrication, Incontinence -Dermatologic - Diminished collagen content of skin, Breast tissue changes Nonhormonal Therapy -Keep a cool environment and limit caffeine and alcohol to reduce heat production -Behavioral changes such as relaxation techniques may help -Increase air circulation at night and avoid bedding that traps heat -Wear loose fitting clothing that does not retain body heat -Apply cool cloths to flushed areas -Take vitamin E in up to doses of 800IU to reduce hot flashes -Encourage exercise to decrease anxiety and to reduce CAD risk factors for menopausal women Nutritional Therapy -Teach good nutrition to reduce risk of CAD. -Teach a decrease in metabolic rate and careless eating habits can cause weight gain and fatigue in menopause -Encourage an adequate amount of calcium and vitamin D to counteract loss of bone density (1500mg calcium when no estrogen replacement is used and 1000 mg with estrogen replacement) -Instruct on a diet high in complex carbs and vitamin B complex, especially B6. -Foods containing photoestrogens may reduce menopausal symptoms such as soy, tofu, chickpeas and sunflower seeds -Evidence exists that herbs such as black cohosh may help symptoms (consult with PHCP or nutritionist first) Nursing Management -Be aware of cultural beliefs regarding menopause -Help the woman foster a positive self image -Remind them symptoms are temporary and encourage non drug therapies -Recommend the use of moisturizing soaps and lotions for dry skin -Teach Kegal exercises o decrease incontinence -Encourage use of a water soluble lubricant during intercourse if vaginal dryness occurs -Encourage patient to talk about sexual concerns -Remind her an active sex life helps increase lubrication and maintains the pliabiity of vaginal tissues

Bartholinitis

Inflammation of the Bartholin's glands, located at the posterior and lateral aspects of the vaginal orifice, Assess for Clinical Manifestations - swelling of one or both glands, pain, and development of an abscess in the infected gland. A fistula may develop from the gland to the vagina, anus, or perineum. Nursing Management- consistent with those for other infections/ inflammations/ PID

Autonomic Dysreflexia

Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system -SNS responds to stimulation of sensory receptors - parasympathetic nervous system unable to counteract these responses. -Hypertension and bradycardia The return of reflexes after the resolution of spinal shock means that patients with an injury level at T6 or higher may develop autonomic dysreflexia. Autonomic dysreflexia (also known as autonomic hyperreflexia) is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It involves stimulation of sensory receptors below the level of the SCI. The intact sympathetic nervous system below the level of the injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP, but the parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord. Baroreceptors in the carotid sinus and the aorta sense the hypertension and stimulate the parasympathetic system. This results in a decrease in heart rate, but the visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the injured spinal cord. Most common precipitating factor is distended bladder or rectum. Manifestations -Hypertension (up to 300 mm Hg systolic) -Throbbing headache -Marked diaphoresis above level of injury -Bradycardia -piloerection (erection of body hair) -blurred vision or spots -nasal congestion -anxiety -nausea It is important to measure BP when a patient with an SCI complains of a headache. The most common precipitating cause of autonomic dysreflexia is a distended bladder or rectum. This is a life-threatening condition that requires immediate resolution. If uncorrected, autonomic dysreflexia can lead to status epilepticus, stroke, myocardial infarction, and even death. However, any sensory stimulation may cause autonomic dysreflexia. Contraction of the bladder or rectum, stimulation of the skin, or stimulation of the pain receptors may also cause autonomic dysreflexia. Manifestations include -hypertension (up to 300 mm Hg systolic) -throbbing headache -marked diaphoresis above the level of the injury -bradycardia (30 to 40 beats/minute). It is important to measure BP when a patient with a SCI complains of a headache. Manifestations -Piloerection (erection of body hair) as a result of pilomotor spasm -Flushing of skin above level of injury -Blurred vision or spots in visual field -Nasal congestion -Anxiety -Nausea Nursing interventions -Elevate head, notify HCP Assess for and remove cause -immediate catheterization -remove stool impaction if cause -remove constrictive clothing and tight shoes Patient and family teaching The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. Nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. The most common cause is bladder irritation. Immediate catheterization to relieve bladder distention may be necessary. Lidocaine jelly should be instilled in the urethra before catheterization. If a catheter is already in place, it should be checked for kinks or folds. If plugged, small-volume irrigation should be performed slowly and gently to open a plugged catheter, or a new catheter may be inserted. Stool impaction can also result in autonomic dysreflexia. A digital rectal examination should be performed only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increase of symptoms. Remove all skin stimuli, such as constrictive clothing and tight shoes. Monitor BP frequently during the episode. If symptoms persist after the source has been relieved, an α-adrenergic blocker or an arteriolar vasodilator (e.g., nifedipine [Procardia]) is administered. Careful monitoring must continue until the vital signs stabilize. Teach the patient and caregiver to recognize the causes and symptoms of autonomic dysreflexia. They must understand the life-threatening nature of this dysfunction and know how to relieve the cause. Immediate interventions •Raise the person to a sitting position. •Remove the noxious stimulus (fecal impaction, kinked urinary catheter, tight clothing). •Call the health care provider if above actions do not relieve the signs and symptoms. Measures to decrease the incidence of autonomic dysreflexia •Maintain regular bowel function. •If manual rectal stimulation is used to promote bowel function, local anesthetics may prevent autonomic dysreflexia. •Monitor urine output. •Wear a Medic Alert bracelet indicating a history of risk for autonomic dysreflexia.

Headache

Nursing Assessment Health history -Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuli -Medications -Surgery and other treatments Obtain information about previous illnesses, surgery, trauma, allergies, family history, and response to medication. Specific details about the headache: -Location -Type of pain -Onset -Frequency -Duration, time of day -Relation to outside events Emotional, psychologic, and physical events should be noted. The nurse may suggest that the patient keep a diary of headache episodes with specific details. This type of record can be of great help in determining the type of headache and the precipitating events. If the patient has a history of migraine, tension-type, or cluster headaches, it is important to determine if the character, intensity, or location of the headache has changed. This may be an important clue as to the cause of the headache. Objective data -Anxiety or apprehension -Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis Nursing diagnoses may include but are not limited to -Acute pain related to headache -Ineffective self-health management related to drug therapy and lifestyle adjustments. Planning -Have decreased or no pain. -Demonstrate understanding of triggering events and treatment strategies. -Use positive coping strategies. -Experience increased quality of life and decreased disability. Nursing Implementation An inability to cope with daily stresses can cause headaches. Effective therapy may be to help patients -Examine their lifestyle. -Recognize stressful situations. -Learn to cope more appropriately. Patients with chronic headache present a great challenge to health care providers. Help the patient identify precipitating factors and develop ways to avoid them Daily exercise, relaxation periods, and socializing help reduce recurrence and should be encouraged. Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis. Encourage a quiet, dim environment. Massage and heat packs can help with tension-type. Patient should make a written note of medications to prevent accidental overdose. The patient should learn about the drugs prescribed for preventive/prophylactic and abortive/symptomatic treatment of headache and should be able to describe the purpose, action, dosage, and side effects of the drug. Teach patient about prophylactic treatment. Dietary counseling for food triggers Avoid smoking and smoke exposure and other environmental triggers The patient needs to be encouraged to eliminate foods that may provoke headaches, such as chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, alcohol (particularly red wine), excessive caffeine, and fermented or marinated foods. Active challenge and provocative testing with specific foods may be necessary to determine the specific causative agents. However, food triggers may change over time. Teach the patients to avoid smoking and exposure to triggers such as strong perfumes, volatile solvents, and gasoline fumes. Cluster headache attacks may occur at high altitudes with low oxygen levels during air travel. Ergotamine, taken before the plane takes off, may decrease the likelihood of these attacks. Evaluation Expected outcomes -Reports satisfaction with pain relief -Uses drug and nondrug measures appropriately to manage pain

Head Injury

Nursing Assessment Subjective Data Past medical history -Mechanism of injury: motor vehicle collision, sports injury, industrial incident, assault, falls Medications -Anticoagulants Subjective Data -Alcohol/drug use; risk-taking behaviors -Headache -Mood or behavioral changes -Mentation changes; impaired judgment -Aphasia, dysphasia -Fear, denial, anger, aggression, depression -Coping-stress tolerance: Fear, denial, anger, aggression, depression Objective Data -Altered mental status -Lacerations, contusions, abrasions -Hematoma -Battle's sign -Periorbital edema and ecchymosis -Otorrhea -Exposed brain -Rhinorrhea -Impaired gag reflex -Altered/irregular respirations -Cushing's triad -Vomiting -Bowel and bladder incontinence -Uninhibited sexual expression -Altered LOC -Seizures -Pupil dysfunction -Cranial nerve deficit(s) -Motor deficit -Palmar drift -Paralysis -Spasticity -Posturing -Rigidity or flaccidity -Ataxia Possible focused assessment findings include: General -Altered mental status Integumentary -Lacerations, contusions, abrasions, hematoma, Battle's sign, periorbital edema and ecchymosis, otorrhea, exposed brain matter Respiratory -Rhinorrhea, impaired gag reflex, inability to maintain a patent airway. Impending herniation: altered/irregular respiratory rate and pattern Cardiovascular -Impending herniation: Cushing's triad (systolic hypertension with widening pulse pressure, bradycardia with full and bounding pulse, irregular respirations) Gastrointestinal -Vomiting, projectile vomiting, bowel incontinence Urinary -Bladder incontinence Reproductive -Uninhibited sexual expression Neurologic -Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s) Musculoskeletal -Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia Possible Diagnostic Findings -Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI; abnormal EEG; positive toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP Nursing diagnoses and a potential complication for the patient who has sustained a head injury may include, but are not limited to, the following: •Risk for ineffective cerebral tissue perfusion related to interruption of CBF associated with cerebral hemorrhage, hematoma, and edema •Hyperthermia related to increased metabolism, infection, and hypothalamic injury •Impaired physical mobility related to decreased LOC •Anxiety related to abrupt change in health status, hospital environment, and uncertain future •Potential complication: increased ICP related to cerebral edema and hemorrhage The overall goals are that the patient with an acute head injury will -maintain adequate cerebral -oxygenation and perfusion; remain normothermic; -achieve control of pain and discomfort; -be free from infection; -have adequate nutrition; and -attain maximal cognitive, motor, and sensory function. Nursing Implementation Health Promotion -Prevent car and motorcycle accidents. -Wear safety helmets. -Use seat belts and child car seats. -Home safety to prevent falls One of the best ways to prevent head injuries is to prevent car and motorcycle collisions. The use of helmets by cyclists has led to fewer TBIs. The use of car seat belts and the use of child car seats are also associated with reduced TBI mortality rates. Be active in campaigns that promote driving safety and speak to driver education classes regarding the dangers of unsafe driving and of driving after drinking alcohol and using drugs. The use of seat belts in cars and the use of helmets for riding on motorcycles are the most effective measures for increasing survival after crashes. The wearing of protective helmets by lumberjacks, construction workers, miners, horseback riders, bicycle riders, snowboarders, and skydivers is also recommended. Additionally, individuals who are at risk for falls (e.g., older adults) should be evaluated for safety in the home, as falls are the second leading cause of head injuries. Acute Intervention -Maintain cerebral perfusion. -Prevent secondary cerebral ischemia. -Monitor for changes in neurologic status. -Patient and family teaching Management at the injury scene can have a significant impact on the outcome of the head injury. The general goal of nursing management of the head-injured patient is to maintain cerebral oxygenation and perfusion and prevent secondary cerebral ischemia. Surveillance or monitoring for changes in neurologic status is critically important because the patient's condition may deteriorate rapidly, necessitating emergency surgery. Because of the close association between hemodynamic status and cerebral perfusion, be aware of any coexisting injuries or conditions. Perform neurologic assessments at intervals based on the patient's condition. The GCS is useful in assessing the LOC . Indications of a deteriorating neurologic state, no matter how subtle, such as a decreasing LOC or decreasing motor strength, should be reported to the health care provider. Monitor the patient's condition closely. Explain the need for frequent neurologic assessments to both the patient and caregiver. Behavioral manifestations associated with head injury can result in a frightened, disoriented patient who is combative and resists help. Your approach should be calm and gentle. A family member may be available to stay with the patient and thus prevent increasing anxiety and fear. One of the most important needs for the caregiver and family members in the acute injury phase is information about the patient's diagnosis, treatment plan, and rationale for the interventions. Major focus of nursing care relates to increased ICP. Eye problems -Eye drops, compresses, patch Hyperthermia -Goal 36°to 37° C -Prevent shivering The major focus of nursing care for the brain-injured patient relates to increased ICP. However, there may be problems that require specific nursing intervention. Eye problems may include loss of the corneal reflex, periorbital ecchymosis and edema, and diplopia. Loss of the corneal reflex may necessitate administering lubricating eye drops or taping the eyes shut to prevent abrasion. Periorbital ecchymosis and edema decrease with time, but cold and, later, warm compresses provide comfort and hasten the process. Diplopia can be relieved by use of an eye patch. A consult with an ophthalmologist should be considered. Hyperthermia may occur from injury to or inflammation of the hypothalamus. Elevations in body temperature can result in increased CBF, cerebral blood volume, and ICP. Increased metabolism secondary to hyperthermia increases metabolic waste, which in turn produces further cerebral vasodilation. Avoid hyperthermia with a goal of 36°to 37°C as the standard of care. Use interventions to reduce temperature in conjunction with sedation as necessary to prevent shivering Measures for patients leaking CSF -Head of bed elevated -Loose collection pad -No sneezing or blowing nose -No NG tube -No nasotracheal suctioning If CSF rhinorrhea or otorrhea occurs, inform the physician immediately. -The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. -A loose collection pad may be placed under the nose or over the ear. Do not place a dressing in the nasal or ear cavities. -Instruct the patient not to sneeze or blow the nose. Nasogastric tubes should not be used, and nasotracheal suctioning should not be performed on these patients due to the high risk of meningitis. Measures for immobilized patients Antiemetics Analgesics Pre-op preparation, if needed Nursing measures specific to the care of the immobilized patient, such as those related to bladder and bowel function, skin care, and infection, are also indicated. Nausea and vomiting may be a problem and can be alleviated by antiemetic drugs. Headache can usually be controlled with acetaminophen or small doses of codeine. If the patient's condition deteriorates, intracranial surgery may be necessary. A burr-hole opening or craniotomy may be indicated, depending on the underlying injury that is causing the symptoms. The emergency nature of the surgery may hasten the usual preoperative preparation. Consult with the neurosurgeon to determine specific preoperative nursing measures. The patient is often unconscious before surgery, making it necessary for a family member to sign the consent form for surgery. This is a difficult and frightening time for the patient's caregiver and family and requires sensitive nursing management. The suddenness of the situation makes it especially difficult for the family to cope. Ambulatory and Home Care Acute rehabilitation -Motor and sensory deficits -Communication issues -Memory and intellectual functioning -Nutrition -Bowel and bladder management Seizure disorders Mental and emotional difficulties Progressive recovery Family participation and education Once the condition has stabilized, the patient is usually transferred for acute rehabilitation management. There may be chronic problems related to motor and sensory deficits, communication, memory, and intellectual functioning. Many of the principles of nursing management of the patient with a stroke are appropriate for these patients. Conditions that may require nursing and collaborative management include poor nutritional status, bowel and bladder management, spasticity, dysphagia, deep vein thrombosis, and hydrocephalus. The patient's outward appearance is not a good indicator of how well the patient will ultimately function in the home or work environment. The outward physical appearance does not necessarily reflect what has happened in the brain. Seizure disorders are seen in approximately 5% of patients with a nonpenetrating head injury. Seizures are most likely to develop during the first week after the head injury. Some patients may not develop a seizure disorder until years after the initial injury. Antiseizure drugs may be used prophylactically to manage posttraumatic seizure activity. The mental and emotional sequelae of brain trauma are often the most incapacitating problems. One of the consequences of TBI is that the person may not realize that a brain injury has occurred. Many of the patients with head injuries who have been comatose for more than 6 hours undergo some personality change. They may suffer loss of concentration and memory and defective memory processing. Personal drive may decrease. Apathy may increase. Euphoria and mood swings, along with a seeming lack of awareness of the seriousness of the injury, may occur. The patient's behavior may indicate a loss of social restraint, judgment, tact, and emotional control. Progressive recovery may continue for 6 months or more before a plateau is reached, and a prognosis for recovery can be made. Specific nursing management in the posttraumatic phase depends on specific residual deficits. In all cases, the family must be given special consideration. They need to understand what is happening and be taught appropriate interaction patterns. Provide guidance and referrals for financial aid, child care, and other personal needs. Assist the family in involving the patient in family activities whenever possible. Help the patient and family develop and maintain hope. The family often has unrealistic expectations of the patient as the coma begins to recede. The family expects full return to pretrauma status. In reality, the patient usually experiences a reduced awareness and ability to interpret environmental stimuli. Prepare the family for the emergence of the patient from coma and explain that the process of awakening often takes several weeks. Arrange for social work and chaplain consultations for the family in addition to providing open-visitation and frequent status updates. When it is the time for discharge planning, the caregiver, family, and patient may benefit from specific posthospitalization instructions to avoid family-patient friction. Special "no" policies that may be appropriately suggested by the neurosurgeon, neuropsychologist, and nurse include no drinking of alcoholic beverages, no driving, no use of firearms, no work with hazardous implements and machinery, and no unsupervised smoking. Family members, particularly spouses, go through role transition as the role changes from that of spouse to that of caregiver. Nursing Evaluation: The expected outcomes are that the patient with a head injury will •Maintain normal cerebral perfusion pressure. •Achieve maximal cognitive, motor, and sensory function. •Experience no infection or hyperthermia.

IICP

Nursing Assessment Subjective data Level of consciousness (LOC) Glasgow Coma Scale -Eye opening -Best verbal response -Best motor response Subjective data about the patient with increased ICP can be obtained from the patient, caregiver, or family who are familiar with the patient. Describe the LOC by noting the specific behaviors observed. When a deviation from the normal state of consciousness occurs, use a more structured method of observation. Assess the LOC using the Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is a quick, practical, and standardized system for assessing the level of consciousness. Three indicators of response are evaluated: (1) opening of the eyes, (2) the best verbal response, and (3) the best motor response. Specific behaviors observed as responses to the testing stimulus are given a numeric value. Your responsibility is to elicit the best response on each of the scales: the higher the scores, the higher the level of brain functioning. The subscale scores are particularly important if a patient is untestable in one area. For example, severe periorbital edema may make eye opening impossible. The total GCS score is the sum of the numeric values assigned to each of the three areas evaluated. The highest GCS score is 15 for a fully alert person, and the lowest possible score is 3. A GCS score of less than or equal to 8 is generally indicative of coma. Plot the data on a graph, which can be used to determine whether the patient is stable, improving, or deteriorating. The GCS offers several advantages in the assessment of the unconscious patient. It allows different health care professionals to arrive at the same conclusion regarding the patient's status and can be used to discriminate between different or changing states. While the GCS is the gold standard assessment tool for level of consciousness, it is important to note that there are other scales available and used in the clinical setting. Compare the pupils with one another for size, shape, movement, and reactivity. If the oculomotor nerve [CN III] is compressed, the pupil on the affected side (ipsilateral) becomes larger until it fully dilates. If ICP continues to increase, both pupils dilate. Test pupillary reaction with a penlight. The normal reaction is brisk constriction when the light is shone directly into the eye. Also note a consensual response (a slight constriction in the opposite pupil) at the same time. A sluggish reaction can indicate early pressure on CN III (oculomotor nerve). A fixed pupil unresponsive to light stimulus usually indicates increased ICP. However, it is important to note that there are other causes of a fixed pupil, including direct injury to CN III, previous eye surgery, administration of atropine, and use of mydriatic eyedrops. Cranial nerves -Eye movements -Corneal reflex -Oculocephalic reflex (doll's eye reflex) -Oculovestibular (caloric stimulation) Evaluation of other cranial nerves can be included in the neurologic assessment. Eye movements controlled by cranial nerves III, IV, and VI can be examined in the patient who is awake and able to follow commands and can be used to assess the function of the brainstem. Testing the corneal reflex gives information about the functioning of cranial nerves V and VII. If this reflex is absent, initiate routine eye care to prevent corneal abrasion. Eye movements of the uncooperative or unconscious patient can be elicited by reflex with the use of head movements (oculocephalic) and caloric stimulation (oculovestibular). To test the oculocephalic reflex (doll's-eye reflex), turn the patient's head briskly to the left or right while holding the eyelids open. A normal response is movement of the eyes across the midline in the direction opposite that of the turning. Next, quickly flex and then extend the neck. Eye movement should be opposite to the direction of head movement—up when the neck is flexed and down when it is extended. Abnormal responses can help locate the intracranial lesion. This test should not be attempted if a cervical spine problem is suspected. Test motor strength by asking the awake and cooperative patient to squeeze your hands to compare strength in the hands. The palmar drift test is an excellent measure of strength in the upper extremities. The patient raises the arms in front of the body with the palmar surface facing upward. If there is any weakness in the upper extremity, the palmar surface turns downward, and the arm drifts downward. Asking the patient to raise the foot from the bed or to bend the knees up in bed is a good assessment of lower extremity strength. Test all four extremities for strength and evaluate for any asymmetry in strength or movement. Assess the motor response of the unconscious or uncooperative patient by observation of spontaneous movement. If no spontaneous movement is possible, apply a pain stimulus to the patient and note the response. Resistance to movement during passive range-of-motion exercises is another measure of strength. Do not include hand squeezing as part of the assessment of motor movement in the unconscious or uncooperative patient, as this is a reflex action and can provide a misrepresentation of the patient's status. Also record the vital signs, including BP, pulse, respiratory rate, and temperature. Be aware of Cushing's triad because this indicates severely increased ICP. Besides recording respiratory rate, also note the respiratory pattern. Motor strength -Squeeze hands -Palmar drift test -Raise foot off bed or bend knees Motor response -Spontaneous or to pain Vital signs Test motor strength by asking the awake and cooperative patient to squeeze your hands to compare strength in the hands. The palmar drift test is an excellent measure of strength in the upper extremities. The patient raises the arms in front of the body with the palmar surface facing upward. If there is any weakness in the upper extremity, the palmar surface turns downward, and the arm drifts downward. Asking the patient to raise the foot from the bed or to bend the knees up in bed is a good assessment of lower extremity strength. Test all four extremities for strength and evaluate for any asymmetry in strength or movement. Assess the motor response of the unconscious or uncooperative patient by observation of spontaneous movement. If no spontaneous movement is possible, apply a pain stimulus to the patient and note the response. Resistance to movement during passive range-of-motion exercises is another measure of strength. Do not include hand squeezing as part of the assessment of motor movement in the unconscious or uncooperative patient, as this is a reflex action and can provide a misrepresentation of the patient's status. Also record the vital signs, including BP, pulse, respiratory rate, and temperature. Be aware of Cushing's triad because this indicates severely increased ICP. Besides recording respiratory rate, also note the respiratory pattern. Abnormal Respiratory Patterns of Coma -Cheyne-Stokes -Central neurogenic hyperventilation -Apneustic breathing -cluster breathing -ataxic breathing Nursing diagnoses for the patient with increased ICP include, but are not limited to, the following: •Decreased intracranial adaptive capacity related to decreased cerebral perfusion or increased ICP •Risk for ineffective cerebral tissue perfusion related to reduction of venous and/or arterial blood flow and cerebral edema •Risk for disuse syndrome related to altered level of consciousness, immobility, and altered nutritional intake The overall goals for the patient with increased ICP are to (1) maintain a patent airway; (2) have ICP within normal limits; (3) have normal fluid, electrolyte, and nutritional balance, and (4) prevent complications secondary to immobility and decreased LOC. Nursing Implementation: -Respiratory function -Maintain patent airway. -Elevate head of bed 30 degrees. -Suctioning needs -Minimize abdominal distention. -Monitor ABGs. -Maintain ventilatory support. Maintenance of a patent airway is critical in the patient with increased ICP and is a primary nursing responsibility. As the LOC decreases, the patient is at an increased risk of airway obstruction from the tongue dropping back and occluding the airway or from accumulation of secretion. In general, any patient with a GCS less than or equal to 8 or an altered LOC who is unable to maintain a patent airway or effective ventilation needs intubation and mechanical ventilation. Prevent hypoxia and hypercapnia in order to minimize secondary injury. Proper positioning of the head is important. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. Remove accumulated secretions by suctioning as needed. An oral airway facilitates breathing and provides an easier suctioning route in the comatose patient. Suctioning and coughing will cause transient decreases in the PaO2 and increases in the ICP. Keep suctioning to a minimum and less than 10 seconds in duration, with administration of 100% oxygen before and after to prevent decreases in the PaO2. To avoid cumulative increases in the ICP with suctioning, limit suctioning to two passes per suction procedure, if possible. Try to prevent abdominal distention as it can interfere with respiratory function. Insertion of a nasogastric tube to aspirate the stomach contents can prevent distention, vomiting, and possible aspiration. However, in patients with facial and skull fractures, a nasogastric tube is contraindicated unless a basal skull fracture has been ruled out, and oral insertion of a gastric tube is preferred. ABGs should be measured and evaluated regularly. Frequently monitor the ABG values and take measures to maintain the levels within prescribed or acceptable parameters. The appropriate ventilatory support can be ordered on the basis of the PaO2 and PaCO2 values. Pain and anxiety management -Opioids -Propofol (Diprivan) -Dexmedetomidine (Precedex) -Neuromuscular blocking agents -Benzodiazepines Pain, anxiety, and fear from the primary injury, therapeutic procedures, or noxious stimuli can increase ICP and BP, thus complicating the management and recovery of the brain-injured patient. The appropriate choice or combination of sedatives, paralytics, and analgesics for symptom management presents a challenge to the ICU team. Administration of these agents may alter the neurologic state, thus masking true neurologic changes. It may be necessary to temporarily suspend drug therapy to appropriately assess neurologic status. The choice, dose, and combination of agents may vary depending on the patient's history, neurologic state, and overall clinical presentation. Opioids, such as morphine sulfate and fentanyl (Sublimaze), are rapid-onset analgesics with minimal effect on CBF or oxygen metabolism. The IV anesthetic sedative propofol (Diprivan) has gained popularity in the management of anxiety and agitation in the ICU because of its rapid onset and short half-life. An accurate neurologic assessment can be performed very soon after turning off the infusion of propofol. A side effect of this drug is hypotension. Dexmedetomidine (Precedex), an alpha-2 adrenergic agonist, is used for continuous IV sedation of intubated and mechanically ventilated patients in the ICU setting for up to 24 hours. It is another ideal agent for neurologic patients because of the ease in obtaining a neurologic assessment without altering the dose due to its anxiolytic properties. When using continuous IV sedatives, be aware of the side effects of these drugs, especially hypotension, as this can result in a lower CPP value. Nondepolarizing neuromuscular blocking agents (e.g., vecuronium [Norcuron], cisatracurium besylate [Nimbex]) are useful for achieving complete ventilatory control in the treatment of refractory intracranial hypertension. Because these agents paralyze muscles without blocking pain or noxious stimuli, they are used in combination with sedatives, analgesics, or benzodiazepines. Benzodiazepines, although useful for sedation, are usually avoided in the management of the patient with increased ICP because of the hypotensive effect and long half-life, unless they are used as an adjunct to neuromuscular blocking agents. Fluid and electrolyte balance -Monitor IV fluids. -Daily electrolytes -Monitor for DI or SIADH. Monitor and minimize increases in ICP. Fluid and electrolyte disturbances can have an adverse effect on ICP. Closely monitor IV fluids with the use of an accurate IV infusion control device or pump. Intake and output, with insensible losses and daily weights taken into account, are important parameters in the assessment of fluid balance. Electrolyte determinations should be made daily, and any abnormal values should be discussed with the physician. It is especially important to monitor serum glucose, sodium, potassium, magnesium, and osmolality. Monitor urinary output to detect problems related to diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH). Diabetes insipidus is caused by a decrease in antidiuretic hormone (ADH). It results in increased urinary output and hypernatremia. The usual treatment of diabetes insipidus is fluid replacement, vasopressin (Pitressin), or desmopressin acetate (DDAVP) (see Chapter 50). If not treated, severe dehydration will occur. SIADH is caused by an excess secretion of ADH. SIADH results in decreased urinary output and dilutional hyponatremia. It may result in cerebral edema, changes in LOC, seizures, and coma. ICP monitoring is used in combination with other physiologic parameters to guide the care of the patient and assess the patient's response to treatment. Valsalva maneuver, coughing, sneezing, suctioning, hypoxemia, and arousal from sleep are factors that can increase ICP. Be alert to these factors and attempt to minimize them. Interventions to optimize ICP and CPP -HOB elevated appropriately -Prevent extreme neck flexion -Turn slowly -Avoid coughing, straining, Valsalva -Avoid hip flexion Maintain the patient with increased ICP in the head-up position. Take care to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Adjust the body position to decrease the ICP maximally and to improve the CPP. Elevation of the head of the bed promotes drainage from the head and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the CPP by lowering systemic BP. Careful evaluation of the effects of elevation of the head of the bed on both the ICP and the CPP is required. Position the bed so that it lowers the ICP while optimizing the CPP and other indices of cerebral oxygenation. Take care to turn the patient with slow, gentle movements because rapid changes in position may increase the ICP. Prevent discomfort in turning and positioning the patient because pain or agitation also increases pressure. Increased intrathoracic pressure contributes to increased ICP by impeding the venous return. Thus coughing, straining, and the Valsalva maneuver should be avoided. Avoid extreme hip flexion to decrease the risk of raising the intra-abdominal pressure, which increases ICP. Minimize complications of immobility Protection from self-injury -Judicious use of restraints; sedatives -Seizure precautions -Quiet, non-stimulating environment Psychologic considerations Provide the physical care to minimize complications of immobility, such as atelectasis and contractures. The patient with increased ICP and a decreased LOC needs protection from self-injury. Confusion, agitation, and the possibility of seizures increase the risk for injury. Use restraints judiciously in the agitated patient. If restraints are absolutely necessary to keep the patient from removing tubes or falling out of bed, they should be secure enough to be effective, and the skin area under the restraints should be observed regularly for irritation. Agitation may increase with the use of restraints, which indicates the need for other measures to protect the patient from injury. Light sedation with agents such as midazolam (Versed) or lorazepam (Ativan) may be needed. Having a family member stay with the patient may have a calming effect. For the patient with seizures or the patient at risk for such activity, institute seizure precautions. Seizures are most likely to occur in the first 7 days following traumatic injury, so prophylactic antiseizure therapy is usually used during this time. Additional seizure precautions include padded side rails, an airway at the bedside, suction readily available, accurate and timely administration of antiseizure drugs, and close observation. The patient can benefit from a quiet, nonstimulating environment. Always use a calm, reassuring approach. Touch and talk to the patient, even one who is in a coma. In addition to carefully planned physical care, also be aware of the psychologic well-being of patients and their families. Anxiety over the diagnosis and the prognosis can be distressing to the patient, the caregiver and family, and the nursing staff. Your competent and assured manner in performing care is reassuring to everyone involved. Short, simple explanations are appropriate and allow the patient and the caregiver to acquire the amount of information they desire. There is a need for support, information, and education of both patients and families. Assess the family members' desire and need to assist in providing care for the patient and allow for their participation as appropriate. Encourage interdisciplinary management of the patient (social work, chaplain, etc.) and involve the family in decision making as much as possible. Evaluation: Expected Outcomes -Maintain ICP and CPP within normal parameters -No serious increases in ICP during or following care activities -No complications of immobility

STIs (Sexually Transmitted Infections)

Subjective Data -Past medical history, including sexual history -Medication use -IV drug use -Nausea/vomiting -Dysuria -Urethral discharge -Burning lesions -Vaginal discharge -Presence of genital or perianal lesions Objective Data -Fever -Visual assessment of lesions, warts, rash -Purulent rectal discharge -Proctitis -Urethral and cervical discharge -Laboratory findings Nursing Diagnosis: -Risk for infection -Anxiety -Ineffective health maintenance Patient with STI will -Demonstrate understanding of mode of transmission and risks imposed. -Complete treatment and follow-up. -Notify or assist in notification of sexual contacts. -Abstain until infection is resolved. -Demonstrate knowledge of safer sex practices. Health Promotion Discuss practices with all patients. -Abstinence -Monogamy -Avoidance of high-risk sexual practices -Use of barriers and condoms Screen for cervical cancer. Many approaches to stopping the spread of STIs have been advocated and have met with varying degrees of success. Be prepared to discuss "safe" sex practices with all patients, not only those who are perceived to be at risk. Sexual abstinence is a certain method of avoiding all STIs, but few people consider this a feasible alternative to sexual expression. Limiting sexual intimacies outside of a well-established monogamous relationship can reduce the risk of contracting an STI. All sexually active women should be screened for cervical cancer using a Pap smear. Women with a history of STIs are at greater risk for cervical cancer. Anal pap smears should also be done for all individuals who are recipients of anal sex Measures to prevent infection -Teach to inspect partner's genitals -Some protection if void immediately after intercourse -Wash genitalia and adjacent areas with soap and water -Proper use of mechanical barriers -Consistent use with all partners regardless of circumstances The patient should remember that, when engaging in sex, there is exposure to the infections of everyone with whom the partner has ever had sex. The decision to proceed, not to proceed, or to proceed with modifications can be made. Postcoital voiding and washing can provide some protection but do not provide adequate protection against STIs after exposure to infection. Spermicidal jellies and creams may serve as supplementary lubrication, thereby decreasing irritation and friction, and thus reduce the chance that a minor laceration could serve as the entry point for an infectious organism. They have not been shown to reduce the risk of contracting STIs. Proper use of a condom provides a highly effective mechanical barrier to infection. The condom should be undamaged and correctly in place throughout all phases of sexual activity. Use of barrier contraceptives requires planning and motivation, both of which are impaired with alcohol or drug ingestion. Information about the mechanics of sexual arousal and incorporating a condom into lovemaking can help in overcoming both the individual's or partner's resistance to its use. Female condoms are lubricated polyurethane sheaths designed for vaginal use but are considerably more expensive than male condoms . Among couples with one infected partner, consistent and scrupulous condom use can reduce transmission to the uninfected partner. Unprotected anal intercourse and other high-risk behaviors should be eliminated, and condoms should be used if sexual contact continues. Measures to prevent infection Assess risk for contracting an STI through a respectful, compassionate, and nonjudgmental conversation -Number of partners -Type of birth control used/use of condoms -History of an STI -Use of IV drugs -Sexual preference Instead of asking if a patient is homosexual or asking only about sexual preference, it is useful to be more specific and ask, "Do you have sex with men or women or both?" This approach can be much more revealing. Some men who have sex with men do not identify themselves as homosexual or bisexual. This sexual practice is a major contributor of infection to wives and female partners, as well as men. While the majority of STIs are transmitted between MSM and heterosexual contact it is possible to transmit an STI between women. Plan teaching based on the response to these questions. Do not assume that older people are not at risk, as an increasing number of older people are becoming infected. Screening programs Can help prevent certain STIs -Syphilis -HIV -Gonorrhea -Chlamydia -Genital herpes -HPV infection For many years, there have been various screening programs to identify cases of syphilis. Many institutions offer voluntary prenatal HIV and syphilis testing and counseling for pregnant women. Screening programs have been developed and implemented for detection of gonorrhea and chlamydial infection. These programs are targeted to women because women are more likely to have asymptomatic gonorrhea and thereby serve as sources of infection. Routine gonorrheal and chlamydial testing during pelvic examinations and prenatal visits are being performed as a major part of these programs. Mass application of screening programs for genital chlamydial infections, genital herpes, and HPV infections (warts) may also be possible with the advent of rapid, cost-effective tests. Case Finding Locate and examine all contacts as soon after exposure as possible. Caseworkers are often nurses. -Expedited partner therapy allows a health care provider to provide treatment to a patient to take to his/her partner without examining the partner and is available in some states. Sexual contacts are often not informed about the origin of the information naming them as a contact so that greater cooperation and privacy is ensured. Partner notification and treatment imposes a heavy burden on public health departments, and as a result the notification often becomes the responsibility of the infected partner. The infected partner may choose not to inform sexual partners, and the partners may choose not to seek treatment. EPT has been shown to be useful in ensuring partner treatment among males and reducing repeat infections among females. Several states have adopted legislation to allow health care providers to dispense antibiotic therapy for sex partners of individuals infected with Chlamydia and gonorrhea. The legality of treating without evaluating the patient is uncertain in some states and illegal in others. Educational and research programs -Teenagers should be prime targets. -Older adults should be included. -Vaccines should be initiated prior to beginning sexual activity. -Stress cancer prevention as motivation. Actively encourage your community to provide better education about STIs for its citizens. Older adults are less likely to use condoms and in general have a harder time initiating discussion of sexual health issues. Knowledge and understanding can decrease the STI epidemic. The HPV vaccine that protects against genital warts and cervical cancer should be encouraged before the start of sexual activity. Accurate and current information may help to reduce parental fears and caution related to the vaccine. Consider stressing the prevention of cancer as a reason for the vaccine, which may be more productive and less controversial, thus making the parent and adolescent more receptive. Efforts are being made to develop vaccines for syphilis, gonorrhea, genital herpes, and HIV. The development of effective vaccines is viewed by many clinicians as a prerequisite for the eradication of STIs. Psychologic support -Emotional responses include shame, guilt, anger, vengeance. Provide counseling -May have to consider issues of infidelity -May have to consider there is no cure -May have to deal with prolonged, costly, unpleasant, ongoing care and concern Encourage the patient to verbalize feelings. Couples in marital or committed relationships are confronted with an added problem when an STI is diagnosed. A patient who has genital herpes is faced with the fact that repeated infections can occur and that no cure is available. This can be frustrating and disruptive to the patient's physical, emotional, social, and sexual lives. Help the patient identify and avoid any factors that may precipitate the condition. Inform the patient that the incidence and severity of recurrences will probably decrease over time. HPV infections involve a prolonged course of treatment. The patient can become frustrated and distressed because of frequent office visits, associated costs, potential for unpleasant side effects as a result of treatment, and effects of the infection on future health and sexual relationships. Support and a willingness to listen to the patient's concerns are needed. Support groups are also available. Follow-Up -You are in a position to explain and interpret treatment measures. -You are more likely to encounter a patient with an STI if you work in an outpatient setting. Frequently, single-dose treatment for gonorrhea, chlamydial infection, and syphilis helps prevent the problems associated with noncompliance with drug therapy. Give special instructions to the patient requiring multiple-dose therapy to complete the prescribed regimen. Inform the patient about problems resulting from nonadherence. All patients should return to the treatment center for a repeat culture from the infected sites or for serologic testing at designated times to determine the effectiveness of the treatment. Explaining to the patient that cures are not always obtained on the first treatment can reinforce the need for a follow-up visit. Also advise the patient to inform sexual partners of the need for testing and treatment, regardless of whether they are free of symptoms or experiencing symptoms. Hygiene measures -Frequent hand washing and bathing -Do not douche. -Use cotton undergarments. Bathing and cleaning of the involved areas can provide local comfort and prevent secondary infection. Because douching may spread the infection or undermine local immune responses, it is contraindicated. The synthetic materials used in most undergarments frequently increase or exacerbate local irritations by trapping moisture. Cotton undergarments provide better absorption and are cooler and more comfortable for the patient with an STI. Sexual activity -Abstinence during the communicable phase of the infection -Use condoms to help prevent infection or reinfection. -Learn to relate sexually without use of high-risk activities. If sexual activity occurs before treatment has been completed, emphasize to the patient the importance of using condoms to help prevent the spread of infection and reinfection. Encourage condom usage after treatment to prevent future exposure to infection. The patient can also choose to relate to a partner in an intimate way that avoids both coitus and oral-genital contact. Note that even single-dose treatments can take up to 1 week to be effective and thus the patient is infectious during this period. Ambulatory and Home Care Because treatment is not involved, many take a casual approach to STIs. -Delay seeking treatment -Noncompliant with instructions -Development of complications which can be serious and costly Because many STIs are cured with a single dose or short course of antibiotic therapy, many persons are casual about the outcome of these infections. The complications can result in disfigurement and destruction of important tissues and organs. Surgery and prolonged therapy are indicated for many patients with infection-related complications. Major surgical procedures such as resection of an aneurysm or aortic valve replacement may be necessary to treat cardiovascular problems caused by syphilis. Pelvic surgery and procedures to correct fertility problems secondary to an STI may include lysis of adhesions, dilation of strictures, reconstructive tuboplasty, and in vitro fertilization. Patient with STI will -Describe modes of transmission. -Use appropriate hygienic measures. -Experience no reinfection. -Demonstrate compliance with follow-up protocol.

Spinal Cord Injury (SCI)

Subjective Data Health history Functional health patterns -Health perception-health management -Activity-exercise -Cognitive-perceptual -Coping-stress tolerance Obtain a health history from patient, including cause of SCI. Obtain the following important health information related to pertinent functional health patterns: -Health perception-health management: Use of alcohol or recreational drugs; risk-taking behaviors -Activity-exercise: Loss of strength, movement, and sensation below level of injury; dyspnea, inability to breathe adequately ("air hunger") -Cognitive-perceptual: Presence of tenderness, pain at or above level of injury; numbness, tingling, burning, twitching of extremities -Coping-stress tolerance: Fear, denial, anger, depression Objective Data -Poikilothermism unable to regulate body heat) -Warm, dry skin (neurogenic shock) -Respiratory difficulties -Bradycardia, hypotension -Decreased or absent bowel sounds -Abdominal distention -Constipation, incontinence, impaction -Urinary retention -Flaccid or spastic bladder -Priapism -Loss of sexual function -Paralysis -Hyperactive deep tendon reflexes -Muscle atony, contractures Respiratory -Injury at C1-3: apnea, inability to cough -Injury at C4: poor cough, diaphragmatic breathing, hypoventilation -Injury at C5-T6: decreased respiratory reserve Cardiovascular -Injury above T5: bradycardia, hypotension, postural hypotension, absence of vasomotor tone Gastrointestinal -Decreased or absent bowel sounds (paralytic ileus in injuries above T5), abdominal distention, constipation, fecal incontinence, fecal impaction Urinary -Retention (for injuries between T1 and L2); flaccid bladder (acute stages); spasticity with reflex bladder emptying (later stages) Reproductive -Priapism, loss of sexual function Neurologic -Complete: Flaccid paralysis and anesthesia below level of injury resulting in tetraplegia (for injuries above C8) or paraplegia (for injuries below C8), hyperactive deep tendon reflexes, bilaterally positive Babinski test (after resolution of spinal shock) Incomplete: Mixed loss of voluntary motor activity and sensation Musculoskeletal -Muscle atony (in flaccid state), contractures (in spastic state) ASIA Impairment Scale: -A=Complete: No motor or sensory function is preserved in the sacral segments S4-S5 -B=Incomplete: Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4-S5 -C=Incomplete: Motor function is preserved below the neurologic level, and more than half of key muscles below the neurologic level have a muscle grade less than 3 -D=Incomplete: Motor function is preserved below the neurologic level, and at least half of key muscles below the neurologic level have a muscle grade of 3 or more -E=Normal: Motor and sensory function are normal Nursing diagnoses for the patient with an SCI depend on the severity of the injury and the level of dysfunction. The nursing diagnoses for a patient with an SCI may include, but are not limited to, the following: -Ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and/or retained secretions -Impaired skin integrity related to immobility and/or poor tissue perfusion -Impaired urinary elimination related to spinal injury and/or limited fluid intake -Constipation related to neurogenic bowel, inadequate fluid intake, and/or immobility -Risk for autonomic dysreflexia related to reflex stimulation of sympathetic nervous system The overall goals are that the patient with an SCI will -maintain an optimal level of neurologic functioning; -have minimal or no complications of immobility; -learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so; and -return to home and the community at an optimal level of functioning. Health Promotion Identify -High-risk populations -Counseling -Education -Referral to programs -Facilitate wheelchair-accessible health care screening, exam rooms, etc. Support legislation on seat belt use, helmets for motorcyclists/bicyclists, and child safety seats. Nursing interventions for the prevention of an SCI include identification of high-risk populations, counseling, and teaching. Support of legislation related to seat belt use in cars, helmets for motorcyclists and bicyclists, child safety seats, and tougher penalties for drunk-driving offenses is a professional responsibility. It is important to emphasize the importance of other health promotion and health screening in addition to SCI care. After injury, health-promoting behaviors can have a significant impact on the health and well-being of the individual with an SCI. Nursing interventions include teaching, counseling, and referral to programs such as smoking cessation classes, recreation and exercise programs, and alcohol treatment programs, and maintaining routine physical examinations for non-neurologic problems. Outpatient health care requires that screening and prevention programs be accessible to people with SCI. Nurses in these settings should facilitate wheelchair-accessible examination rooms, adjustable-height examination tables, and scheduling that allows extra time if needed. Immobilization Maintain neutral position. Stabilize to prevent lateral rotation. -Blanket or towel -Hard cervical collar -Backboard Keep body correctly aligned. Log roll Proper immobilization of the neck involves the maintenance of a neutral position. -Use a blanket or towel roll, a hard cervical collar, and a backboard to stabilize the neck to prevent lateral rotation of the cervical spine. -The body should always be correctly aligned. -Turning should be performed so that the patient is moved as a unit (i.e., logrolling) to prevent movement of the spine. Skeletal traction -Realignment or reduction of injury -Rope, pulley, and weights -Traction maintained at all times. -Stabilize head in neutral position if dislodged and then summon help. -Pin site care For cervical injuries, skeletal traction is used less frequently with the development of better surgical stabilization. When skeletal traction is used, realignment or reduction of the injury is targeted. Crutchfield, Vinke, or Gardner-Wells tongs or other types of devices are used to provide this type of traction. Traction is provided by a rope that is extended from the center of the tongs over a pulley and has weights attached at the end. Traction must be maintained at all times. Depending on the type of injury and the goal of treatment, the tongs and traction may be removed 1 to 4 weeks after the injury. One disadvantage of skull tongs is that the skull pins can be displaced. If this occurs, hold the head in a neutral position and summon help. Stabilize the head while the physician reinserts the tongs. Infection at the sites of tong insertion is another potential problem. Preventive care includes cleansing the sites twice a day with normal saline solution and applying an antibiotic ointment, which acts as a mechanical barrier to the entrance of bacteria. The procedures for preventive care of insertion sites may vary depending on individual hospital standards of care. Kinetic therapy -Continual side-to-side slow rotation ->200 turns/day -Manual or automatic -Decreases pressure sores and cardiopulmonary complications -Risk for motion sickness Special beds are often used in the management of the patient with an SCI. Kinetic therapy uses a continual side-to-side slow rotation laterally with the patient in constant motion. The bed allows a frequency of turns greater than 200 times per day. The bed is used to decrease the likelihood of pressure sores and cardiopulmonary complications. However, in some patients the turning can induce motion sickness and fear of falling out of bed when turned to the extremes. (Motion sickness is unlikely when automatic rather than manual turning is used.) After cervical fusion or other stabilization surgery, a hard cervical collar or sternal-occipital-mandibular immobilizer brace can be worn In a stable injury for which surgery is not done, a halo fixation apparatus may be applied. The halo is the most frequently used method of stabilizing cervical injuries. The halo apparatus can be used to apply cervical traction by means of a jacket-like arrangement Hanging weights, such as those used with tongs, can be incorporated with the halo. In addition, the apparatus can be attached to a body vest, stabilizing the injured area and allowing ambulation if the patient is neurologically intact. Another alternative is to use the halo after the patient has had traction removed. It allows the patient to be more mobile and to begin active rehabilitation. Thoracic or lumbar spine injuries -Custom thoracolumbar orthosis ("body jacket") Meticulous skin care critical with all types of immobilization Patients with thoracic or lumbar spine injuries are immobilized with a custom thoracolumbar orthosis ("body jacket"), which inhibits spinal flexion, extension, and rotation, or with a Jewett brace, which restricts forward flexion. Immobilization of the neck of the patient with an SCI prevents further injury, but the effects of immobility are profound. Meticulous skin care is critical because decreased sensation and circulation make the patient particularly susceptible to skin breakdown. Remove patients from backboards as soon as possible and replace them with other forms of immobilization to prevent coccygeal and occipital area skin breakdown. Properly fit cervical collars. Inspect the areas under the halo vest or jacket or under braces or orthoses to assess the skin condition. Respiratory Dysfunction: -May increased during first 48 hours -May need intubation and mechanical ventilation -↑ Risk for pneumonia and atelectasis -Regular assessment -Aggressive chest physiotherapy -Adequate oxygenation -Proper pain management -Assisted coughing -Tracheal suctioning -Incentive spirometry During the first 48 hours after injury, spinal cord edema may increase the level of dysfunction, and respiratory distress may occur. The possibility of respiratory arrest requires careful monitoring and prompt action should it occur. If the injury is at or above C3, or if the patient is exhausted from labored breathing or ABGs deteriorate (indicating inadequate oxygenation or ventilation), endotracheal intubation or tracheostomy and mechanical ventilation should be initiated. Pneumonia and atelectasis are potential problems because of reduced vital capacity and the loss of intercostal and abdominal muscle function, resulting in diaphragmatic breathing, pooled secretions, and an ineffective cough. Regularly assess (1) breath sounds, (2) ABGs, (3) tidal volume, (4) vital capacity, (5) skin color, (6) breathing patterns (especially the use of accessory muscles), (7) subjective comments about the ability to breathe, and (8) the amount and color of sputum. A PaO2 (partial pressure of oxygen in arterial blood) greater than 60 mm Hg and a PaCO2 (partial pressure of carbon dioxide in arterial blood) less than 45 mm Hg are acceptable values in a patient with uncomplicated tetraplegia. A patient who is unable to count to 10 aloud without taking a breath needs immediate attention. In addition to monitoring, you can intervene to maintain ventilation. Aggressive chest physiotherapy, adequate oxygenation, and proper pain management are essential to maximize respiratory function and gas exchange. Administer oxygen until ABGs stabilize. Chest physiotherapy and assisted coughing facilitate the raising of secretions. Assisted (augmented) coughing simulates the action of the ineffective abdominal muscles during the expiratory phase of a cough. Place the heels of both hands just below the xiphoid process and exert firm upward pressure to the area timed with the patient's efforts to cough. Perform tracheal suctioning if crackles or rhonchi are present. Incentive spirometry is an additional technique that can be used to improve the patient's respiratory status. Cardiovascular Instability: -Risk for bradycardia and cardiac arrest -Chronic low blood pressure with postural hypotension -↑ Risk for DVT -Frequent assessment -Anticholinergic drug/pacemaker -Vasopressor agent -Sequential compression devices and/or gradient stockings -Range-of-motion exercises -Prophylactic heparin Because of unopposed vagal response, the heart rate is slowed, often to less than 60 beats/minute. Any increase in vagal stimulation, such as turning or suctioning, can result in cardiac arrest. Loss of sympathetic nervous system tone in peripheral vessels results in chronic low blood pressure with potential postural hypotension. Lack of muscle tone to aid venous return can result in sluggish blood flow and predispose the patient to DVT. Frequent assessments -Vital signs If blood loss has occurred from other injuries, hemoglobin and hematocrit levels should be monitored, and blood should be administered according to protocol. Also monitor the patient for indications of hypovolemic shock secondary to hemorrhage. Assess the thighs and calves of the legs every shift for signs of DVT (e.g., deep reddish color, edema). If bradycardia is symptomatic, an anticholinergic drug such as atropine is administered. A temporary or permanent pacemaker may be inserted in some patients. Hypotension is managed with a vasopressor agent, such as dopamine or norepinephrine, and fluid replacement. Sequential compression devices or compression gradient stockings can be used to prevent thromboemboli and to promote venous return. Remove the stockings every 8 hours for skin care. Venous duplex studies may be performed before applying compression devices. Also regularly perform range-of-motion exercises and stretching. Prophylactic heparin or low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) may be used to prevent DVT unless contraindicated. Contraindications include internal bleeding and recent surgery. Fluid and Nutritional Maintenance: -Initial paralytic ileus and nasogastric tube -Monitor fluid and electrolytes. -Gradually introduce oral food and fluids. --High-protein, high-calorie diet During the first 48 to 72 hours after the injury, the GI tract may stop functioning (paralytic ileus), and a nasogastric tube must be inserted. Because the patient cannot have oral intake, carefully monitor fluid and electrolyte status. Specific solutions and additives are ordered based on individual requirements. Once bowel sounds are present or flatus is passed, oral food and fluids can gradually be introduced. Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, enteral or parenteral nutrition may be used to provide nutritional support. Inadequate nutritional intake -Assess for cause -Contract with patient -Pleasant eating environment -Calorie count -Dietary supplements -Dietary fiber Some patients experience anorexia, which can be due to depression, boredom with institutional food, or discomfort at being fed (often by a hurried nurse). Some patients have a normally small appetite. Occasionally, refusal to eat is used as a means of maintaining control over the environment because of diminished or absent body control. If the patient is not eating adequately, thoroughly assess the cause. On the basis of this assessment, a contract may be made with the patient using mutual goal setting regarding the diet. This gives the patient increased control of the situation and often results in improved nutritional intake. General measures such as providing a pleasant eating environment, allowing adequate time to eat (including any self-feeding the patient can achieve), encouraging the family to bring in special foods, and planning social rewards for eating may be useful. Keep a calorie count and record the patient's daily weight as a means of evaluating progress. If feasible, the patient should participate in recording calorie intake. Dietary supplements may be necessary to meet nutritional needs. Increased dietary fiber should be included to promote bowel function. Avoid allowing the patient's nutritional intake to become a basis for a power struggle. Bladder Management: Indwelling urinary catheter initially -Strict aseptic technique -↑Fluid intake Intermittent catheterization program -Every 3-4 hours -Monitor for s/s of urinary tract infections Immediately after the injury, urine is retained because of the loss of autonomic and reflex control of the bladder and sphincter. Because there is no sensation of fullness, overdistention of the bladder can result in reflux into the kidney with eventual renal failure. Bladder overdistention may even result in rupture of the bladder. Consequently, an indwelling catheter is usually inserted as soon as possible after injury. Ensure the patency of the catheter by frequent inspection and irrigation if necessary. In some institutions a physician's order is required for this procedure. Strict aseptic technique for catheter care is essential to avoid introducing infection. During the period of indwelling catheterization, a large fluid intake is required. Check the catheter to prevent kinking and ensure free flow of urine. UTIs are a common problem. The best method for preventing UTIs is regular and complete bladder drainage. After the patient is stabilized, assess the best means of managing long-term urinary function. Usually the patient is started on an intermittent catheterization program. Intermittent catheterization should be done every 3 to 4 hours to prevent bacterial overgrowth resulting from urinary stasis. If the appearance or odor of the urine is suspicious or if the patient develops symptoms of a UTI (e.g., chills, fever, malaise), a specimen is sent for culture. Bowel Management Bowel program started during acute care -Daily rectal stimulant -Digital stimulation or manual evacuation -Upright position when able Constipation is generally a problem during spinal shock because no voluntary or involuntary (reflex) evacuation of the bowels occurs. A bowel program should be started during acute care. This consists of choosing a rectal stimulant (suppository or small-volume enema) to be inserted daily at a regular time of day followed by gentle digital stimulation or manual evacuation until evacuation is complete. Initially the program may be done in bed in the side-lying position, but as soon as the patient has resumed sitting, it should be done in the upright position on a padded bedside commode chair. Temperature Control -No vasoconstriction, piloerection, or heat loss through perspiration below level of injury -Temperature control external -Monitor environment and body temperature. -Do not overload or unduly expose patient. Because there is no vasoconstriction, piloerection, or heat loss through perspiration below the level of injury, temperature control is largely external to the patient. Monitor the environment closely to maintain an appropriate temperature. Also regularly monitor body temperature. Do not overload patients with covers or unduly expose them (such as during bathing). If an infection with high fever develops, more extensive means of temperature control, such as a cooling blanket, may be necessary. Stress Ulcers: -increased Risk secondary to severe trauma and physiologic stress -Monitor stool, gastric contents, and hematocrit. -Prophylactic medications Stress ulcers are a problem for the patient with an SCI because of the physiologic response to severe trauma and psychologic stress. Peak incidence of stress ulcers is 6 to 14 days after injury. Test stool and gastric contents daily for blood and monitor the hematocrit for a slow drop. Histamine (H2)-receptor blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]) or proton pump inhibitors (e.g., pantoprazole [Protonix], omeprazole [Prilosec]) may be given prophylactically to decrease the secretion of HCl acid and prevent the occurrence of ulcers during the initial phase. Sensory Deprivation: Secondary to absent sensations -Stimulate patient above level of injury. -Conversation, music, strong aromas, and interesting flavors -Prism glasses to read and watch TV -Prevent patient from withdrawing. You need to compensate for the patient's absent sensations to prevent sensory deprivation. Do this by stimulating the patient above the level of injury. Conversation, music, and interesting foods can be a part of the nursing care plan. Provide prism glasses so that the patient can read and watch television. Make every effort to prevent the patient from withdrawing from the environment. Patients with SCI often report altered sensorium and vivid dreams during the acute phase of their treatment. Whether this is due to drugs used to manage pain and anxiety is not known. Patients may also experience disrupted sleep patterns as a result of the hospital environment or post-traumatic stress disorder Reflexes Return may complicate rehab. -Hyperactive -Exaggerated responses -Penile erections -Spasms Patient teaching Antispasmodic drugs Once spinal cord shock is resolved, the return of reflexes may complicate rehabilitation. Lacking control from the higher brain centers, reflexes are often hyperactive and produce exaggerated responses. Penile erections can occur from a variety of stimuli, causing embarrassment and discomfort. Spasms ranging from mild twitches to convulsive movements below the level of the injury may also occur. This reflex activity may be interpreted by the patient or caregiver as a return of function. Tactfully explain the reason for the activity. Inform the patient of the positive use of these reflexes in sexual, bowel, and bladder retraining. Spasms may be controlled with the use of antispasmodic drugs such as baclofen (Lioresal), dantrolene (Dantrium), and tizanidine (Zanaflex). Botulism toxin injections may also be given to treat severe spasticity. Rehabilitation and Home Care -Complex -Goal to function at highest level of wellness -Retraining focus -Interdisciplinary endeavor Rehabilitation of the person with an SCI is complex. With physical and psychologic care and intensive and specialized rehabilitation, the patient with an SCI can learn to function at the highest level of wellness. It is recommended that all patients with a new SCI receive comprehensive inpatient rehabilitation in a rehabilitation unit or center that specializes in spinal cord rehabilitation. Many of the problems identified in the acute period become chronic and continue throughout life. Rehabilitation focuses on retraining of physiologic processes and extensive patient, caregiver, and family teaching about how to manage the physiologic and life changes resulting from the injury Rehabilitation is an interdisciplinary endeavor carried out through a team approach. Team members include rehabilitation nurses, physicians, physical therapists, occupational therapists, speech therapists, vocational counselors, psychologists, therapeutic recreation specialists, prosthetists, orthotists, and dietitians. Organized around individual patient's goals and needs Patient expected -To be involved in therapies -To learn self-care Can be very stressful Frequent encouragement Rehabilitation care is organized around the individual patient's goals and needs. During rehabilitation, patients are expected to be involved in therapies and learn self-care for several hours each day. Such intensive work at a time when the patient is dealing with the sudden change in health and functional status can be very stressful. Progress may be slow. The rehabilitation nurse has a pivotal role in providing encouragement, specialized nursing care, and patient and caregiver teaching, and helping to coordinate the efforts of the rehabilitation team. Respiratory Rehabilitation -Phrenic nerve stimulator -Diaphragmatic pacemaker -Mobile ventilators -Patient teaching --Home ventilator care --Assisted coughing -Incentive spirometry -Deep breathing exercises The patient with high cervical spinal cord injury may have greatly increased mobility with phrenic nerve stimulators or electronic diaphragmatic pacemakers. These devices are not appropriate for all ventilator-dependent patients but may be helpful for those with an intact phrenic nerve. Ventilators are also reasonably portable, and ventilator-dependent tetraplegic patients can be mobile and somewhat independent. Patients and caregivers should be taught all aspects of home ventilator care, and referrals should be made to appropriate community agencies. Teach patients with cervical-level injuries who are not ventilator-dependent assisted coughing, regular use of incentive spirometry, or deep breathing exercises. Neurogenic Bladder: -Areflexic (flaccid), hyperreflexic (spastic), or dyssynergia Common problems -Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys A neurogenic bladder is any type of bladder dysfunction related to abnormal or absent bladder innervation. After spinal cord shock resolves, depending on the completeness of the spinal cord injury, patients usually have some degree of neurogenic bladder. Normal voiding requires nervous system coordination of urethral and pelvic floor relaxation with simultaneous contraction of the detrusor muscle. Depending on the injury, a neurogenic bladder may have no reflex detrusor contractions (areflexic, flaccid), may have hyperactive reflex detrusor contractions (hyperreflexic, spastic), or may have lack of coordination between detrusor contraction and urethral relaxation (dyssynergia). Common problems with a neurogenic bladder include urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into the kidneys. Drug therapy -Anticholinergic drugs -alpha-Adrenergic blockers -Antispasmodic drugs Drainage methods -Bladder reflex training -Indwelling, intermittent, external catheterization -Urinary diversion surgery Patient teaching Many factors are considered when selecting a bladder management strategy. These include the preference of the patient, upper extremity function, availability of a caregiver, and lifestyle choices. The type of bladder dysfunction also determines management options. Various drugs can be used to treat neurogenic bladders. Anticholinergic drugs (oxybutynin [Ditropan], tolterodine [Detrol]) may be used to suppress bladder contraction. α-Adrenergic blockers (e.g., terazosin [Hytrin], doxazosin [Cardura]) may be used to relax the urethral sphincter, and antispasmodic drugs (e.g., baclofen [Lioresal]) may be used to decrease spasticity of pelvic floor muscles. Numerous drainage methods are possible, including bladder reflex retraining if partial voiding control remains, indwelling catheter, intermittent catheterization, and external catheter (condom catheter). Evaluate the long-term use of an indwelling catheter because of the associated high incidence of UTI, fistula formation, and diverticula. However, there may be patients for whom this is the best option. Patients with indwelling catheters need to have an adequate fluid intake (at least 3-4 L/day). Regularly check the patency of the indwelling catheter. The frequency of routine catheter changes ranges widely depending on the type of catheter used and agency policy. Intermittent catheterization is the most commonly recommended method of bladder management. Nursing assessment is important in selecting the time interval between catheterizations. Initially, catheterization is done every 4 hours. Bladder volume can be assessed before catheterization using the portable bladder ultrasound machine. If less than 200 mL of urine is measured, the time interval may be extended. If greater than 500 mL of urine is measured, the time interval is shortened. The number of intermittent catheterizations per day is usually five or six. Urinary diversion surgery may be necessary if the patient has repeated UTIs with renal involvement or repeated stones or if therapeutic interventions have been unsuccessful. Surgical treatment of neurogenic bladder includes bladder neck revision (sphincterotomy), bladder augmentation (augmentation cystoplasty), penile prosthesis, artificial sphincter, perineal ureterostomy, cystotomy, vesicotomy, and anterior urethral transplantation. (Urinary diversion procedures are discussed in Chapter 46.) No matter which bladder management strategy is selected, teach the patient, caregiver, and family how to accomplish successful self-management. Inform them about management techniques, how to obtain necessary supplies, care of supplies and equipment, and when to seek health care. Arrange for resources and referrals for supplies and ongoing care. Neurogenic Bowel: -Voluntary control may be lost. -High-fiber diet -Adequate fluid intake -Suppositories -Small-volume enemas -Digital stimulation -Mandatory for upper motor neuron injury -Stool softener -Oral stimulant laxatives -Valsalva maneuver with manual stimulation --For lower motor neuron injuries -Use of gastrocolic reflex Careful management of bowel evacuation is necessary in the patient with an SCI because voluntary control of this function may be lost. This condition is called neurogenic bowel. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. In addition, suppositories (bisacodyl [Dulcolax] or glycerin) or small-volume enemas and digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In the patient with an upper motor neuron injury, digital stimulation is necessary to relax the external sphincter to promote defecation. A stool softener such as docusate sodium (Colace) can be used to regulate stool consistency. Oral stimulant laxatives should be used only if absolutely necessary for a day or two and not on a regular basis. Valsalva maneuver and manual stimulation are useful in patients with lower motor neuron injuries. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. Timing of defecation may also be an important factor. If bowel evacuation is planned for 30 to 60 minutes following the first meal of the day, this may enhance success by taking advantage of the gastrocolic reflex induced by eating. This reflex may also be stimulated by drinking a warm beverage immediately following the meal. In general, a bowel movement every other day is considered adequate. However, preinjury patterns should be considered. Fecal incontinence can result from too much stool softener or a fecal impaction. Carefully record bowel movements Remember that patient, caregiver, and family teaching is required to promote successful independent bowel management. Neurogenic Skin -Prevention essential -Patient teaching -Comprehensive daily exam -Carefully reposition every 2 hours. -Pressure-relieving cushion or mattress -Adequate nutrition -Avoid thermal injury. Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with SCI. Nurses in rehabilitation are responsible for teaching these skills and providing information about daily skin care. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Initially carefully position and reposition every 2 hours, with gradual increases in the times between turns if there is no redness over bony prominences at the time of turning. Pressure-relieving cushions must be used in wheelchairs, and special mattresses may also be needed. Movement during turns and transfers should be done carefully to avoid stretching and folding of soft tissues (shear), as well as friction or abrasion. Assess nutritional status regularly. Both body weight loss and weight gain can contribute to skin breakdown. Adequate intake of protein is essential for skin health. Measurement of prealbumin, total protein, and albumin can help identify inadequate protein intake. Stress the importance of nutrition to skin health to the patient and caregiver. Protection of the skin also requires avoidance of thermal injury. Burns can be caused by hot food or liquids, bath or shower water that is too warm, radiators, heating pads, and uninsulated plumbing. Thermal injury also can result from extreme cold (frostbite). Injuries may not be noticed until severe damage is done. Anticipatory guidance about potential risks is essential. Sexuality Important issue regardless of patient's age or gender Nurse must -Have an awareness and an acceptance of personal sexuality. -Have knowledge of human sexual responses. -Use medical terminology. To provide accurate and sensitive counseling and teaching about sexuality, you need to be aware of your own sexuality, as well as understand human sexual responses. When discussing sexual potential, use scientific terminology rather than slang whenever possible. Injury level and completeness of injury impacts function. Psychogenic versus reflex erection Treatments for erectile dysfunction -Drugs -Vacuum devices -Surgical procedures Fertility issues Knowledge of the level and completeness of injury is needed to understand the male patient's potential for orgasm, erection, and fertility and the patient's capacity for sexual satisfaction. Men normally have two types of erections: psychogenic and reflex. The process of psychogenic erections begins in the brain with sexual thoughts. Signals from the brain are then sent through the nerves of the spinal cord down to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. A reflex erection occurs with direct physical contact to the penis or other erotic areas. A reflex erection is involuntary and can occur without sexually stimulating thoughts. These reflex erections are often short-lived and uncontrolled and cannot be maintained or summoned at the time of coitus. The nerves that control a man's ability to have a reflex erection are located in the sacral nerves (S2-S4) of the spinal cord. For men with SCI, the ability to have a psychogenic erection depends on the level and extent of injury. Generally, men with low-level incomplete injuries are more likely to have psychogenic erections than men with higher-level incomplete injuries. Men with complete injuries are less likely to experience psychogenic erections. However, most men with SCI are able to have a reflex erection with physical stimulation regardless of the extent of the injury if the S2-S4 nerve pathways are not damaged. Because each SCI is different, the impact of injury on sexual function can also differ. Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures. Sildenafil (Viagra) has become the treatment of choice in men with SCI. Penile injection of vasoactive substances (papaverine, prostaglandin E) is another medical treatment. Risks include priapism (prolonged penile erection) and scarring, so these substances are often considered only after failure of sildenafil. Vacuum suction devices use negative pressure to encourage blood flow into the penis. Erection is maintained by a constriction band placed at the base of the penis. The main surgical option is implantation of a penile prosthesis. Male fertility is affected by SCI causing poor sperm quality and ejaculatory dysfunction. Recent advances in methods of retrieving sperm (penile vibratory stimulation and electroejaculation) combined with ovulation induction and intrauterine insemination of the female partner have changed the prognosis for men with SCI to father children from unlikely to a reasonable possibility of successful outcomes. Female sexual issues -Lubrication -Orgasm in about 50% of women Fertility not usually affected -Pregnancy complicated -Risk for precipitous delivery The effect of SCI on female sexual response is less clear. Lubrication is similar to erections in males, with reflex and psychogenic components. Women with upper motor neuron injuries may retain the capacity for reflex lubrication, whereas psychogenic lubrication depends on the completeness of injury. Orgasm is reported by about 50% of women with SCI. The woman of childbearing age with an SCI usually remains fertile. The injury does not affect the ability to become pregnant or to deliver normally through the birth canal. Menses may cease for as long as 6 months after injury. If sexual activity is resumed, protection against an unplanned pregnancy is necessary. A normal pregnancy may be complicated by UTIs, anemia, and autonomic dysreflexia. Because uterine contractions are not felt, a precipitous delivery is always a danger. Open discussion Alternative methods Urinary catheterization Planning for bowel evacuation prior Water-soluble lubricant Open discussion with the patient regarding sexual rehabilitation is essential. This important aspect of rehabilitation should be handled by someone specially trained in sexual counseling. A nurse or other rehabilitation professional with such expertise works with the patient and partner to provide support, with the emphasis on open communication. As a nurse, you should respect every couple's personal standards of religious and cultural beliefs. Alternative methods of obtaining sexual satisfaction, such as oral-genital sex (cunnilingus and fellatio), may be suggested. Explicit films may also be used, such as a film demonstrating the sexual activities of a patient with paraplegia and a nondisabled partner. Graphics should be used cautiously because they may be too limiting or focus too much on the mechanics of sex rather than on the relationship. Care should be taken not to dislodge an indwelling catheter during sexual activity. If an external catheter is used, it should be removed before sexual activity and the patient should refrain from fluids. The bowel program should include evacuation the morning of sexual activity. The partner should be informed that incontinence is always possible. The woman may need a water-soluble lubricant to supplement diminished vaginal secretions and facilitate vaginal penetration. The injury does not affect the ability to become pregnant or to deliver normally through the birth canal. Menses may cease for as long as 6 months after injury. If sexual activity is resumed, protection against an unplanned pregnancy is necessary. A normal pregnancy may be complicated by UTIs, anemia, and autonomic dysreflexia. Because uterine contractions are not felt, a precipitous delivery is always a danger. Grief and Depression: -Overwhelming sense of loss -Loss of control -Adjustment more than acceptance -Wide fluctuation in emotions -Allow mourning while encouraging hope. -Caregiver and family counseling -Support group -Sympathy not helpful -Encourage patient participation. -Consistency of care -Psychiatric consult if needed Patients with SCIs may feel an overwhelming sense of loss. They may temporarily lose control over everyday life activities and must depend on others for ADLs and for life-sustaining measures. Patients may believe that they are useless and burdens to their families. At a stage when independence is often of great importance, they may be totally dependent on others. With recent advances in rehabilitation, it is usual for the patient to be independent physically and discharged from the rehabilitation center before completion of the grief process. The goal of recovery is related more to adjustment than to acceptance. Adjustment implies the ability to go on with living with certain limitations. Although the patient who is cooperative and accepting is easier to treat, expect a wide fluctuation of emotions from a patient with an SCI. Your role in grief work is to allow mourning as a component of the rehabilitation process. Maintaining hope is an important strategy during the grieving process and should not be interpreted as denial. During the shock and denial stage, reassure the patient. During the anger stage, assist the patient in achievement of control over the environment, particularly by allowing the patient's input into the plan of care. Do not respond to anger or manipulation or become involved in a power struggle with the patient. As self-care abilities increase, the patient's independence increases The patient's caregiver and family also require counseling to avoid promoting dependency in the patient through guilt or misplaced sympathy. The family is also experiencing an intense grieving process. A support group of family members and friends of patients with SCI can help increase family members' knowledge of and participation in the grieving process, the physical difficulties, the rehabilitation plan, and the meaning of the disability in society. During the stage of depression, be patient. Sympathy is not helpful. Treat the patient as an adult and encourage participation in care planning. A primary nurse relationship is helpful. Staff planning and sessions in which staff members can express their feelings are helpful in providing consistency of care. To achieve the stage of adjustment, the patient needs continual support throughout the rehabilitation process in the forms of acceptance, affection, and caring. Be attentive when the patient needs to talk and sensitive to needs at the various stages of the grief process. Although the stage of depression during the grief process usually lasts days to weeks, there are some individuals who may become clinically depressed and require treatment for depression. Evaluation by a psychiatric nurse or psychiatrist is recommended. Treatment may include drugs and therapy. Expected outcomes are that the patient with an SCI will -Maintain adequate ventilation and have no signs of respiratory distress. -Maintain intact skin over bony prominences. -Establish a bowel management program based on neurologic function and personal preference. -Establish a bladder management program based on neurologic function, caregiver status, and lifestyle choices. -Experiences no episodes of autonomic dysreflexia. -Establishes a bowel management program based on neurologic function and personal preference. -Maintains a bowel movement every other day. -Establishes a bladder management program based on neurologic function, caregiver status, and lifestyle choices. -Develops no complications of immobility. -Experiences no episodes of dysreflexia. Gerontologic Considerations -Increased incidence -Increased complications -Health promotion and screening -Rehabilitation lengthened Because of increased work and recreational activities of older adults, more older adults are experiencing SCI. Falls are the leading cause of SCI for people 65 and older. Besides having greater mortality rates, older adults with traumatic injuries experience more complications than younger ones, and they are hospitalized longer. The demographics of patients living with SCI are changing. The fact that persons with SCI now have longer life spans has contributed to the increasing number of older adults living with an SCI. Aging is also associated with an increased occurrence of other chronic illnesses in the person with an SCI. This can have a serious impact on these older adults. As patients with SCI age, both individual aging changes, and length of time since injury can affect functional ability. For example, bowel and bladder dysfunction can increase with the duration and severity of SCI. Health promotion and screening are important for the older patient with an SCI. Daily skin inspections, UTI prevention measures, and monthly breast examinations for women and regular prostate cancer screening for men are recommended. Cardiovascular disease is the most common cause of morbidity and mortality among older adults with an SCI. The lack of sensation, including chest pain, in those with high-level injuries may mask acute myocardial ischemia. Altered autonomic nervous system function and decreases in physical activity can place the patient at risk for cardiovascular problems, including hypertension. Health promotion to decrease the risk of injuries includes fall prevention strategies (e.g., using a stepstool or a grab bar to reach high shelves, handrails on stairs). Rehabilitation for the older person who has had an SCI may take longer because of other preexisting conditions and poorer health status at the time of the initial injury. An interdisciplinary team approach to rehabilitation is essential in preventing secondary complications associated with SCI, especially in older adults.

External Radiation

The most common form of radiation treatment delivery. With this technique, the patient is exposed to radiation from a megavoltage treatment machine. Instruct to urinate immediately before treatment to minimize radiation exposure to the bladder Advise about radiation side effects including enteritis and cystitis (natural side effects) Teach: -Use mild, unscented soap or nondrying antipruitic soap if dryness & itchiness persist -Pat the area dry, avoid rubbing -Avoid applying deodorant to affected area -Avoid tight tops or underwire bra -Avoid extremes in temperature -Protect area from ultraviolet light for at least 1 year post therapy -Report worsening pain/discomfort to HCP

Vasectomy

bilateral surgical ligation or resection of the ductus deferens performed for the purpose of sterilization The procedure requires only 15 to 30 minutes and is usually performed with the patient under local anesthesia on an outpatient basis. Although vasectomy is considered a permanent form of sterilization, successful reversals (vasovasotomy) have been done. After vasectomy, the patient should not notice any difference in the look or feel of the ejaculate because its major component is seminal and prostatic fluid. The patient needs to use an alternative form of contraception until semen examination reveals no sperm. This usually requires at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site. Sperm cells continue to be produced by the testes but are absorbed by the body rather than being passed through the ductus deferens. Occasionally postoperative hematoma and swelling of the scrotum occur. Vasectomy does not affect the production of hormones, ability to ejaculate, or physiologic mechanisms related to erection or orgasm. Psychologic adjustment may be a problem after surgery. It may be difficult for the patient to separate vasectomy from castration at a subconscious level. Some men may develop ED or may feel the need to become more sexually active than they were in the past to prove their masculinity. Careful discussion of the procedure and its outcome before the surgery can help detect patients who may have problems with psychologic adjustment. Surgery should be delayed for these patients. Consider any ethical dilemmas regarding spousal consent Teaching regarding other forms of birth control for at least 6 weeks or 10 ejaculations Post op teaching: -May use ice packs to decrease swelling -Decrease activity/ feet and scrotum elevated in recliner for 48 hours -Keep incision clean and dry

Cryptorchidism

failure of the testes to descend into the scrotal sac before birth. It is the most common congenital testicular condition. It may occur bilaterally or unilaterally and may be the cause of infertility if corrective surgery is not done by 2 years of age. The incidence of testicular cancer is also higher if the condition is not corrected before puberty. Surgery is performed to locate and suture the testis or testes to the scrotum. Visual and palpate for testes Provide pre and post op care if necessary

Sexual Dysfunction (female)

Assess for Clinical Manifestations -Desire to have sex is low or absent. -Inability maintain arousal during sexual activity, or don't become aroused despite a desire to have sex. -Inability to experience an orgasm. -pain during sexual contact. Nursing Management -Encourage psychological counseling is necessary -Provide active listening and therapeutic communication -Assess for s/s of underlying medical conditions -Monitor Hormonal treatment carefully --Estrogen therapy --Androgen therapy

C

Interferon β-1b (Betaseron) has been prescribed for a patient who has been diagnosed with relapsing-remitting multiple sclerosis. Which statement, if made by the patient, indicates that additional teaching is needed? A. "I must rotate injection sites with each dose." B. "I should report depression or suicidal thoughts." C. "I will reduce my sodium intake to prevent edema." D. "It is important to avoid direct sunlight and use sunscreen."

Pelvic Exenteration

When other forms of therapy fail to control the spread of cancer and no metastases have been found outside of the pelvis, this may be performed. This radical surgery usually involves removal of the uterus, ovaries, fallopian tubes, vagina, bladder, urethra, and pelvic lymph nodes. In some situations, the descending colon, rectum, and anal canal may also be removed. Candidates for this procedure are selected on the basis of their likelihood of surviving the surgery and their ability to adjust to and accept the resulting limitations. Performed only when other forms of therapy fail and when metastasis has not been found outside of the pelvis Preop care and teaching (many psychological implications) Postop care -Similar to care of a TAH, perineal resection, ileostomy or colostomy -Inclusion of the family is important -Sexual counseling is usually needed -Teach followups to look for early return of cancer -Avoid strenuous activity for 6 months

A

You are called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, what do you think you should do first? A. Turn the patient to the side. B. Start oxygen by mask at 6 L/min. C. Restrain the patient's arms and legs to prevent injury. D. Record the time sequence of the patient's movements and responses as they occur.

Orchitis

acute inflammation of the testis. the testis is painful, tender, and swollen. It generally occurs after an episode of bacterial or viral infection such as mumps, pneumonia, tuberculosis, or syphilis. It can also be a side effect of epididymitis, prostatectomy, trauma, infectious mononucleosis, influenza, catheterization, or complicated UTI. Mumps orchitis is a condition contributing to infertility that could be avoided by childhood vaccination against mumps. Treatment involves the use of antibiotics (if the organism is known), pain medications, or bed rest with the scrotum elevated on an ice pack. Assess for history of mumps; or epidiymitis Assess for Symptoms: pain, swelling of testicle / scrotal sac Teach no lifting, straining, no sexual activity, encourage STD testing, Bed rest; elevation of the scrotum

Epididymitis

acute, painful inflammatory process of the epididymis which is often due to an infectious process, trauma, or urinary reflux down the ductus (vas) deferens. It is usually unilateral. Swelling may progress to the point that the epididymis and testis are indistinguishable. In men younger than 40 years of age, the most common cause is gonorrhea or chlamydial infection. UTI and prostatitis are common causes in older men. The use of antibiotics is important for both partners if the transmission is through sexual contact. Encourage patients to refrain from sexual intercourse during the acute phase. If they do engage in intercourse, a condom should be used. Conservative treatment consists of bed rest with elevation of the scrotum, ice packs, and analgesics. Ambulation places the scrotum in a dependent position and increases pain. Most tenderness subsides within 1 week, although swelling may last for weeks or months. Assess for history of STD's; trauma; prostatitis, or UTI's Assess for Symptoms: pain along spermatic cord & inguinal canal; fever, chills, UTI Teach no lifting, straining, no sexual activity, encourage STD testing, Bed rest; elevation of the scrotum

Pelvic Inflammatory disease (PID)

an infectious condition of the pelvic cavity that may involve the fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (peritonitis). PID is referred to as "silent" when women do not perceive any symptoms. Other women with PID are in acute distress. PID may also be a cause of chronic pelvic pain often the result of untreated cervicitis. The organism infecting the cervix ascends higher into the uterus, fallopian tubes, ovaries, and peritoneal cavity. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causative organisms of PID. Women at increased risk for chlamydial infections (those younger than 24 years of age, who have multiple sex partners, or who have a new sex partner) should be routinely tested for chlamydia. Chlamydial infections can be asymptomatic and unknowingly transmitted during intercourse. Silent PID is a major cause of female infertility. Women with PID usually go to a health care provider because they are experiencing lower abdominal pain. The pain typically starts gradually and then becomes constant. The intensity may vary from mild to severe. Movement such as walking can increase the pain. The pain is also frequently associated with intercourse. Spotting after intercourse and purulent cervical or vaginal discharge may also be noted. Fever and chills may be present. Women with less acute symptoms often notice increased cramping pain with menses, irregular bleeding, and some pain with intercourse. Women who have mild symptoms may go untreated either because they did not seek care or the health care provider misdiagnosed their complaints. Nursing Assessment Assess for history of use of IUD, previous PID, gonorrhea or chlamydial infection, multiple sexual partners, exposure to partner with urethritis, infertililty -Use of and allergy to antibiotics -Surgery or other treatments (recent abortion or pelvic surgery Assess for Clinical Manifestations -Range from asymptomatic (Silent PID) to severe, chronic pain -Gradual to frequent, mild to severe which increases with movement and intercourse -Spotting after intercourse and purulent cervical or vaginal discharge -Fever and chills -Lower abdominal tenderness below the umbilicus and between the hips Assess for s/s of Complications -Septic shock (tachycardia, fever, hypotension) -Fitz-Hugh- Curtis Syndrome (spreads to the liver) --Jaundice, liver enzymes -Rupture of the ovarian tubes resulting in peritonitis --Fever, drainage -Embolisms from thrombophlebitis of the pelvic veins --Dyspnea, tachycardia, decreased 02 sats, chest pain, stroke -Adhesions and strictures in the fallopian tubes -Ectopic pregnancy from obstruction -Infertility Sitz Bath Teach no intercourse for 3 weeks & examine and treat sexual partner(s) Teach physical rest (semi-fowlers to promote pelvic drainage) and oral fluids Encourage Heat applications, sitz baths If above ineffective pre and post op teaching and care for surgical treatment -Laparoscopy or laparotomy to drain abscess -Hysterectomy for severe cases Immediate complications of PID include septic shock and Fitz-Hugh-Curtis syndrome, which occurs when PID spreads to the liver and causes acute perihepatitis. The patient has symptoms of right upper quadrant pain, but liver function tests are normal. Tubo-ovarian abscesses may "leak" or rupture, resulting in pelvic or generalized peritonitis. As the general circulation is flooded with bacterial endotoxins from the infected areas, septic shock may result. Embolisms may occur as the result of thrombophlebitis of the pelvic veins. PID can cause adhesions and strictures in the fallopian tubes. Ectopic pregnancy may result when a tube is partially obstructed because the sperm can pass through the stricture, but the fertilized ovum cannot reach the uterus. After one episode of PID, the risk of having an ectopic pregnancy increases 10-fold. Further damage can obstruct the fallopian tubes and cause infertility.

Parkinson's Disease

chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor at rest, and gait disturbance. It is the most common form of parkinsonism (a syndrome characterized by similar symptoms). Health History -CNS trauma -Cerebrovascular disorders -Exposure to metals and CO2 -Encephalitis -Fatigue -Excessive salivation -Dysphagia -Weight loss -Constipation -Incontinence -Difficulty initiating movements, falls -Loss of dexterity -Diffuse pain in head, shoulders, neck, back, legs, and hips -Insomnia -Depression -Mood swings Medications -Tranquilizers -Reserpine -Methyldopa -Amphetamines Objective Data -Blank faces, infrequent blinking -Seborrhea -Dandruff -Ankle edema -Postural hypotension -Tremor at rest -"Pill rolling" -Poor coordination -Subtle dementia -Cogwheel rigidity -Dysarthria -Bradykinesia -Contractures -Stooped posture -Shuffling gait Nursing Diagnoses: -Impaired physical mobility -Imbalanced nutrition: less than body requirements -Impaired swallowing -Impaired verbal communication Planning: -Maximize neurologic function. -Maintain independence in activities of daily living (ADLs) for as long as possible. -Optimize psychosocial well-being. PD is a chronic degenerative disorder with no acute exacerbations. Focus teaching and nursing care -Maintenance of good health -Encouragement of independence -Avoidance of complications such as contractures and falls Promote physical exercise and a well-balanced diet. -Limit the consequences from decreased mobility. -Specific exercises to strengthen muscles involved with speaking and swallowing The American Parkinson Disease Association (see Resources at the end of this chapter) publishes a series of booklets and videotapes that are helpful in terms of exercise that can be used by family members and health care professionals. A physical therapist may be consulted to design a personal exercise program aimed at strengthening and stretching specific muscles. Problems secondary to bradykinesia can be alleviated by -Consciously thinking about stepping over a line on the floor -Lifting toes when stepping -One step back and . . . -Two steps forward Get out of a chair by using arms and placing the back legs on small blocks. Remove rugs and excess furniture. Simplify clothing from buttons and hooks. Use elevated toilet seats. Use an ottoman to elevate legs. An ottoman can help avoid dependent ankle edema. Clothing can be simplified by the use of slip-on shoes and Velcro hook-and-loop fasteners or zippers on clothing, instead of buttons and hooks. Assist patients as they make adjustments to their lifestyle to accommodate symptoms. Caregivers may also experience stress associated with disease progression (i.e., dementia). Effective management of sleep problems can greatly improve the quality of life for patients with PD. Some PD patients find the use of satin nightwear and/or satin sheets beneficial. In the early stage of the disease, there are also subtle changes in cognitive function that can progress to dementia. This results in increased caregiver burden, an increase in caregiver health problems, and the potential for long-term care placement. Evaluation Expected Outcomes -Perform physical exercise to deter muscle atrophy and joint contractures. -Use assistive devices appropriately for ambulation and mobility. -Maintain nutritional intake adequate for metabolic needs. -Experience safe passage of fluids and/or solids from the mouth to the stomach. -Use methods of communication that meet needs for interaction with others. As the disease progresses, complications increase. These include motor symptoms (e.g., dyskinesias [spontaneous, involuntary movements], weakness, akinesia [total immobility]), neurologic problems (e.g., dementia), and neuropsychiatric problems (e.g., depression, hallucinations, psychosis). As PD progresses, it often results in a severe dementia, which is associated with an increase in mortality. As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result. General debilitation may lead to pneumonia, urinary tract infections, and skin breakdown. Orthostatic hypotension may occur in some patients and, along with loss of postural reflexes, may result in falls or other injury.

B

An appropriate nursing diagnosis for M.J. at this stage of advanced Parkinson's disease is A. risk for injury related to limited vision. B. risk for aspiration related to impaired swallowing. C. urge incontinence related to effects of drug therapy. D. ineffective breathing pattern related to diaphragm fatigue.

Cancer of the repro system

Health Promotion Teach importance of routine screenings Educate women about risk factors for cancers of the repro system -Teach limit of sexual activity in adolescence -Condom use -Fewer sexual partners -Not smoking -Avoid high fat diet -Lifestyle modification

D

Several years later you see M.J. at your outpatient clinic with a cough and fever. It is obvious that his Parkinson's disease has advanced. During your assessment of him, you would expect to find A. slurred speech, visual disturbances, and ataxia. B. muscle atrophy, spasticity, and speech difficulties. C. muscle weakness, double vision, and reports of fatigue. D. drooling, stooped posture, tremors, and a propulsive gait.

infertility (female)

Teach rigid adherence to an intercourse schedule can cause psychological stress and inhibit sexual relationships Provide emotional support Teach how to use temperature log -Graph basal body temperature on awakening before any activity -Use same site (oral, rectal) each time -Note any variation such as illness -Note when temperature decreases as ovulation approaches for timing of intercourse

Priapism

Assess for -A painful erect penis which does not return to it's flaccid state within 6 hours despite no physical or psychological stimulation -Assess for a history of thrombosis of the corpora cavernosal venis, leukemia, sickle cell anemia, diabetes mellitus, degenerative lesions of the spine, neoplasms of the CNS, vasoactive medications injected into the corpora cavernosa and other meds (sildenafil, cocaine, trazodone). Nursing Management -Teaching regarding the necessity to seek medical attention to prevent complications -Administer Sedatives -Assist with Injection of smooth muscle relaxants directly into the penis -Assist with aspiration and irrigation of the corpora cavernosa with a large bore needle -Pre and post op teaching if Surgical creation of a drain of the corpora is needed

Cervicitis/Vaginitis

Assess for Clinical Manifestations - abnormal vaginal discharge, reddened vulvar lesions, thick white curdlike discharge -Itching and dysuria are common with vulvovaginal candidiasis (yeast infections) -Fishy odor is the hallmark sign of bacterial vaginosis Important to teach not to scratch the itching to prevent secondary damage to the skin Candidiasis (Candida or yeast infection)

Multiple Sclerosis

chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and spinal cord. The onset of MS is usually between 20 and 50 years of age, although it can occur in young teens and much older adults. Women are affected two to three times more often than men. more prevalent in temperate climates (between 45 and 65 degrees of latitude), such as those found in the northern United States, Canada, and Europe, as compared with tropical regions. Common manifestations of MS include motor, sensory, cerebellar, and emotional problems. Motor symptoms include weakness or paralysis of the limbs, the trunk, or the head; diplopia; scanning speech; and spasticity of the muscles that are chronically affected. Patients with MS experience a variety of sensory abnormalities, including numbness and tingling and other paresthesias, patchy blindness (scotomas), blurred vision, vertigo, tinnitus, decreased hearing, and chronic neuropathic pain. Radicular (nerve root) pains may be present, particularly in the low thoracic and abdominal regions. Lhermitte's sign is a transient sensory symptom described as an electric shock radiating down the spine or into the limbs with flexion of the neck. Cerebellar signs include nystagmus, ataxia, dysarthria, and dysphagia. Many patients have severe fatigue, sometimes with significant disability. The fatigue is aggravated by heat, humidity, deconditioning, and medication side effects.16 Bowel and bladder function can be affected if the sclerotic plaque is located in areas of the CNS that control elimination. Problems with defecation usually involve constipation rather than fecal incontinence. Urinary problems are variable. A common problem in MS patients is a spastic (uninhibited) bladder. As a result, the bladder has a small capacity for urine, and its contractions are unchecked. This is accompanied by urinary urgency and frequency and results in dribbling or incontinence. A flaccid (hypotonic) bladder indicates a lesion in the reflex arc controlling bladder function. A flaccid bladder has a large capacity for urine because there is no sensation or desire to void, no pressure, and no pain. Generally, the patient has urinary retention, but urgency and frequency may also occur with this type of lesion. Another urinary problem is a combination of the previous two. Urinary problems cannot be adequately diagnosed and treated without urodynamic studies. Sexual dysfunction occurs in many persons with MS. Physiologic erectile dysfunction may result from spinal cord involvement in men. Women may experience decreased libido, difficulty with orgasmic response, painful intercourse, and decreased vaginal lubrication. Diminished sensation can prevent a normal sexual response in both sexes. The emotional effects of chronic illness and the loss of self-esteem also contribute to loss of sexual response. About half of people with MS experience some problems with cognitive function. For most, the problems are difficulties with short-term memory, attention, information processing, planning, visual perception, and word finding. General intellect remains unchanged and intact, including long-term memory, conversational skills, and reading comprehension. Persons with MS may also experience emotional changes such as anger, depression, or euphoria. Physical and emotional trauma, fatigue, and infection may aggravate or trigger signs and symptoms. The average life expectancy after the onset of symptoms is more than 25 years. Death usually occurs due to infectious complications (e.g., pneumonia) of immobility or because of an unrelated disease. Subjective Data Health history -Viral infections or vaccinations -Residence in cold or temperate climates -Physical and emotional stress -Medications -Elimination problems -Weight loss, dysphagia -Muscle weakness or fatigue, tingling or numbness, muscle spasms -Blurred or lost vision, diplopia, vertigo, tinnitus -Decreased libido, impotence -Anger, depression, euphoria, isolation Objective Data -Apathy, inattentiveness -Pressure ulcers -Scanning speech -Tremor -Nystagmus -Ataxia -Spasticity -Hyperreflexia -decreased hearing -Muscular weakness -Paresis -Paralysis -Foot dragging -Dysarthria Nursing Diagnoses: -Impaired physical mobility -Impaired urinary elimination -Ineffective self-health management Planning: -Maximize neuromuscular function. -Maintain independence in activities of daily living for as long as possible. -Manage disabling fatigue. -Optimize psychosocial well-being. -Adjust to the illness. -decreased factors that precipitate exacerbations Nursing Implementation: Help patient identify triggers and develop ways to avoid them or minimize their effects. Reassure patient during diagnostic phase. Assist patient in dealing with anxiety and grief caused by diagnosis. Exacerbations of MS are triggered by infection (especially upper respiratory and urinary tract infection), trauma, immunization, delivery after pregnancy, stress, and change in climate. Each person responds differently to these triggers. During the diagnostic phase the patient needs reassurance that, even though there is a tentative diagnosis of MS, certain diagnostic studies must be done to rule out other neurologic disorders. Assist the patient in dealing with the anxiety caused by a diagnosis of a disabling illness. The patient with recently diagnosed MS may need assistance with the grieving process. During acute exacerbation, prevent major complications of immobility. Focus teaching on building general resistance to illness. Avoiding fatigue, extremes of hot and cold, exposure to infection During an acute exacerbation, the patient may be immobile and confined to bed. The focus of nursing intervention at this phase is to prevent major complications of immobility, such as respiratory and urinary tract infections and pressure ulcers. This involves avoiding exposure to cold climates and to people who are sick, as well as vigorous and early treatment of infection when it does occur. Teach patient -Good balance of exercise and rest -Minimize caffeine intake -Nutritious, well-balanced meals -Increase roughage if constipated -Treatment regimen -Management of medications -Self-catheterization if necessary -Adequate intake of fiber to aid in regular bowel habits -Emotional adjustments -Lifestyle changes Patients should know their treatment regimens, drug side effects, how to watch for and manage side effects, and drug interactions with over-the-counter medications. The patient should consult a health care provider before taking nonprescription drugs. Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, you may need to teach others self-catheterization. Bowel problems, particularly constipation, occur frequently in patients with MS. Increasing the dietary fiber intake may help some patients achieve regularity in bowel habits. The patient with MS and the caregiver need to make many emotional adjustments because of the unpredictability of the disease, the need to change lifestyles, and the challenge of avoiding or decreasing precipitating factors. The National Multiple Sclerosis Society and its local chapters can offer a variety of services to meet the needs of patients with MS. β-Interferon (Avonex, Betaseron, Rebif) • Rotate injection sites with each dose. • Assess for depression, suicidal ideation. • Wear sunscreen and protective clothing while exposed to sun. • Know that flu-like symptoms are common after initiation of therapy. Surgical therapy •Thalamotomy (unmanageable tremor) •Neurectomy, rhizotomy, cordotomy (unmanageable spasticity) Evaluation Expected outcomes -Maintain or improve muscle strength and mobility. -Use assistive devices appropriately for ambulation and mobility. -Maintain urinary continence. -Make decisions about lifestyle modifications to manage MS.

Benign Prostatic Hyperplasia

Enlargement of the prostate (noncancerous) Most common disorder in aging males (75% or > age 50) Does not predispose to development of prostate cancer Nursing Assessment: Medications -Estrogen or testosterone supplementation Surgery or previous treatment for BPH Knowledge of condition Voluntary fluid restriction Nocturia Assess for Signs & Symptoms: *Urinary frequency / urgency / dysuria *Nocturia / incontinence *Decrease in force of urinary stream *Difficulty initiating urination *Dribbling at end of voiding *Incomplete emptying of the bladder *Prostate gland is enlarged & rubbery * Perform digital rectal exam (usually advanced practitioner) Nursing Management -Teaching regarding complications: Stones (calculi) in the bladder, Damage to bladder, Pyelonephritis, Renal failure, Incomplete bladder emptying, UTI and sepsis Nursing Diagnosis -Acute pain r/t bladder distention secondary to enlarged prostate -Risk for infection r/t an indwelling catheter, urinary stasis or environmental pathogens If surgical intervention (TURP, open prostatectomy) -Acute pain r/t bladder irritability, irrigations and distention and surgical trauma -Impaired urinary elimination r/t post op bladder irritaiton, inflammatory urinary obstruction and sensory motor impairment -Knowledge deficit r/t unfamiliarity with information resources, reluctance to ask about necessary procedures Nursing Management/ -Teaching During Watchful Waiting -Teach patient Void when urge felt -Teach No caffeine or ETOH -Avoid large amt. of fluids in short time; decrease fluid intake at bedtime -Teach Care of Foley or suprapubic catheter for pts who are not candidate for surgery -Teach Avoid decongestants & antihistamines Post Op care for the patient having prostate surgery: -Administer Normal post-op care -Provide interventions to reduce pain including nonpharmacologic (relaxation, guided imagery, distraction, breathing exercises) -Monitor for infection, urinary incontinence, hemorrhage, bladder spasms and urinary retention -Maintain Continuous Bladder Irrigation (CBI/ Murphy drip) --3 way indwelling catheter with 30-50ml balloon --Saline gravity drip for bladder irrigation. Irrigation stops clot formation. Titrated to keep urine light pink or colorless. D/C 24-48 hours after TURP. Urine will be pink tinged for 2-3 days post-op --Maintain patency of the tube because clots can obstruct urine flow resulting in painful bladder spasms - manually irrigate if needed Record I & O: Subtract irrigation fluid from total output. Discharge Teaching for the patient who has had prostate surgery -Teach to limit ingestion of bladder irritants (colas, coffee, tea, chocolate) -Limit fluids 2 to 3 hrs before bedtime to avoid nighttime urgency -Teach patient to drink 8 0z of liquid with meals, between meals and in early evening to produce nonirritating urine -Instruct patient to respond immediately to urge to void to prevent involuntary leakage -Assist to select appropriate incontinence garmet/pad for short-term management (usually "dribbling" with a TURP) -Discuss lifestyle changes to prevent future complications (avoid heavy lifting, straining during defecation, prolonged periods of travel, stair climbing, driving and sexual activity until surgeon approves) Focus: early detection and treatment -Yearly physical exam and DRE for men over 50 -Teach patients that alcohol, caffeine, and cold and cough meds can increase symptoms. Some men find that the ingestion of alcohol and caffeine tends to increase prostatic symptoms because the diuretic effect of these substances increases bladder distention. Compounds found in common cough and cold remedies such as pseudoephedrine (in Sudafed) and phenylephrine (in Allerest and Coricidin preparations) often worsen the symptoms of BPH. These drugs are α-adrenergic agonists that cause smooth muscle contraction.

Endometriosis

the presence of normal endometrial tissue in sites outside the endometrial cavity. The most frequent sites are in or near the ovaries, uterosacral ligaments, and uterovesical peritoneum The typical patient with endometriosis is in her late twenties or early thirties and has never had a full-term pregnancy. Although it is not a life-threatening condition, endometriosis can cause considerable pain. It is also a common cause of infertility and increases the risk of ovarian cancer. Endometriosis is one of the most common gynecologic problems, affecting more than 5.5 million women in North America. Assess for Clinical Manifestations which are wide in range -Secondary dysmenorrhea, Infertility -Pelvic pain, dyspareunia, and irregular bleeding -Backache, painful bowel movements, dysuria -"menstruating" endometrial tissue/blood collects in cystlike nodules which are bluish/black (chocolate cysts) which can rupture causing pain or adhesions Collaborative Care Provide communication with HCP during watch and wait for mild cases Provide pre and post op care for Surgical Therapy -Laparotomy to remove tissue implants and adhesions -TAH-BSO Drug Therapy • Nonsteroidal antiinflammatory drugs (NSAIDs) • Oral contraceptives • danazol (Danocrine) • GnRH agonists (e.g., leuprolide [Lupron])

Encephalitis

Acute inflammation of brain -Serious, sometimes fatal disease Caused by a number of viruses Some are endemic to specific geographic areas and seasons. -Ticks or mosquitoes can transmit epidemic encephalitis. -CMV encephalitis is common with AIDS. In the United States, encephalitis is responsible for about 20,000 cases and 1400 deaths annually. Ticks and mosquitoes transmit certain epidemic encephalitis, such as Eastern equine encephalitis, La Crosse encephalitis, St. Louis encephalitis, West Nile encephalitis, and Western equine encephalitis. Nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. HSV encephalitis is the most common cause of acute nonepidemic viral encephalitis. Nonspecific onset -Fever, headache, nausea, vomiting Signs appear in 2 to 3 days. -May vary from minimal alterations in mental status to coma -Any CNS abnormality can occur. Virtually any CNS abnormality can occur, including hemiparesis, tremors, seizures, cranial nerve palsies, personality changes, memory impairment, amnesia, and dysphasia. Early diagnosis and treatment are essential for favorable outcomes. -CT -MRI -PET -PCR tests for HSV DNA/RNA -Blood test for West Nile viral RNA West Nile virus should be strongly considered in adults >50 years old who develop encephalitis or meningitis in summer or early fall. The best diagnostic test for West Nile virus is a blood test that detects viral RNA. This test is also used in screening blood, organs, cells, and tissues that have been donated. Mosquito control for prevention *Nursing management is symptomatic and supportive for care of cases of encephalitis including West Nile virus infection.* Intensive care may be required initially. Mosquito control includes cleaning rain gutters, removing old tires, draining bird baths, and removing water where mosquitoes can breed. In addition, insect repellant should be used during mosquito season. Acyclovir has fewer side effects than vidarabine and is often the preferred treatment. Acyclovir (Zovirax), vidarabine (Vira-A) for HSV infection -Reduce mortality rates but not necessarily neurologic complications -Start before onset of coma Antiseizure drugs for seizures -May be initiated prophylactically Acyclovir has fewer side effects than vidarabine and is often the preferred treatment.

Dysmenorrhea

Assess for Clinical Manifestations of Primary Dysmenorrhea -Pain begins 12 hours before onset of menses and lasts about 2 days (most severe the 1st day). -Lower abd pain can radiate to lower back and upper thighs. -Can be accompanied by nausea, diarrhea, fatigue, h/a and light-headedness Assess for Clinical Manifestations of Secondary Dysmenorrhea -Begins after problem free periods for a number of years. Pain may be unilateral or constant and continues longer than primary. May cause dyspareunia, painful BM's, & irregular bleeding Primary role is TEACHING -Heat/Cold -Exercise, proper nutritional habits --Avoid constipation -NSAIDs at start of menses and continued every 4 to 8 hours PRN (can prevent) -Distraction -Guided imagery -Reduce stress and fatigue -Acupuncture and transcutaneous nerve stimulation

Erectile Dysfunction

Assessment: patient reports Inability to maintain an erection sufficient for sexual intercourse. Assess for Common Causes: -medications, psychological problems, thyroid or hormonal dysfunction, previous prostatectomy, aging, vascular disease (ex: diabetes) Nursing Management: -Provide active listening and refer for counseling if needed in addition to pharmacological management

Hysterectomy Care

Pre-op Care Psychological support General Preop care -Teach to empty the bladder before going to OR -Indwelling urinary catheter is often inserted prior to procedure Post-Op care -Care of abdominal dressing for abdominal hysterectomy and sterile perineal pad for a vaginal hysterectomy --Observe frequently for any sign of bleeding during first 8 hrs after surgery --A moderate amount of serosanguineous drainage on the perineal pad is expected after a vaginal hysterectomy Provide catheter care (catheter promotes constant drainage of the bladder and decreases stress on the suture line) Consider catherization if indwelling is not used and the patient hasn't voided 8 hours after surgery Report any complication such as backache or decreased urine output (accidental ligation of a ureter is a serious surgical complication) Assess for paralytic illeius Restrict food and fluids if nausea (provide IV fluids) Encourage ambulation to relieve flatus Post-Op Care -Teach measures to prevent DVT -Determine any altered body image perceptions -Identify support groups available for the patient if needed -Encourage the patient to discuss stressors -Teach physical restrictions such as heavy lifting should be avoided for two months -Encourage activity such as swimming -Wearing a girdle is allowed and may provide comfort -An abdominal binder may be needed if BSO -If BSO teach interventions to relieve symptoms of surgical menopause if the woman was in the pre or perimenopause stage

Benign Ovarian Tumors

The cause of most of them is unknown. They can be divided into cysts and neoplasms. Ovarian masses are often asymptomatic until they are large enough to cause pressure in the pelvis. Constipation, menstrual irregularities, urinary frequency, a full feeling in the abdomen, anorexia, an increase in abdominal girth, and peripheral edema may occur, depending on the tumor's size and location. Pelvic pain may be present if the tumor is growing rapidly. Severe pain results when the cyst twists on its pedicle (ovarian torsion). In some cases, an ovarian cyst can rupture. A ruptured ovarian cyst is not only extremely painful, but it can lead to serious complications, such as hemorrhage and infection. Pelvic examination reveals a mass or an enlarged ovary that demands further investigation. If the mass is cystic and smaller than 8 cm, the patient is asked to return for reexamination in 4 to 6 weeks. If the mass is cystic and greater than 8 cm or is solid, laparoscopic surgery or laparotomy is performed. Immediate surgery is necessary if ovarian torsion occurs, causing the ovary to rotate and cutting off circulation. Surgical techniques are used to save as much of the ovary as possible. Assess for Clinical Manifestations -Asymptomatic symptoms associated from pressure from large cysts -constipation -menstrual irregularity -urinary frequency -full feeling -anorexia -peripheral edema -pain from tortion Nursing management - pre and post op teaching and care if surgery (ooporectomy) is indicated for tortion

Prostatitis

a broad term that describes a group of inflammatory and noninflammatory conditions affecting the prostate gland Assess for Clinical Manifestations: -Fever, chills, back pain, perineal pain, dysuria, urinary frequency, urgency and cloudy urine, acute urinary retention caused by swelling -Backache, perineal/pelvic pain, and ejaculatory pain are seen in chronic bacterial prostatitis -Clinical features can be mimicked by UTI however important to remember acute cystitis is not common in men Nursing Management -Measures to relieve acute pain until infection or inflammation is resolved -Teach Physical therapy and taking warm sitz baths may also help -If acute urinary retention develops, insertion and care of bladder drainage with suprapubic catheterization (urethral catheterization may cause more damage) -Provide prostatic massage for most types except acute bacterial. (massage helps squeeze out excess prostatic secretions relieving pain) (usually advanced practitioner) -Teach ejaculation through masturbation or intercourse may help drain the prostate as well and are encouraged -Encourage fluids and manage fever

Fibrocystic Changes

a benign condition characterized by changes in breast tissue. The changes include the development of excess fibrous tissue, hyperplasia of the epithelial lining of the mammary ducts, proliferation of mammary ducts, and cyst formation. Fibrocystic changes are thought to be due to a heightened responsiveness of breast tissue to circulating estrogen and progesterone. These changes produce pain related to nerve irritation from edema in the connective tissue and to fibrosis that pinches the nerve. Fibrocystic changes are the most common breast disorder. The use of the term fibrocystic disease is incorrect because the cluster of problems is actually an exaggerated response to hormonal influence. The terms fibrocystic condition or fibrocystic complex are more accurate. Fibrocystic changes alone are not associated with increased breast cancer risk. Masses or nodularities can appear in both breasts. They are often found in the upper, outer quadrants and usually occur bilaterally. Fibrocystic changes occur most frequently in women between 35 and 50 years of age but often begin as early as 20 years of age. Pain and nodularity often increase over time but tend to subside after menopause unless high doses of estrogen replacement are used. Fibrocystic changes most commonly occur in women with premenstrual abnormalities, nulliparous women, women with a history of spontaneous abortion, nonusers of oral contraceptives, and women with early menarche and late menopause. Symptoms related to fibrocystic changes often worsen in the premenstrual phase and subside after menstruation. Manifestations of fibrocystic breast changes include one or more palpable lumps that are often round, well delineated, and freely movable within the breast. Discomfort ranging from tenderness to pain may also occur. The lump is usually observed to increase in size and perhaps in tenderness before menstruation. Cysts may enlarge or shrink rapidly. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green. Mammography may be helpful in distinguishing fibrocystic changes from breast cancer. However, in some women the breast tissue is so dense that it is difficult to obtain a mammogram. In these situations, ultrasound may be more useful in differentiating a cystic mass from a solid mass. Assessment -Cyst formation in the upper and outer quadrant -Watery-milky, yellow or green nipple discharge Nursing Interventions -Treat pain as described for mastalgia -Teach importance of follow-up care -Pre and Post op teaching and prep if aspiration or surgical excision is indicated

Prostate Cancer

Assess for Clinical Manifestations -Usually asymptomatic in early stages but eventually s/s similar to BPH including dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption or urinary stream and inability to urinate -Pain in the lumbosacral area that radiates down to the hips or legs when coupled with urinary symptoms may indicate metastasis Nursing Diagnosis depend on the stage of the cancer. In addition to those provided for BPH and TURP: -Urinary retention r/t obstruction of urethra or bladder neck by the prostate, blood clots and loss of bladder tone -Impaired urinary elimination r/t bladder neck sphincter damage -Constipation or diarrhea r/t treatment interventions -Sexual dysfunction r/t effects of treatment -Anxiety r/t uncertain outcome of disease process on life and lifestyle and effect of treatment on sexual functioning Overall Goals: Community Awareness: "Movember "No Shave November" -Be an active participant in the treatment plan -Have satisfactory pain control -Follow therapeutic plan -Understand the effect of the therapeutic plan on sexual function -Find a satisfactory way to manage the impact on bladder and bowel function Nursing care of the patient receiving Chemo and or radiation therapy Nursing Management after a Radical Prostatectomy: Assess for complication such as Hemorrhage, Catheter occlusion, Infection, DVT High risk for infection depending on incision location -Implement careful dressing changes -Provide perineal care after each bowel movement -Monitor for Wound dehiscence and prevent stress on wound Nursing interventions to prevent DVT, and Pulmonary emboli

Vulvar Cancer

Cancer of the vulva is relatively rare Similar to cervical cancer, preinvasive lesions referred to as vulvar intraepithelial neoplasia (VIN) precede invasive vulvar cancer. The invasive form occurs mainly in women over 60 years of age, with the highest incidence being in women in their seventies. Patients with vulvar neoplasia may have symptoms of vulvar itching or burning, pain, bleeding, or discharge. Women who are immunosuppressed and/or have diabetes mellitus, hypertension, or chronic vulvar dystrophies are at a higher risk for developing vulvar cancers. Several subtypes of HPV have been identified in some but not all vulvar cancers. Vaccines (Gardasil, Cervarix) are now available to protect against some vaginal and vulvar cancers that are caused by these HPV subtypes. Assess for Clinical Manifestations -vulvar itching -burning -pain -bleeding or discharge -Higher risk associated with immunosuppressed, DM, htn, or chronic vulvar dystrophies. Nursing Management -Pre and post op care if surgical excision is needed VIN can be treated topically with imiquimod cream (Aldara) or surgery. Laser therapy may be used to kill cancer cells. Surgery is the most common treatment for cancer of the vulva. The goal of surgery is to remove all the cancer without any loss of the woman's sexual function. A local excision with removal of the lesion and surrounding tissue may be done.

Premenstrual Syndrome (PMS)

a symptom complex related to the luteal phase of the menstrual cycle. The symptoms can be severe enough to impair interpersonal relationships or interfere with usual activities. PMS is extremely variable in its clinical manifestations between women and, for an individual woman, from one cycle to another. Common physical symptoms include breast discomfort, peripheral edema, abdominal bloating, sensation of weight gain, episodes of binge eating, and migraine headache. Abdominal bloating and breast swelling are caused by fluid shifts because total body weight does not generally change. Anxiety, depression, irritability, and mood swings are some of the emotional symptoms that women may experience. Assess for Clinical Manifestations -Vary but could include breast discomfort -peripheral edema -abdominal bloating -sensation of weight gain -episodes of binge eating -Headache -heart palpitations, dizziness, -anxiety, depression, irritability, mood swings Nursing Management Encourage stress management and relaxation therapy Nutritional therapy -Avoid caffeine -Reduce intake of refined carbs -Eat complex carbs with high fiber -Foods rich in vitamin B and sources of tryptophan (dairy and poultry)are thought to reduce serotonin production and reduce symptoms -Limit salt and increase calcium to alleviate symptoms Encourage Aerobic exercise Therapeutic "listening" and educating partner that the disorder is real

Gynecomastia (in Men)

a transient, noninflammatory enlargement of one or both breasts, is the most common breast problem in men. The condition is usually temporary and benign. Gynecomastia in itself is not a risk factor for breast cancer. The most common cause of gynecomastia is a disturbance of the normal ratio of active androgen to estrogen in plasma or within the breast itself. Gynecomastia may also be a manifestation of other problems. It is seen in developmental abnormalities of the male reproductive organs. It may also accompany diseases such as testicular tumors, adrenal cancer, pituitary adenomas, hyperthyroidism, and liver disease. Gynecomastia may occur as a side effect of drug therapy, particularly with estrogens and androgens, digitalis, isoniazid (INH), ranitidine (Zantac), and spironolactone (Aldactone). The use of heroin and Assessment: -Inspect for transient noninflammatory enlargement of one or both breasts Nursing Intervention: -Reassurance that it is typically temporary -Psychological implications -Pre and Post op care if cosmetic surgery is elected

Infertility (male)

the inability to conceive after 1 year of frequent unprotected intercourse In about 33% of cases, infertility is primarily caused by factors involving the man. Assess amount of time the couple has been trying to conceive, frequency of intercourse Assess for Causes such as hypothalamic-pituitary system, disorders of the testes, and abnormalities of the ejaculation system. Can be caused by past injury, surgery, infections, hot tubs, weight training or wearing tight undergarments, stress, chemo, street drugs, varicocele The most common cause of male infertility is a varicocele. Teach lifestyle changes and meds, invitro and surgical treatments Be concerned and tactful in dealing with the male patient undergoing infertility studies. Many men equate fertility and masculinity. Treatment options for the man include medications, conservative lifestyle changes (e.g., avoidance of scrotal heat, substance abuse, and high stress), in vitro fertilization techniques, and corrective surgery. Infertility can seriously strain a relationship, and the couple may require counseling and discussion of alternatives if conception is not achieved.

Brain Abscess

an accumulation of pus within the brain tissue that can result from a local or systemic infection. Direct extension from an ear, tooth, mastoid, or sinus infection is the primary cause. Other causes for brain abscess formation include spread from a distant site (e.g., pulmonary infection, bacterial endocarditis), skull fracture, and prior brain trauma or surgery. Streptococci and Staphylococcus aureus are the primary infective organisms. Antimicrobial therapy is the primary treatment. -Symptomatic treatment for other manifestations -Abscess may need to be drained or removed if drug therapy is not effective. Mortality approaches 100% in untreated cases. Nursing measures are similar to those for management of meningitis or increased ICP. If surgical drainage or removal is the treatment of choice, nursing care is similar to that described under cranial surgery. Manifestations of brain abscess, which are similar to those of meningitis and encephalitis, include headache, fever, and nausea and vomiting. Signs of increased ICP may include drowsiness, confusion, and seizures. Focal symptoms may reflect the local area of the abscess. For example, visual field defects or psychomotor seizures are common with a temporal lobe abscess, whereas an occipital abscess may be accompanied by visual impairment and hallucinations. CT and MRI are used to diagnose a brain abscess.

Abnormal Vaginal Bleeding

uterine bleeding is a common gynecologic concern. Abnormalities include oligomenorrhea (long intervals between menses, generally greater than 35 days), amenorrhea (absence of menstruation), menorrhagia (excessive or prolonged menstrual bleeding), and metrorrhagia (irregular bleeding or bleeding between menses). The cause of abnormal bleeding may vary from anovulatory menstrual cycles to more serious conditions such as ectopic pregnancy or endometrial cancer. The woman's age provides direction for identifying the cause of bleeding. For example, a postmenopausal woman with abnormal bleeding must always be evaluated for endometrial cancer but does not need to be evaluated for possible pregnancy. For a 20-year-old woman with abnormal bleeding, the possibility of pregnancy must always be considered, and endometrial cancer would be unlikely. Abnormal bleeding may be caused by dysfunction of the hypothalamic-pituitary-ovarian axis such as a pituitary adenoma. Another possible cause is infection. Changes in lifestyle such as marriage, recent moves, a death in the family, financial stress, and other emotional crises can also cause irregular bleeding. Because psychologic factors can influence endocrine function, they should be considered when the patient is evaluated. Teach characteristics of the normal menstrual cycle Encourage PCP follow up even if infrequent or no menses is desirable Encourage frequent changing of tampons or pads to prevent complications such as Toxic Shock Syndrome (caused by staphylococcus aureus & symptoms include fever, vomiting, diarrhea, weakness, myalgia, and sunburn like rash) Teach patient to track # of pads or tampons when bleeding is excessive Monitor fatigue level, blood pressure, for s/s of anemia and hypovolemia Pre and post op teaching and care when needed

Leiomyomas (Uterine Fibroids)

(uterine fibroids) are benign smooth-muscle tumors that occur within the uterus. common benign tumors of the female genital tract The majority of women with leiomyomas do not have any symptoms. When present, the most common symptoms include abnormal uterine bleeding, pain, and symptoms associated with pelvic pressure. Increased bleeding is associated with increased endometrial surface area caused by leiomyomas. Pain occurs with infection or twisting of the pedicle from which the tumor is growing. Devascularization and blood vessel compression may also contribute to pain. Pressure on surrounding organs may result in rectal, bladder, and lower abdominal discomfort. Large tumors may cause a general enlargement of the lower abdomen. These tumors are sometimes associated with miscarriage and infertility. Assess for Clinical manifestations - asymptomatic in most, abnormal uterine bleeding, pain and symptoms associated with pelvic pressure Nursing Management -Encourage communication with HCP's during the watch and wait for mild cases -Pre and post op care for Hysterectomy or myomectomy (surgical removal of the leiomyoma) Clinical diagnosis is based on the characteristic pelvic findings of an enlarged uterus distorted by nodular masses. Treatment depends on the symptoms, the patient's age, her desire to bear children, and the location and size of the tumors. If the symptoms are minimal, the health care provider may elect to follow the patient closely for a time. Persistent heavy menstrual bleeding causing anemia and large or rapidly growing tumors are indications for surgery. The leiomyomas are removed by hysterectomy or by myomectomy for women who wish to have children. In this case, only the fibroids are removed to preserve the uterus. Small tumors may be removed using a hysteroscope and laser resection instruments. Uterine artery embolization is an increasingly used alternative treatment for uterine fibroids.25 Embolic material (small plastic or gelatin beads) is injected into the uterine artery and carried to the fibroid branches. Cryosurgery is another option. In cases of large leiomyomas, a GnRH agonist (e.g., leuprolide) may be used preoperatively to shrink the tumor. However, the risks and benefits of this drug should be fully discussed, including the potential for irreversible loss of bone mass. The treatment should not be used on women planning to have children. Another treatment option uses MRI-guided focused ultrasound to target and destroy uterine fibroids. Treatment requires repeated targeting and heating of the fibroid tissue while the patient lies inside the MRI machine. The procedure can last as long as 3 hours.

Vulvectomy

After a vulvectomy, the patient has a wound in the perineal area extending to the groin. The wound may be covered or left exposed and frequently has drains attached to portable suction (e.g., Hemovac, Jackson-Pratt). A heavy pressure dressing is often in place for the first 24 to 48 hours. The wound is cleaned with normal saline solution or an antiseptic twice daily. Solutions can be applied with an aseptic bulb syringe or a Waterpik machine. Wound care must be meticulous to prevent infection, which results in delayed healing. Special attention to bowel and bladder care is needed. A low-residue diet and stool softeners prevent straining and wound contamination. An indwelling catheter is used to provide urinary drainage. Be careful not to dislodge the catheter because extensive edema makes its reinsertion difficult. Heavy, taut sutures are often used to close the wounds, resulting in severe discomfort. In other instances, the wound may be allowed to heal by granulation. Analgesics may be required to control pain. Carefully position the patient using strategically placed pillows to provide comfort. Anticoagulant therapy to prevent DVTs is common. Because the surgery causes mutilation of the perineal area and the healing process is slow, the patient is likely to become discouraged. Provide opportunities for the patient to express her feelings and concerns about the operation. Teach the patient specific instructions in self-care before discharge. Instruct her to report any unusual odor, fresh bleeding, breakdown of incision, or perineal pain. Home care nursing can benefit the patient during her adjustment period. Sexual function is often retained. Whether clitoral sensation is retained may be critical to some women, particularly if it was a primary source of orgasmic satisfaction. Discussing alternative methods of achieving sexual satisfaction may be indicated. Preop teaching Postop care -Care of drains and portable suction equipment -Heavy pressure dressing for first 24-48 hours -Clean wound with NS or antiseptic twice daily -Apply solutions with aseptic bulb syringe or water pik machine -Carefully use heat lamp or hair dryer to dry the area -Meticulous wound care to prevent infection -Low residue diet and stool softeners to prevent straining -Care of indwelling catheter -Ambulate on 2nd post op day -Psychological interventions (clitoral sensation may or may not be retained)

Cystocele and Rectocele

Cystocele occurs when support between the vagina and bladder is weakened. Similarly, a rectocele results from weakening between the vagina and rectum Cystocele and rectocele are common problems, and in many women they are asymptomatic. With large cystoceles, complete emptying of the bladder can be difficult, predisposing women to bladder infections. A woman with a large rectocele may not be able to completely empty her rectum when defecating unless she helps push the stool out by putting her fingers in her vagina. Clinical manifestations - asymptomatic, difficulty emptying bladder, bladder infections, difficulty completely emptying rectum Nursing Management -Teach Kegal exercises or pessary use -Pre and post op teaching for surgical repair: Anterior (for cystocele) or Posterior (for rectocele) Colporrhaphy - surgery designed to tighten the vaginal wall Assist women in avoiding or decreasing problems with pelvic support by teaching them how to do Kegel exercises. Women of all ages may benefit from these exercises. Instruct the patient to pull in or contract her muscles as if she were trying to stop the flow of urine. She should hold the contraction for several seconds and then relax. Sets of 5 to 10 contractions each should be done several times daily. If vaginal surgery is necessary, the preoperative preparation usually includes a cleansing douche the morning of surgery. A cathartic and a cleansing enema are usually given when a rectocele repair is scheduled. A perineal shave may be done. In the postoperative period the goals of care are to prevent wound infection and pressure on the vaginal suture line. This necessitates perineal care at least twice a day and after each urination or defecation. Apply an ice pack locally to help relieve the initial perineal discomfort and swelling. A disposable glove filled with ice and covered with a cloth works well. Later, sitz baths may be used. After an anterior colporrhaphy, an indwelling catheter is usually left in the bladder for 4 days to allow the local edema to subside. The catheter keeps the bladder empty, preventing strain on the sutures. Twice-daily catheter care with an antiseptic is generally done. After posterior colporrhaphy, straining at stool is avoided by means of a low-residue diet and the prevention of constipation. A stool softener is usually given each night. Review discharge instructions before the patient leaves the hospital. These include the use of douches or a mild laxative as needed; restrictions on heavy lifting and prolonged standing, walking, or sitting; and avoidance of intercourse until the physician gives permission. There may be a temporary loss of vaginal sensation, which can last for several months.

Cervical Cancer

Incidence is higher among Hispanic, African American, and Native American women than among white women. Mortality rates are more than twice as high among African American women as among white women The number of deaths from cervical cancer in the United States has fallen steadily over the past 50 years because of better and earlier diagnosis with the widespread use of the Papanicolaou (Pap) test. In addition to cancer, the Pap test screens for precancerous changes. Treatment of precancerous lesions can prevent progression to cervical cancer. Precancerous changes are asymptomatic. This highlights the importance of routine screening. The peak incidence of noninvasive cervical cancer is in women in their early thirties. The average age for women with invasive cervical cancer is 50. Early cervical cancer is generally asymptomatic, but leukorrhea and intermenstrual bleeding eventually occur. The discharge is usually thin and watery but becomes dark and foul smelling as the disease advances, suggesting an infection. The vaginal bleeding is initially only spotting. As the tumor enlarges, bleeding becomes heavier and more frequent. Pain is a late symptom and is followed by weight loss, anemia, and cachexia. Assess for Clinical Manifestations -precancerous changes are asymptomatic but leukorrhea and bleeding between periods eventually occurs -thin, watery discharge, foul smell as disease advances and if infection is present -pain is a late symptom followed by weight loss, anemia and cachexia (physical wasting) Nursing Management -Teach importance of Vaccines against HPV!!!! -Pre and post op care for Hysterectomy or Pelvic extenteration -Nursing care for radiation therapy and chemotherapy Invasive cancer of the cervix is treated with surgery, radiation, and chemotherapy as single treatments or in combination. Surgical procedures include hysterectomy, radical hysterectomy (involving adjacent structures), and, rarely, pelvic exenteration. Radiation may be by external (e.g., cobalt) or internal implants (e.g., cesium, radium). Standard radiation treatment is 4 to 6 weeks of external radiation followed by one or two treatments with internal implants (brachytherapy). Cisplatin-based chemotherapy regimens benefit patients with cancer spread beyond the cervix.

Testicular Torsion

Twisting of the spermatic cord that supplies blood to the testes and epididymis Teach it is a medical emergency Assess for sudden onset of acute pain and testicular swelling Provide pre and post op care if necessary It is most commonly seen in males younger than age 20. It can occur spontaneously, as a result of trauma, or as a result of an anatomic abnormality. The patient experiences severe scrotal pain, tenderness, swelling, nausea, and vomiting. Urinary symptoms, fever, and WBCs or bacteria in the urine are absent. The pain does not usually subside with rest or elevation of the scrotum. The cremasteric reflex is elicited by lightly stroking (with a reflex hammer or tongue blade) the inner aspect of the thigh in a downward direction. The normal response is a contraction of the cremaster muscle that pulls up the scrotum and testis on the side stroked. In testicular torsion, this reflex is absent on the side of the swelling. Nuclear scan of the testes or Doppler ultrasound is typically performed to assess blood flow within the testicle. Decreased or absent blood flow confirms the diagnosis. Torsion constitutes a surgical emergency because, if the blood supply to the affected testicle is not restored within 4 to 6 hours, ischemia to the testis will occur, leading to necrosis and the possible need for removal. Unless the torsion resolves spontaneously, surgery to untwist the cord and restore the blood supply must be performed immediately.

Ovarian Cancer

a malignant tumor of the ovaries It occurs most frequently in women between 55 and 65 years of age. White women are at greater risk for ovarian cancer than African American women. The cause of ovarian cancer is not known. Women who have mutations of the BRCA genes have an increased susceptibility Assess for Risk Factors -family history (one or more 1st degree relatives) -family or personal hx of breast or colon ca -nulliparity -increasing age -high-fat diet -early menarche or late -menopause -HRT and use of infertility drugs -Oral contraceptives use are associated with lower risk Assess for Clinical Manifestations -Vague in early stages -Abdominal enlargement caused by an accumulation of fluid -Nonspecific symptoms which occur daily for 3 weeks should be evaluated including --Pelvic or abdominal pain, bloating, urinary frequency or urgency, difficulty in eating or feeling full quickly Nursing Management -Pre and Post op care for Abdominal hysterectomy with BSO with pelvic lymph node biopsies -Nursing care of the patient receiving Chemotherapy (adjuvant and palliative) -Nursing care of the patient receiving Radiation (adjuvant and palliative)

Brachytherapy

allows the radiation to be placed internally near or into the tumor. This method can deliver a high dose of radiation directly to the tumor used in the management of cervical and endometrial cancer because of the accessibility of these body parts and the favorable results obtained. Radium and cesium are two commonly used isotopes. involves placing radioactive seed implants into the prostate gland, allowing higher radiation doses directly in the tissue while sparing the surrounding tissue (rectum and bladder). a one-time outpatient procedure, many patients find this more convenient than external beam radiation treatment. Brachytherapy is best suited for patients with early stage disease. The most common side effect is the development of urinary irritative or obstructive problems. Some men may also experience ED. To prepare the patient for the treatment, give a cleansing enema to prevent straining at stool, which could cause displacement of the isotope. Insert an indwelling catheter to prevent a distended bladder from coming into contact with the radioactive source. Place patient in lead-lined private room on absolute bed rest (turning from side to side is permitted) Do not stay in immediate area any longer than necessary to give proper care and attention No individual should attend the patient for more than 30 minutes PER DAY Stay at the foot of the bed or at the entrance to the room Instruct visitors to stay 6 feet away Efficient organization of nursing care is essential Care for indwelling cath inserted prior isotope to prevent distended bladder from putting pressure on the isotope Administer stool softeners to decrease straining Vaginal packing generally left in for 24-72 hours Do not touch the isotope if dislodged. Use long tipped forcepts to place in lead lined container for disposal

Fistula

an abnormal opening between internal organs or between an organ and the exterior of the body Gynecologic procedures cause most urinary tract fistulas. Other causes include injury during childbirth and disease processes, such as cancer. Fistulas may develop between the vagina and the bladder, urethra, ureter, or rectum. When vesicovaginal fistulas (between the bladder and the vagina) develop, some urine leaks into the vagina, whereas with rectovaginal fistulas (between the rectum and the vagina), flatus and feces escape into the vagina. In both instances, excoriation and irritation of the vaginal and vulvar tissues occur and may lead to severe infections. In addition to wetness, offensive odors may develop, causing embarrassment and severely limiting socialization. Because small fistulas may heal spontaneously within a matter of months, treatment may not be needed. If the fistula does not heal, surgical excision is required. Inflammation and tissue edema must be eliminated before surgery is attempted, which may involve a wait of up to 6 months. The fistulectomy may result in the patient's having an ileal conduit or temporary colostomy. Perineal hygiene is of great importance both preoperatively and postoperatively. Cleanse the perineum every 4 hours. Warm sitz baths should be taken three times daily if possible. Change perineal pads frequently. Encourage the patient to maintain an adequate fluid intake. Encouragement and reassurance are needed to help the patient cope with her problems. Postoperatively, emphasize the avoidance of stress on the repaired areas and prevention of infection. Take care so that the indwelling catheter, usually in place for 7 to 10 days, is draining at all times. Urge oral fluids to provide for internal catheter irrigation. Use minimal pressure and strict asepsis if catheter irrigation becomes necessary. The first stool after bowel surgery may be purposely delayed to prevent contamination of the wound. Later, give stool softeners or mild laxatives. Assess for clinical manifestations -Urine or feces escaping into the vagina -Excoriation and irritation of vaginal and vulvar tissues -s/s of severe infection Nursing Management -Teach perineal hygiene - cleanse perineum every 4 hours -Warm sitz baths 3 x day if possible -Change perineal pads frequently -Postop - avoid stress on repaired areas, encourage fluids, catheter care for 7-10 days

Mastalgia

breast pain is the most common breast-related complaint in women the most common form is cyclic mastalgia, which coincides with the menstrual cycle. It is described as diffuse breast tenderness or heaviness. Breast pain may last 2 or 3 days or most of the month. The pain is related to hormonal sensitivity. The symptoms often decrease with menopause. Noncyclic mastalgia has no relationship to the menstrual cycle and can continue into menopause. It may be constant or intermittent throughout the month and last for several years. Symptoms include a burning, aching, or soreness in the breast. The pain may be from trauma, fat necrosis, ductal ectasia, costochronditis, or arthritic pain in the chest or neck radiating to the breast. Mammography and targeted ultrasound are frequently done to exclude cancer and provide information on the etiology of mastalgia. Some relief for cyclic pain may occur by reducing intake of caffeine and dietary fat; taking vitamins E, A, and B complex and gamma-linolenic acid (evening primrose oil); and continually wearing a support bra. Compresses, ice, analgesics, and antiinflammatory drugs may also help. Helpful drugs include oral contraceptives and danazol (Danocrine). The androgenic side effects of danazol (acne, edema, hirsutism) may make this therapy unacceptable for many women. Assessment -Pain, burning, aching, soreness -Is it cyclic or noncyclic? Nursing Interventions -Teach: Decreased Caffeine and dietary fat, Vitamins E, A, B, Primrose oil, support bra, cold compresses, analgesics, anti-inflammatories, oral contraceptives

Polycystic Ovary Syndrome (PCOS)

chronic disorder in which many benign cysts form on the ovaries. It most commonly occurs in women under 30 years old and is a cause of infertility. Classic manifestations include irregular menstrual periods, amenorrhea, hirsutism, and obesity. Of these manifestations, obesity in particular has been associated with severe symptoms such as excess androgens, oligorrhea, amenorrhea, and infertility. Many women start with normal menstrual periods, which after 1 to 2 years become irregular and then infrequent. If PCOS is left untreated, cardiovascular disease and abnormal insulin resistance with type 2 diabetes mellitus may develop. Assess for Clinical Manifestations -Irregular menses including long cycles -amenorrhea or oligomenorrhea -dysfunctional uterine bleeding -infertility, -hirsutism, -obesity,'acne. -Can cause CV disease and abnormal insulin resistance with type 2 diabetes if untreated Nursing Management -Teach about the disease process, clinical manifestations, and collaborative care -Provide pre and post op care for a Hysterectomy with bilateral salpingectomy and oophorectomy if indicated Clomiphene (Clomid) Instruct the patient to notify her physician immediately if •Lower abdominal pain occurs. •Pregnancy is suspected. Teach the patient the importance of weight management and exercise to decrease insulin resistance. Obesity exacerbates the problems related to PCOS. Monitor lipid profile and fasting glucose levels. Hirsutism is cosmetically distressing for many women. Support the patient as she explores measures to remove unwanted hair (e.g., depilating agents, electrolysis). Stress the importance of regular follow-up care to monitor the effectiveness of therapy and to detect any complications.

Uterine prolapse

downward displacement of the uterus into the vaginal canal Rated by degrees. In first-degree prolapse the cervix rests in the lower part of the vagina. Second-degree prolapse means the cervix is at the vaginal opening. Third-degree prolapse means the uterus protrudes through the introits. Symptoms vary with the degree of prolapse. The patient may describe a feeling of "something coming down." She may have dyspareunia, a dragging or heavy feeling in the pelvis, backache, and bowel or bladder problems if cystocele or rectocele is also present. Stress incontinence is a common and troubling problem. When third-degree uterine prolapse occurs, the protruding cervix and vaginal walls are subjected to constant irritation, and tissue changes may occur. Assess for clinical manifestations depend on degree of prolapse but include dragging or heaving feeling of pelvis, dyspareunia, backache, bowel or bladder problems, irritation, tissue changes Nursing Management -Teach Kegel exercises (1st degree) -Pessary - device placed in the vagina to help support uterus; teach manufacturer recommendations for cleaning; teach s/s of complications of pessary including erosion, fistulas and increased incidence of vaginal carcinoma -Pre and Post op care for Vaginal hysterectomy with anterior and posterior repair of the vagina and underlying tissue

Fibroadenoma

ommon cause of discrete benign breast lumps in young women. It generally occurs in women between 15 and 40 years of age. It is the most frequent cause of breast masses in women under 25 years of age. cause of may be increased estrogen sensitivity in a localized area of the breast. Fibroadenomas are usually small (but can be large [2 to 3 cm]), painless, round, well delineated, and very mobile. They may be soft but are usually solid, firm, and rubbery in consistency. There is no accompanying retraction or nipple discharge. The lump is often painless. The fibroadenoma may appear as a single unilateral mass, although multiple bilateral fibroadenomas have been reported. Growth is slow and often ceases when the size reaches 2 to 3 cm. Size is not affected by menstruation. However, pregnancy can stimulate dramatic growth. Fibroadenomas are easily detected by physical examination and may be visible on mammography and ultrasound. However, definitive diagnosis requires FNA, core, or surgical biopsy and tissue examination by a pathologist to exclude other tumors. Treatment of fibroadenomas can include observation with regular monitoring after a malignancy has been ruled out, or surgical excision. In women over 35 years of age, all new lesions should be evaluated by breast ultrasound and possible biopsy. As an alternative to surgery, tumor removal can be done using cryoablation. In this procedure, a cryoprobe is inserted into the tumor using ultrasound guidance. Extremely cold gas is piped into the tumor. The frozen tumor dies and gradually shrinks. Assessment: -Typically 2-3 cm, painless, round, well delineated, fold, firm or rubbery, and mobile without retraction or nipple discharge Nursing Intervention: -Teach importance of regular monitoring -Pre and Post op care if surgical excision or cryoablation is needed

Testicular Cancer

rare and accounts for less than 1% of all cancers found in males Assess for Risk Factors: -Cryptorchidism -Family history -Race / ethnicity Assess for S & S: -Mass or lump on the testicle -Painless swelling of the testicle -Heaviness in the scrotum or lower abdomen The scrotal mass usually is nontender and firm. Some patients complain of a dull ache or heavy sensation in the lower abdomen, the perianal area, or the scrotum. Acute pain is the initial symptom in about 10% of patients. Manifestations associated with advanced disease are varied and include lower back or chest pain, cough, and dyspnea. Teach Self Testicular Exam 1. During a shower or bath is the easiest time to examine the testes, warm temperatures make the testes hang lower in the scrotum 2. Use both hands to feel each testes. Roll the testis between the thumb and first 3 fingers until the entire surface has been covered. Palpate each separately 3. Identify the structures. The testis should feel round and smooth, like a hard-boiled egg. Differentiate the testis from the epididymis. The epididymis is not a smooth as the egg shaped testis. One testis may be larger than the other. Size is not as important as texture. 4. Check for lumps, irregularities, pain in the testes, or a dragging sensation. Locate the spermatic cord, which is usually firm and smooth and goes up toward the groin 5. Choose a consistent day of the month (one that is easy to remember) on which to examine the testes 6. Notify the healthcare provider at once if any abnormalities are found The scrotum is easily examined, and beginning tumors are usually palpable. Instruct and encourage every male starting at puberty to perform a monthly testicular self-examination for the purpose of detecting testicular tumors or other scrotal abnormalities such as varicoceles. Teach male patients, especially those with a history of an undescended testis or a previous testicular tumor, how to perform self-examination. The procedure for self-examination is not difficult. The man may indicate some reluctance to examine his own genitalia, but with your encouragement he can learn this simple procedure. 1. During a shower or bath is the easiest time to examine the testes. Warm temperatures make the testes hang lower in the scrotum. 2. Use both hands to feel each testis. Roll the testis between the thumb and first three fingers until the entire surface has been covered. Palpate each one separately. 3. Identify the structures. The testis should feel round and smooth, like a hard-boiled egg. Differentiate the testis from the epididymis. The epididymis is not as smooth as the egg-shaped testis. One testis may be larger than the other. Size is not as important as texture. Check for lumps, irregularities, pain in the testes, or a dragging sensation. Locate the spermatic cord, which is usually firm and smooth and goes up toward the groin. 4. Choose a consistent day of the month (one that is easy to remember, such as a birth date) on which to examine the testes. The examination can be performed more frequently if desired. 5. Notify the health care provider at once if any abnormalities are found.

Phimosis

tightness or constriction of the foreskin around the head of the penis, making retraction difficult is caused by edema or inflammation of the foreskin, usually associated with poor hygiene techniques that allow bacterial and yeast organisms to become trapped under the foreskin. The goal of treatment is to return the foreskin to its natural position over the glans penis through manual reduction. One strategy involves pushing the glans back through the prepuce by applying constant thumb pressure while the index fingers pull the prepuce over the glans. Ice and/or hand compression on the foreskin, glans, and penis may be done before this technique to reduce edema. Topical corticosteroid cream applied two or three times daily to the exterior and interior of the tip of the foreskin may also be effective. Assess for: -Edema, Inflammation, Infection, tightness of skin Nursing Management Teaching regarding completing antibiotics, warm soaks, pre and post op teaching for circumcision, or dorsal slit of the prepuce may be required Teach proper hygiene

Viral Meningitis

usually manifests as a headache, fever, photophobia, and stiff neck. The fever may be moderate or high. Most common causes are enterovirus, arbovirus, HIV, and HSV. -Most often spread through direct contact with respiratory secretions Usually presents as headache, fever, photophobia, and stiff neck -Fever may be moderate or high. Diagnostic testing of CSF: Rapid diagnosis with Xpert EV test -Sample of CSF is evaluated for enterovirus. -Results available within hours Lumbar puncture -CSF may be clear or cloudy. -Lymphocytosis PCR to detect viral-specific DNA/RNA Organisms are not seen on Gram-stain or acid-fast smears. Polymerase chain reaction (PCR) used to detect viral-specific DNA or RNA is a highly sensitive method for diagnosing CNS viral infections. Treat with antibiotics after obtaining diagnostic sample but before receiving test results -Symptomatic management -Disease is self-limiting. -Full recovery expected Antibiotics are the best defense for bacterial meningitis and can be easily discontinued if the meningitis is found to be viral in nature. Rare sequelae include persistent headaches, mild mental impairment, and incoordination. Antibiotics should be administered after the lumbar puncture while awaiting the results of the CSF analysis. Antibiotics are the best defense for bacterial meningitis and can be easily discontinued if the meningitis is found to be viral. managed symptomatically because the disease is self-limiting. Full recovery from viral meningitis is expected.