Life as A Nurse

– is an inflammatory process involving the respiratory bronchioles, alveolar space and walls, and lobes, caused primarily by chemical irritants or by specific bacterial, viral, fungal, mycoplasmal, or parasitic organisms

– “Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion

B. ETIOLOGY

Classification:

1. Community-Acquired Pneumonia

Ø Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization

Pneumonia caused by Streptococcus pneumoniae

Ø Most common CAP in people younger than 60 years of age and above

Ø A gram-positive, capsulated, non-motile coccus that resides naturally in the respiratory tract

Ø May occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness

b. Mycoplasma pneumonia

Ø Occurs most often in older children and young adults and is spread by infected respiratory droplets through

Ø person-to-person contact

Ø Spreads throughout the entire respiratory tract, including the bronchioles, and has the characteristics of a bronchopneumonia

c. Haemophilus influenzae (type B)

Ø Frequently affects elderly people and those with comorbid illnesses (eg. COPD, alcoholism,diabetes mellitus)

Ø The presentation is indistinguishable from that of other forms of bacterial CAP and may be subacute, with cough or low-grade fever for weeks before diagnosis

Ø Chest x-rays may reveal multilobar, patchy bronchopneumonia or areas of consolidation (tissue that solidifies as a result of collapsed alveoli or pneumonia)

d. Viruses

Ø The most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults

Ø In immunocompetent adults, the chief causes of viral pneumonia are influenza viruses types A and B, adenovirus, parainfluenza virus, coronavirus, and varicella-zoster virus

Ø In immunocompressed adults, cytomegalovirus is the most common viral pathogen, followed by herpes simplex virus, adenovirus, and respiratory synctial virus

Ø Acute stage of a viral respiratory infection occurs within the ciliated cells of the airways. This is followed by infiltration of the tracheobronchial tree

B.Hospital-Acquired Pneumonia

Ø Also known as nosocomial pneumonia

Ø Defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission

Occurs when at least one of three conditions exists:

Ø host defenses are impaired

Ø an inoculum of organisms reaches the lower respiratory tract and overwhelms the host’s defenses

Ø a highly virulent organism is present

Ø The common organisms responsible for HAP include the pathogens Enterobacter species, Escherichiacoli, H. influenzae, Klebsiella species, Proteus, Serratia marcescens,

P. aeruginosa, methicillin- sensitive or methicillin-resistant Staphylococcus aureus (MRSA), and S. pneumoniae

3. Pneumonia in the Immunocompromised Host

Ø Pneumocystis pneumonia (PCP), fungal pneumonias, and Mycobacterium tuberculosis

Ø Pneumocystis jiroveci causes PCP

Ø May be caused by the organisms also observed in CAP or HAP

Ø Rarely observed in immunocompetent hosts and is often an initial AIDS-defining complication

Ø Has a subtle onset, with progressive dyspnea, fever, and a non-productive cough

4. Aspiration Pneumonia

Ø Refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway

Ø The most common form of aspiration pneumonia is bacterial infection from aspiration of bacteria that normally reside in the upper airways

Ø May occur in the community or hospital setting

Ø Common pathogens are S. pneumoniae, H. influenzae, and S. aureus

Ø Causes and contributing factors to pneumonia include:

a. Inability to move pulmonary secretions.

b. Aspiration pneumonia due to an abnormal swallowing mechanism or tube feedings

c. Immunosupressed clients

d. Frequent alcohol intoxication

e. Immobility

f. Cigarette smoking

D. INCUBATION PERIOD

• The incubation period for pneumonia varies, depending on the type of virus or bacteria causing the infection. Some common incubation periods are: respiratory syncytial virus, 4 to 6 days; influenza, 18 to 72 hours.

E. PERIOD OF COMMUNICABILITY

• Not known.

• It appears that transmission can occur as long as the organism remains in respiratory secretions.

F. MODE OF TRANSMISSION (Dependent on the infecting organism)

• Breathing in small droplets that contain the organisms that can cause pneumonia

• Sharing drinking glasses and eating utensils to the infected person

• Touching the used tissues or handkerchiefs of an infected person.

G. ASSESSMENT FINDINGS

a. Clinical Manifestations

• Dullness with consolidation on percussion of chest

• Bronchial breath sounds auscultated over consolidated lung fields; egophony “EE” to “AY”

• Sudden onset fever over 100 degrees Fahrenheit

• Shaking chills (with bacterial pneumonia)

• Chest pain aggravated by hacking cough

• Dyspnea, respiratory grunting, and nasal flaring

• Flushed cheeks; cyanotic lips and nail beds

• Purulent sputum

• Anxiety and confusion

• In the elderly, the only signs may be mental status' change and dehydration.

b. Laboratory Findings

• Sputum culture and sensitivity are positive for a specific causative organism.

• White blood cell (WBC) count is elevated in pneumonia of bacterial origin; WBC count is depressed in pneumonia of mycoplasmal or viral origin.

c. Diagnostic Findings

• Chest radiograph shows density changes, primarily in the lower lung fields.

• Cytologic findings - neutrophilic inflammation that may or may not be septic

• Bacterial culture - indicated to detect secondary infection

H. TREATMENT MODALITIES

• Bacterial pneumonia (caused by the streptococcus pneumonia bacteria) is often treated with penicillin, ampicillin-clavulanate (Augmentin) and erythromycin.

• Bacterial pneumonia (caused by the hemophilus influenza bacteria) is treated with antibiotics, such as cefuroxime (Ceftin), ampicillin-clavulanate (Augmentin), ofloxacin (Floxin), and trimethoprim-sulfanethoxazole (Bactrim and Septra).

• Bacterial pneumonia (caused by legionella pneumophilia and staphylococcus aureus bacteria) are treated with antibiotics, such as erythromycin.

• Mycoplasma pneumonia is often treated with antibiotics, such as erythromycin, clarithromycin (Biaxin), tetracycline or azithromycin (Zithromax).

• Bedrest

• Plenty of fluids

• Therapeutic coughing, breathing exercises

• Proper diet

• Cough suppressants

• Pain relievers and fever reducers, such as aspirin (not for children) or acetaminophen

• In severe cases, oxygen therapy and artificial ventilation may be required.

I. NURSING MANAGEMENT

• Administer prescribed medications, which may include antibiotics, mucolytics expectorants, or antitussive agents.

• Promote infection control measures, especially droplet precautions as indicated.

• Prevent aspiration pneumonia in a client receiving tube feedings. Keep the client in an upright position during feedings and for 30 minutes afterward. Check for residual gastric contents; if more than 100 mL, stop feeding and reevaluate.

• Pt will need to have breath sounds monitored q 4hr to determine if pneumonia is progressing.

• O2 saturation should be done regularly ( at least q4°during acute phase) to make sure that patient is getting adequate perfusion.

• Make sure to give all scheduled antibiotics on schedule so that therapeutic ranges are maintained.

• Any signs and symptoms of infection must be monitored and reported to the physician.

J. METHODS OF PREVENTION

• Practice good hygiene.

• Get a pneumonococcal vaccine.

• Practice good preventive measures by eating a proper diet, getting regular exercise and plenty of sleep.

• Stop smoking. Smoking makes it more likely you will get pneumonia.

• Avoid contact with people who have respiratory tract infections, such as colds and influenza (flu). Pneumonia may develop after these types of infections.

• If you have not had measles or chickenpox, avoid contact with people who have these infections. Pneumonia can be a complication of measles and chickenpox, so getting these infections can put you at risk for developing pneumonia.

LARYNGITIS

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DEFINITION

Ø an inflammation of your voice box (larynx)

due to overuse, irritation or infection.

Ø The larynx is a framework of cartilage,

muscles and mucous membranes that forms

the entrance of the windpipe (trachea). Inside

the larynx are the vocal cords — two folds of

mucous membrane covering muscle and

cartilage.

Ø The vocal cords become inflamed or irritated.

They swell, causing distortion of the sounds

produced by air passing over them. As a

result, the voice sounds hoarse.

Ø In some cases of laryngitis, the voice can

become so faint as to be undetectable.

Ø The vocal cords become inflamed or irritated.

They swell, causing distortion of the sounds

produced by air passing over them. As a

result, the voice sounds hoarse.

Ø In some cases of laryngitis, the voice can

become so faint as to be undetectable.

• Acid reflux, also known as gastroesophageal reflux disease, can cause chronic laryngitis.

• Persistent laryngitis in the absence of an infection or other cause could be a sign of cancer.

SIGNS AND SYMPTOMS

• hoarseness and loss of voice

• a raw throat, a dry cough, a tickling

sensation in the back of the throat, and a

constant need to clear the throat

ETIOLOGY

• Acute laryngitis is usually caused by an upper respiratory tract infection. The infection may be localized to the larynx (voice box), or it may be part of a wider respiratory tract infection such as a cold or flu.

• Most cases of laryngitis are caused by viral infections, but bacterial infections such as bronchitis and pneumonia can also result in inflammation of the vocal cords.

SIGNS and SYMPTOMS

• hoarseness and loss of voice

• a raw throat, a dry cough, a tickling sensation in the back of the throat, and a constant need to clear the throat

• symptoms may include pain, fever, difficulty swallowing, and general malaise

• The severity of inflammation determines the severity of symptoms. Severe swelling of the vocal cords may cause difficulty breathing.

PROGNOSIS

• Most cases of laryngitis resolve within a few days to a week. Acute laryngitis almost invariably resolves after the infection or other transient cause is cleared. Although chronic inflammation can lead to permanent changes in the vocal cords, most people with chronic laryngitis recover completely when the underlying cause is eliminated. Chronic laryngitis caused by nerve damage or cancer, however, usually does not fully resolve.

ASSESSMENT FINDINGS

Many times you can be thoroughly evaluated with only a complete history and physical exam.

• The doctor will pay particular attention to your ears, nose, throat, and neck.

• If symptoms are severe, particularly in children, the doctor may order an x-ray of your neck or chest.

• The doctor may also choose to look at your throat with a small, lighted scope.

This thin scope is inserted through your nose after numbing the nose and nostrils. The procedure only takes a few minutes and may yield valuable information.

• Sometimes in children, rarely in adults, the doctor may order blood work such as a complete blood cell count.

TREATMENT MODALITIES

• After a careful exam the doctor will decide on a course of treatment.

o Most of the time, the doctor will recommend the home care actions and may prescribe a steroid injection or prescription.

o If the doctor is concerned about a bacterial infection causing the laryngitis, then he or she will prescribe a course of antibiotics.

o Sometimes, the doctor may choose to observe in the office or the emergency department for a short period of time in order to be sure it is not getting worse quickly.

• If you have any signs of respiratory distress or think your airway could swell and close, then you will be admitted to the hospital.

o In some emergency situations, more commonly in children than adults, the danger of your throat swelling shut exists.

o It may be necessary to place a breathing tube into the throat in order to breathe.

o The patient will be placed on a machine to breathe called a ventilator.

o In this situation, he/she will receive IV antibiotics and likely steroids.

METHODS of PREVENTION

• Wash hands often especially before touching your face.

• For children, it is important that they receive the Haemophilus influenzae vaccine in order to protect them from this possibly life-threatening bacterial infection.

• Do not overuse your voice.

EPISTAXIS

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DESCRIPTION

Ø The most common causes of which are

nose picking and injury

ETIOLOGY

Ø Epistaxis may be spontaneous or may

result from trauma (usually nose picking)

Ø It also may be be associated with chemical

irritation, acute or chronic infection (such as

rhinitis or sinusitis), purpura, leukemia and

other blood dyscrasias, hypertension,

anticoagulant therapy, or deviated septum.

PATHOPHYSIOLOGY

Ø In children, epistaxis usually originated in the

anterior nose and tends to be mild. In adults,

it tends to originate in the posterior nose and

be more severe.

Ø Slight to moderate epistaxis usually causes

no complications; however, severe bleeding

(persisting longer than 10 minutes after

pressure is applied) may cause blood up to

1 L/hr

ASSESSMENT FINDINGS

Ø Clinical manifestation may include:

1. Bleeding through the nares, blood tricking

into the oropharynx

2. Blood in the corner of eyes (through the

lacrimal ducts)

3. Blood in the auditory canal if the tympanic

membrane is perforated

Ø Diagnostic Findings:

1. Nasal inspection with a bright and speculum

may locate the source of bleeding.

2. Artery legation may be required for anterior

posterior packs fail to control epistaxis.

NURSING INTERVENTIONS

Ø Instruct client to minimize activity for

approximately 10 days, such as avoiding

strenuous exercises, not blowing the nose;

sneezing with the mouth open; and not

lifting; stooping, or straining.

TREATMENT MODALITIES

Important step to prevent nosebleed include:

Ø Avoiding picking the nose

Ø Bleeding usually can be controlled at home by

pinching the sides of the nose together for 5 to

10 minutes

Ø Icepacks to the nose

Ø Putting wads of tissue paper in the nostrils

Ø And placing the head in various position are not

effective

NURSING MANAGEMENT

Ø Interventions to control bleeding, as follow:

1. Instruct patient to sit upright, breathe through

the mouth, and refrain from talking.

2. Instruct patient to compress the soft outer

portion of the nares against the septum for 5

to 10 minutes.

3. Instruct patient to avoid nose blowing during

or after the episode.

METHODS OF PREVENTION

Ø If pressure does not control bleeding, insert

anterior packing or posterior pack as

appropriate. Keep scissors and hemostat on

hand to cut the string and remove the

packing in the event of airway obstruction.

Ø Monitor bleeding: inspect for blood trickling into the posterior pharynx; observe for hemoptysis, hematemesis.

Ø Frequent swallowing or belching; instruct the patient not to swallow but to spit out any blood.

Ø If indicated, provide information regarding electrocautery.

The Digestive System

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DIGESTIVE ORGAN

Divided into two groups:

Alimentary tract (GI tract):

• Mouth

• Pharynx

• Esophagus

• Stomach

• Small intestine

• Large intestine

• Anus

Accessory digestive organs

• Teeth

• Tongue

• Salivary glands

• Liver

• Gallbladder

• Pancreas

SIX BASIC PROCESSES:

Ingestion – this process involves taking foods and liquids into the mouth (eating).

Secretion – production and release from a cell or a gland of a physiologically active substance

Mixing and propulsion – alternating contraction and relaxation of smooth muscle in the walls of the GI tract mixing food and secretions and propel them towards the anus.

Digestion – mechanical and chemical process

• Mechanical digestion: teeth and smooth muscles

• Chemical digestion: use of digestive enzymes produced by the salivary glands

Absorption – the passage of digested foods from the gastrointestinal tract into blood or lymph.

Defecation – wastes, indigestible substances, bacteria, and digested materials that are not absorbed leave the body through the anus in the process of defecation.

Layers of the GI tract

MUCOSA

Inner lining of the GI tract which is a mucous membrane

Epithelium

• Squamous epithelium:

serves as protective function

Found in the mouth, pharynx, esophagus, and anal canal

• Squamous columnar:

Secretion and absorption

Lines the stomach and the intestines

Contains two types of cells:

Exocrine cells are present - secretes mucus and fluid into the lumen of the tract

Enteroendocrine cells - secretes hormone into the bloodstream

• Simple columnar epithelial cells

Are firmly sealed to each other by tight junctions that restricts leakage between cells

Lamina propria

– Is an areolar connective tissue containing many blood and lymphatic vessels, which are the routes by which nutrients absorbed into the GI tract reach the other tissues of the body.

– It also contains MALT (mucosa – associated lymphatic tissue). MALT are lymphatic nodules that contains immune system cells that protects against diseases.

MALT is present a along the GI tract, especially in the tonsils, small intestine, appendix, and large intestine

Muscularis mucosae

– The one that form the folds of the mucous membrane of the stomach and small intestine. This folds increases the surface area for digestion and absorption.

– It ensures that a absorptive cells are fully exposed to the contents of the GI tract

SUBMUCOSA

Consists of areolar connective tissue that binds the mucosa to the muscularis

It has many blood vessels and lymphatic vessels that receive absorbed food molecules

Submucosal plexus or Plexus of Meissner (a network of neurons) . These neurons are part of the enteric nervous system. It contains sensory and motor enteric neurons, plus parasympathetic and sympathetic postganglionic neurons that innervate the mucosa and submucosa.

Also contains glands and lymphatic tissue

MUSCULARIS

Consists of:

– Skeletal muscles - produces voluntary swallowing and it is found in the mouth, pharynx, superior and middle parts of the esophagus

– Smooth muscles – found in two sheets. The 1. Inner sheet of muscular fiber and 2. Outer sheet of longitudinal fibers. It is found all throughout the rest of the tract.

Involuntary contractions of the smooth muscle help break down food physically, mix it with digestive secretions, and propel it along the tract.

Myenteric plexus

Contains enteric neurons, parasympathetic ganglia, parasympathetic postganglionic neurons, and sympathetic postganglionic neurons that innervates the muscularis.

Controls GI tract motility (frequency and strength of the muscularis)

SEROSA

A superficial layer of those portion of the GI tract that are suspended in the abdominopelvic cavity

A serous membrane composed of areolar connective tissue and simple squamous epithelium.

PERITONEUM

It is the largest serous membrane of the body.

It consist of a layer of simple squamous epithelium with an underlying supporting layer of connective tissue.

Two divisions:

Parietal peritoneum – lines the wall of the abdominopelvic cavity

Visceral peritoneum – covers some of the organs in the cavity

Peritoneal cavity – the slim space found between the parietal and viscera cavity.

Contains large folds that weave between the viscera.

PERITONEAL FOLDS

GREATER OMENTUM

Omentum (fat skin)

The largest peritoneal fold.

Drapes over the transverse colon and coils of the small intestine

It is a double sheet that folds back upon itself

Contains considerable amount of adipose tissue

It has many lymph nodes (contributes macrophages and antibody – producing plasma cells that help combat and contain infections of the GI tract).

LESSER OMENTUM

Arises as two folds in the serosa of the stomach and duodenum

It suspends the duodenum and the stomach from the liver.

MESENTERY

Is fan – shaped.

Binds the small intestine to the posterior abdominal wall.

It extends from the posterior abdominal wall to wrap around the small intestine and then return to its origin, forming a double layer.

MESOCOLON

Binds the large intestine to the posterior wall

It carries blood and lymphatic vessels to the intestines

Together the mesentery and mesocolon holds the intestine loosely in place, allowing for a great amount of movement as muscular contractions mix and moved the contents along the GI tract.

ALIMENTARY CANAL

MOUTH
PHARYNX
ESOPHAGUS
STOMACH
SMALL INTESTINE
LARGE INTESTINE
ANUS

I.MOUTH/ ORAL/ BUCCAL CAVITY

• It is a cavity bounded externally by the lips and cheeks and leading into the pharynx.

• The roof is formed by the hard and soft palates

• And the anterior two thirds of the tongue fills the floor of the mouth.

• Lips

– are fleshy folds that surrounds the opening of the mouth.

– It is covered externally by skin and internally by a mucous membrane

– There is a transition zone where the 2 kinds of covering tissue meet. This portion of the lips is non-keratinized, and the color of the blood in the underlying blood vessels is visible through the transparent surface layer

• Hard Palate

– The anterior portion of the roof of the mouth

– Is formed by the maxillae and palatine bones

– It forms a bony partition between the ora and nasal cavity

• Soft Palate

– Posterior portion of the roof of the mouth

– An arch-shaped muscular partition between the oropharynx and nasopharynx that is lined by mucous membrane

• Uvula

– a conical muscular process that hangs from the border of the soft palate

– Uvula and soft palate closes off the nasopharynx and oropharynx during swallowing. This prevents swallowed food and liquids from entering the nasal cavity.

– Lateral to the base of the uvula are two muscular folds that run down the lateral sides of the soft palate:

• Palatoglossal arch – anteriorly, extends to the sides of the base of the tongue

• Palatopharyngeal arch – posteriorly, extends to the sides of the pharynx

• Palatine tonsils

– Located between the arches

• Soft Palate

w Posterior portion of the roof of the mouth

w An arch-shaped muscular partition between the oropharynx and nasopharynx that is lined by mucous membrane

• Uvula

w a conical muscular process that hangs from the border of the soft palate

w Uvula and soft palate closes off the nasopharynx and oropharynx during swallowing. This prevents swallowed food and liquids from entering the nasal cavity.

w Lateral to the base of the uvula are two muscular folds that run down the lateral sides of the soft palate:

s Palatoglossal arch – anteriorly, extends to the sides of the base of the tongue

s Palatopharyngeal arch – posteriorly, extends to the sides of the pharynx

• Palatine tonsils

w Located between the arches

II. PHARYNX (throat)

It is a funnel-shaped tube that extends from the internal nares to the esophagus posteriorly and to the larynx anteriorly.

It is composed of skeletal muscle and lined by mucous membrane.

Deglutition – or the movement of food from the mouth into the stomach is achieved by the act of swallowing. It is facilitated by saliva and involves the mouth, pharynx, and esophagus.

Swallowing occurs in three stages:

Voluntary stage: the bolus is forced to the back of the oral cavity and into the oropharynx by the movement of the tongue upward and backward against the palate

Pharyngeal stage:

when the bolus is going into the oropharynx, the involuntary pharyngeal stage begins The respiratory passage closes, and breathing is temporarily interrupted

The bolus stimulates receptors in the oropharynx, which sends impulses into the deglutition center in the brain stem particularly the lower pons and medulla oblongata

The returning impulses causes the soft palate and uvula to move upward to close off the nasopharynx, and the larynx is pulled forward and upward under the tongue. The movement of the larynx pulls the vocal chords together further sealing off the respiratory tract. The bolus passes through the laryngopharynx and esophagus in 1 – 2 seconds

Pharyngeal stage:

when the bolus is going into the oropharynx, the involuntary pharyngeal stage begins The respiratory passage closes, and breathing is temporarily interrupted

The bolus stimulates receptors in the oropharynx, which sends impulses into the deglutition center in the brain stem particularly the lower pons and medulla oblongata

Esophageal stage

the passage of food from the laryngopharynx into the esophagus is regulated at the entrance to the esophagus by a sphincter called the UES (upper esophageal sphincter).

The elevation of the larynx during the pharyngeal stage of swallowing causes the sphincter to relax, making the bolus enter the esophagus.

During this stage, because of peristalsis (a progression of coordinated contractions and relaxations of the circular muscles and longitudinal layers of the muscularis, wavelike motion) the bolus is push onward and towards the stomach. The passage of solid and semi solid from the mouth to the stomach takes about 4 – 8 seconds; while very soft foods and liquids pass through in about 1 second.

The LES (lower esophageal sphincter), relaxes during swallowing and thus allowing the bolus to pass from the esophagus to the stomach.

III. Esophagus

It is a collapsible tube that lies posterior to the trachea

It is about 25 cm (10 inches) long

It begins at the level of the sixth cervical vertebra and descends through the mediastinum in front of the vertebral column and behind the trachea.

It passes through the diaphragm at the level of the 10^th thoracic vertebrae and ends at the cardiac orifice of the stomach at the level of the eleventh thoracic vertebrae

The esophagus has four layers:

Fibrous outer layer: consists of areolar tissue containing many elastic fibers

Muscular layer: comprised of two layers, the outer with fibers running longitudinally and the inner layer consisting of circular fibers

Areolar or muscular layer:connects the mucous and muscular coats and contains the larger blood vessels and nerves, as well as the mucous glands.

mucous membrane

IV. STOMACH

Location:

Inferior to the diaphragm in the epigastric, umbilical, and left hypochondriac region.

J - shaped

Anatomy:

It has four main regions:

• Cardia: superior opening of the stomach

• Fundus: rounded portion

• Body: large central portion

• Pylorus: the region of the stomach that connects to the duodenum

Four layers of the stomach wall:

Outer serous layer

Muscular layer – this consists of three layers of smooth muscle fibers, the outer being longitudinal, the middle circular and the inner oblique

Submucous layer – this is composed of loose areolar tissue

The lining of the mucous membrane – it has numerous folds(rugae), which run longitudinally and flattens out once stomach is full

Functions of the stomach:

Mixes saliva, food, and gastric juice to chyme.

Reservoir for holding food before release into small intestine.

Secretes gastric juice (2000 – 300ml per day), which contains:

• HCl: kills bacteria and denatures proteins in food and stimulates secretion of hormones that promote the flow of bile and pancreatic juice

• Pepsin: protein-digesting enzyme

• Intrinsic factor: aids in absorption of Vitamin B₁₂

• Gastric lipase: aids digestion of triglycerides

Mixes gastrin (a type of hormone that is secreted by the G cell which is located in the pyloric antrum) in the blood

Regulation of Secretion and Motility

Cephalic Phase:

The cephalic phase of gastric digestion consists of reflexes initiated by sensory receptors in the head.

Sight, smell, thought of food

the cerebral cortex and the feeding center in the hypothalamus send nerve impulses to the medulla oblongata

Stimulate the gastric glands to secrete pepsinogen, hydrochloric acid, and mucus into stomach chyme and gastrin into the blood; and increase gastric motility

Gastric Phase

Once food reaches the stomach

The stomach walls distends and a peristaltic movement called mixing waves pass over the stomach every 15 – 25 seconds.

Macerates, mixes the food with gastric juice and reduce the food into a soupy liquid (chyme).

chyme (10 –15 ml) will got to the duodenum passing the pyloric sphincter making the stomach wall less distended

The negative feedback cycle suppresses secretion of gastric juice

Intestinal Phase

This phase is an inhibitory phase wherein it prevents chyme from totally leaving the stomach and overloading the duodenum.

Two hormones are release into the blood that affects the stomach:

• Secretin – decreases gastric secretion

• Cholecystokinin – inhibits stomach emptying

Small Intestine

It is where the major event of digestion and absorption occurs

Length: 3 meters (10 feet)

Divided into three regions:

• Duodenum – the shortest region

Only about 10 inches

Starts at the pyloric sphincter and merges with the jejunum

• Jejunum – about 1 m (3 feet)

• Ileum – measures about 2 m (6 feet)

Muscles of the Small Intestine

Mucosa and submucosa facilitates the process of digestion and absorption

Mucosa – forms a series of fingerlike villi

- each villi has a connective tissue which contains a venule, arteriole and a blood capillary network and a lymphatic capillary

- microvilli

- lined with epithelium that formed intestinal glands which secretes intestinal juice;

- epithelial cells in the mucosa are also goblet cells which secretes mucus

Submucusa – contains duodenal glands that secretes an alkaline mucus that helps neutralize gastric acid in the chyme.

Mechanical digestion in the Small Intestine

Two types of movement in the small intestine

A. Segmentation

B. Are localized, mixing contractions that occur in portions of intestine distended by a large portion of chyme. Chyme is mix with the digestive juices and bring the particles of food into contact with the mucosa for absorption.

C. Segmentation is usually faster in the duodenum at is slower at the ileum.

• Migrating motility complex (MMC)

• Begins when all the food is absorbed and segmentations stops and peristalsis begins.

• Starts at the lower portion of the stomach and pushes chyme forward a long stretch of small intestine before it dries up.

• It takes about 90 – 120 minutes to reach the ileum, so chyme stays in the smal intestine for about 3 – 5hours

Chemical digestion in the Small intestine

The chyme that enters the small intestine contains partially digested carbohydrates, proteins, and lipids

Digestion of carbohydrates:

Starches that are not broken by the salivary amylase re acted on by pancreatic amylase (an enzyme in pancreatic juice) except for cellulose.

Digestion of Proteins:

Protein starts its digestion in the stomach. The following enzymes that act on protein are the following: trypsin, cymotrypsin, carboxypeptidase, and elastase

Digestion of Lipids:

Triglycerides are emulsified by the the bile salts

Absorption

Carbohydrates:

It is absorbed as monosaccharides via a facilitated diffusion.

Proteins:

Is absorbed as amino acids via active transport

Lipids

Absorbed via simple diffusion

Electrolytes

Via an active transport

Vitamins

ADEK (fat soluble): absorbed via simple diffusion

Most B vitamins and Vitamin C: simple diffusion

Vitamin B12: combines with intrinsic factor

Water

Absorb through osmosis

Large Intestine

- It is the terminal portion of the GI tract

Length: 1.5 m (5 feet)

Diameter: 6.5 cm (2.5 in.)

From the anus to the ileum

Parts:

Ileocecal sphincter (valve)

Cecum – a blind pouch

Appendix – a coiled tube attached to the cecum

Colon : ascending, transverse, and descending

Rectum

Anal canal

Mechanical Digestion

The passage of chyme from the ileum into the cecum is regulated by the action of the Ileocecal sphincter.

Presence of food

Gastroileal reflex

Intensifies ileal peristalsis

Pushes chyme in the ileum into the cecum making the cecum distended and contractions t the ileocecal sphincter intensifies

Absorption and Feces formationAbsorption and Feces formationAbsorption and Feces formation

Chyme becomes solid or semi solid because of water absorption and it will becomes as feces.

Approximately 100 – 200 ml of water is reabsorb back.

The large intestine also absorbs ions, sodium and potassium, and some vitamins.

Defecation

Distention of the recital wall stimulates stretch receptors which in return will initiate the defecation reflex.

Send impulses to the sacral spinal chord which will initiate contraction of the rectal muscles thereby increasing the pressure within.

Internal anal sphincter is open.

External anal sphincter is relaxed

Defecation occurs

Major Salivary glands

Where most saliva is secreted

Lies beyond the oral mucosa but has ducts that lead to the oral cavity

3 pairs of major salivary glands:

1. Parotid glands

• Are located inferior and anterior to the ears (between the skin and the masseter muscle)

• Secretes saliva into the oral cavity via a parotid duct

• Contains cells that secrete a watery (serous) liquid containing salivary amylase

2. Submandibular glands

• Found beneath the base of the tongue in the posterior aspect of the floor of the mouth

• Submandibular ducts – run under the mucosa on either side of the floor of the mouth

• Contains cells similar to those found in the parotid glands, plus some mucous cells

Sublingual glands

1. Are superior to the submandibular glands

2. The lesser sublingual ducts, open into the floor of the mouth in the oral cavity

3. It contains mostly mucous cells, so they secrete a much thicker fluid that contributes only a small amylase to the saliva

TONGUE

An accessory digestive organ that is composed of skeletal muscle covered with mucous membrane

Extrinsic muscles:

located on the side of the mouth

moves the tongue from side to side, in and out to maneuver food for for chewing, shape the food into a rounded mass, and force the food to the back of the mouth for swallowing.

Holds the tongue in position

Intrinsic muscles:

alter the shape of the tongue for speech and swallowing

Lingual frenulum:

A fold in the midline of the undersurface of the tongue and is attached to the floor

Limits the movement of the tongue posteriorly

TONGUE

3 MAJOR REGIONS:

CROWN – VISIBLE PORTION ABOVE THE LEVEL OF THE GUM

ROOT - SOCKET

NECK – CONSTRICTIVE JUNCTION OF THE CROWN AND ROOT NEAR THE GUM LINE

COMPOSITION:

Dentin – a calcified connective tissue that gives the teeth its basic shape and rigidity

Pulp cavity – lies within the crown and is filled with pulp

Enamel – the one that covers the dentin

Function:

Cut, tear, and pulverize food to reduce solids to smaller particles for swallowing

LiveR

The heaviest gland in the body

Weighs about 3 bs

And it is the 2^nd largest organ of the body

Divisions:

Right lobe

Left lobe – the smaller of the two

Falciform ligament – the one that divides the two lobes

STRUCTURE:

FUNCTIONAL UNIT: LOBULES

Lobules: made up of epithelial cells called hepatocytes

BLOOD SUPPLY:

It receives blood from two sources:

Hepatic artery – receives the oxygenated blood

Hepatic portal vein – receives the deoxygenated blood containing newly absorbed nutrients, drugs, and possibly microbes and toxins from the GIT.

FUNCTION

Metabolic function:

Desaturation – wherein is breaks down stored fats

Breaks down excess amino acids and converts to urea

Converts excess carbohydrates into fat for storage

Detoxifies drugs and poisons

Synthesizes Vit. A, plasma protein, and prothrombin and fibrinogen

It is the main heat producing organ in the body

Manufactures antibodies, antitoxins, and heparin

Storage function

Vitamins A and D

Anti anemic factor

Iron from the diet and worn out blood cells

Secretory function:

Secretes bile

GALBLADDER

It is a pear – shaped organ situated on the undersurface of the right lobe of the liver.

It has a cystic duct that passes backwards and downwards to form the common hepatic duct and together they form the bile duct.

It stores bile

When fatty foods enters the duodenum the sphincter at the entrance to the bile duct relaxes and bile that is stored goes to the intestine

PANCREAS

Location: lies posterior to the greater curvature of the stomach

Parts:

Head - attaches to the duodenum

Body

Tail

Ducts: 2 major ducts found

Pancreatic duct (duct of Wirsung) – larger of the two

• It joins the common bile duct and forms the hepatopancreatic ampulla (ampulla of Vater)

Accessory duct (duct of Santorini)

• Empties directly to the duodenum

Pancreas is made up of small clusters of glandular epithelial cells.

Acini – 99 percent of the pancreas

- exocrine portion of the organ

- Secretes pancreatic juice (a mixture of fluid and digestive enzymes)

- approx 1200-1500/day.

- clear, colorless liquid made up mostly of water, some salts, sodium bicarbonate and some enzymes

enzymes:

s pancreatic amylase – digests CHO

s trypsin, chymotrypsin, carboxypeptidase, and elastase – digests CHON

s Pancreatic lipase – digests triglycerides

Islet of Langerhans – 1% of the pancreas

s endocrine portion of the of the pancreas

s Secretes the following hormones: glucagon, insulin, somatostatin, and pancreatic polypeptide

NATUROPATHY

2008-03-09T11:37:00.000-07:00

I came across this article in Yahoo! Health. Its interesting how many new remedies arise from time to time with the advancement of technology, now medicine seems to have gone back to the time of herbal healing. Read on, this may be useful.

What is naturopathic medicine?

Naturopathic medicine (or naturopathy) is based on the belief that the body can heal itself naturally. Naturopathic medicine attempts to improve health, prevent disease, and treat illness by promoting the use of organic foods and exercise; encouraging a healthy, balanced lifestyle; and applying concepts and treatments from other areas of complementary medicine (such as ayurveda, homeopathy, and herbal therapies).

Most traditional naturopathic physicians (naturopaths) believe in natural therapies, such as nutritional and lifestyle counseling. They generally avoid prescribing medicines or performing surgery. Some naturopaths prescribe herbal medicines, homeopathic dilutions, nutritional supplements, or perform minor surgeries.

What is naturopathy used for?

People use naturopathic medicine for promoting good health, preventing disease, and treating illness. Most naturopaths can treat earaches, allergies, and other common medical problems. Naturopathic medicine tries to find the underlying cause of the condition rather than focusing solely on treating symptoms. A properly trained naturopathic physician works with other health professionals, referring people to other practitioners for diagnosis or treatment when appropriate.

Venipuncture Techniques

2008-03-06T06:17:00.001-08:00

I found this article on www.nursinglink.com for those of you practicing venipuncture...this is a lot of help.

Always use universal precautions and aseptic technique. Avoid needle sticks.

Excess hair may be removed to enhance site preparation and to facilitate catheter insertion, taping, and dressing adherence. INS advocates use of scissors for this. Extremely dirty skin should be cleaned with soap and water before an anti-microbial solution is applied. Skin cleansing solution should be applied in a concentric circle, from the center to the periphery of the intended site to be accessed. Solution should be allowed to air dry before proceeding. The area that is prepped should extend beyond the size of the dressing used. Alcohol is applied first, allowed to dry, and then Betadine is applied unless the patient is allergic to iodine/Betadine. Extra alcohol wipes should be used in case of patient allergy to Betadine. The site is considered clean when the last alcohol wipe used comes away clean. Alcohol is an anti-microbial agent. It kills staphylococcus epidermis. It also removes oil from the skin. Additionally, the alcohol rub applied over the vein dilates the vein. Much of the Betadine’s germicidal action takes place in the first minute after application. It is effective for up to six hours after drying. Blot the Betadine dry with a sterile 2X2 gauze to allow for better visibility of the vein.

Preparation for Venipuncture

Success at the first stick depends on proper preparation. If rushed and nervous, failure of the cannulation attempt is likely. The nurse should put him/herself and the patient at ease. The patient needs an explanation of the procedure in appropriate, understandable terminology. The patient needs to have confidence in the clinician. The clinician should determine the patient’s history with I.V. therapy.

A patient may have a history of needle phobia. Needle phobia is an inherited vasovagal response and/or a learned reaction as result of previous I.V. sticks. The symptoms prior to insertion are tachycardia and hypertension. On insertion bradycardia and a drop in blood pressure occurs with signs and symptoms of pallor, diaphoresis, syncope and in rare occasions, asystole and death. The onset of vasovagal response is usually immediate or sometimes it can occur five to thirty minutes after the stick. Patients with needle phobia will avoid medical help at all costs. Techniques for managing patients with needle phobia are reassurance, education, keeping needles out of sight until the last minute before use, distraction, elevation of legs, use of valium (diazepam), or topical anesthetics (Emla, ice, or lidocaine 1% without epinephrine.)

Tourniquet Application

Before applying a tourniquet, the nurse should look for blue lines (veins) on the arm or rounding out of veins under the skin starting with the hand and moving up the arm. To obtain a maximally vein, a tourniquet should be applied correctly and the selected vein should be tapped lightly. Care should be taken to not pinch the patient’s skin in the tourniquet. Use of blood pressure cuff at 30 mm/hg will also provide a dilated vein.

THIRTEEN I.V. TIPS AND TRICKS

1. TAKE YOUR TIME when choosing the right vein!

2. TAKE YOUR TIME performing the venipuncture!

3. Think: Purpose->Appropriate Access->Appropriate Catheter Size->Appropriate Site

4. Apply tourniquet 6 to 8 inches above the selected puncture site.

5. No veins: Let arm hang down for a while-the “praying position” for venipuncture.

6. No veins: Apply warm towels over several minutes.

7. Bad filling: Some people swear on “milking the vein”-gently stroke from distal to proximal.

8. No veins: Some people swear on double tourniquets-one high on the arm, one 4 inches above the puncture site.

9. For low blood pressure: Use a BP cuff, not a tourniquet.

10. For well filled, but fragile veins: Try puncture without using a tourniquet.

11. In patients with hypovolemia: Use larger veins as small veins collapse quicker.

12. When a patient’s upper extremities are grossly edematous, apply a tourniquet for a few minutes to create an “indentation”; after removal a vein can usually be seen in the well of the indentation.

13. Apply warm towels on the cannulated arm if an irritating medicine is being infused.

Discussion with the patient about his/her I.V. history at this juncture will provide the R.N. with information to become the patient’s advocate. Venous status or patient’s condition may suggest the use of a central line instead of a peripheral line placement. At this point you should also inquire whether the patient is allergic to Betadine, lidocaine, tape, or latex. Most hospitals allow the I.V. therapist the option to use lidocaine intradermally to numb the skin prior to a needle stick.

Lidocaine 1%, without epinephrine, should be offered to each patient prior to an I.V. stick, if the patient reports no allergies to the Lidocaine. A dosage of 0.02 cc to 0.03 cc in a 1 cc T.B. syringe should be administered at a 5’ angle intradermally over the vein to be cannulated. The exact spot where the angiocath enters the skin should be numbed. The site will be immediately numbed and will remain numb for up to 15 minutes. If too much Lidocaine is administered (e.g. 0.1 cc), the skin and vein will constrict and accessing the vein will become more difficult. In patients with loose skin, i.e. the elderly, the medicine may diffuse under the skin, possible resulting in less effective numbing. The nurse should be aware of this possibility and compensate accordingly.

A high number of individuals with spina bifida or congenital urological abnormalities tend to have latex allergies or may be predisposed to developing such allergy. Latex allergy can lead to anaphylactic shock. Latex is found in yellow tourniquets, I.V. bag ports, Y-sites on I.V. tubing, tops to medication/N.S. bottles, to name a few. If the patient has a latex allergy, cover the tourniquet with stockinet. Healthcare workers are also at risk for developing latex allergies. Good hand washing is required and use of non-latex gloves is advocated.

Cannulation Supplies

1. Favorite tourniquet (or two) 2. Appropriately sized angiocath 3. I.V. extension tubing 4. 2 packages of 2X2 gauze 5. Tape 6. 4 alcohol wipes 7. 1 Betadine wipe 8. Needle and syringe 9. N.S. bottle 10 cc 10. Supplies for doing blood work as needed 11. Warm pack consisting of a warm, wet towel in a plastic blue chux 12. Magic marker to label dressing

Steps in Cannulation Techniques

After having found or made a vein large enough for cannulation

1. Use the top approach

2. Use lidocaine 1% to numb the skin prior to insertion of a 22 or larger gauge needle (remember that only the wall of the vein where lidocaine is injected intradermally will be numb but if the R.N. rides along the vein with the needle and accesses the vein away from the lidocaine injection site, the patient will still feel discomfort of the stick. Use of too much lidocaine will obliterate the vein.) CHECK FOR PATIENT ALLERGIC RESPONSE

3. Hold angiocath with bevel facing up at a 10 to 20 degree angle on top of the skin over the chosen vein.

4. Pull skin taut (but not so taut that you flatten the vein). If cannulating on hand, have the patient loosely close the hand.

5. Using a continuous, slow motion, advance angio through the skin. Round out angio slightly while under the skin.

6. With continuing slow motion, advance the cannula a minimal amount to pass it through the wall of the vein (you should now see the beginning of a “flashback”) and you should have felt a “pop” as the needle penetrated the vein wall (DO NOT CANNULATE THROUGH THE OPPOSITE WALL!) Lower the angle of the cannula as you continue to minimally advance the angio into the center of the vein. The flashback will continue. Now loosen the tourniquet.

7. Once in the center of the vein, slide the angio further into the center of the vein and off the stylette. Pull the stylette back a minimal amount. Flashback will now be observed in the cannula, which remains in the vein.

8. You should now be able to easily advance the cannula up the center of the vein. Continue to watch for flashback. If the cannula is stuck (it could be hung up on a valve within the vein), advance it by flushing it up the vein with N.S. The entire process of accessing a vein should be done with one slow, continuous motion from start to finish.

9. Loosen the tourniquet for sure at this point (if not done earlier) and SMILE!

Patient education is an important part of I.V. cannulation placement. Instruct the patient to report ANY signs and symptoms of soreness at the I.V. site and remind the patient that once an I.V. site is sore, it will not get any better. This soreness is irreversible until the I.V. is removed. Document that the nurse/medical technician has instructed the patient about reporting soreness.

Challenging Veins

Veins with valves are recognized as having little bumps along the track of the vein. Weight lifters, sculptors, and construction workers tend to have more valves in their veins than the average person. If unsuccessful in advancing an angiocath up such vein, use a floating technique to open the valves and subsequently advance the angio up the vein. This floating technique is accomplished by attaching a primed extension tubing to the cannula and flushing that tubing with N.S. via a syringe.

Some patients will have arms and hands the shape of which will interfere with the placement of the cannula by the nurse. In these cases, use a sterile cap to slightly bend the tip with the bevel facing up and then approach the vein. This will change the angle and facilitate accessing the veins of the inner arm.

Bifurcated veins are recognized by an inverted “V” shape. These veins are less likely to roll; however, the vein should be accessed below the bifurcation for the highest probability of cannulation success.

Accessing large, “ropy” veins, often found in the elderly, should be done without the use of a tourniquet because the veins are less structurally sound and tend to rupture easily.

Similarly, use of hand veins in the elderly is not recommended because they, too, tend to rupture easily.

Basilic veins located immediately below the elbow, particularly those in male patients, are large and attractive for venipuncture; however, the accessing is difficult for two reasons: 1) the angle of approach for the nurse is awkward and 2) they tend to roll easily and therefore require significant attempts to stabilize them.

Troubleshooting Insertion Technique

Success of I.V. placement is VERY DEPENDENT on the nurses own confidence level, the nurse’s relaxation level, and of rapport with the patient. Success also depends on proper tourniquet placement and the selection of a proper, well-rounded vein. Tourniquet pressure is critical; too loose, and the vein will not round properly, too tight, it can result in a ruptured vein that turns into a hematoma.

Consider the following problems when troubleshooting your insertion technique:

1. An improper tourniquet placement

2. Failure to release tourniquet once angiocath is in the vein

3. With a tentative start and stop approach, the vein disappears

4. Failure to recognize when a cannula has gone through the vein; resulting in a hematoma

5. Stopping too soon after insertion can cause a hematoma or a disappearing vein

6. Inserting a cannula too deep and missing the vein altogether is generally a result of too steep an angle of approach for the depth of the vein

7. Failure to penetrate the vein is generally a result of a dull angiocath or a sclerosed vein

8. Getting stuck in the wall of the vein is usually the result of not advancing the angiocath far enough in towards the center of the vein. Signs of this condition are a positive flashback with the inability to advance the angiocath with ease.

9. A difficult to advance angiocath is generally indicative of not being in the center of the vein. Advancing the angiocath a small amount will generally place it in the center of the vein.

10. A ruptured vein on insertion is generally a result of the use of too large an angiocath for the size of the vein

11. Pain during insertion can be a result of touching a nerve ending. Start over at a new location and document that the I.V. therapist has possibly hit a nerve. If the cannula is left in place, this nerve will continue to be triggered and will result in a painful I.V. site for the patient.

12. Improper taping of the I.V. tubing across the cannula and the vein beneath it will later cause pain during infusion. Tape the tubing away from the cannula site.

DO NOT PROBE FOR VEIN UNDER THE SKIN! Very seldom will an incorrectly placed angiocath end up properly in the center of the vein. This action will cause damage to the vein and surrounding tissue.

The aim of I.V. placement is to make a direct, clean stick into the vein and to do so slowly.

Documentation

Documentation provides a means for recording and retrieving information. It also provides information about the patient’s clinical outcome. Information provided through documentation can help the medical professionals decide upon the best vascular access device for that particular patient. Documentation should include date and time of I.V. insertion, specific vein chosen, gauge and length of inserted device, solution(s) and medication(s) infused, the rate of infusion, and any comments made by the patient about the insertion. Document any difficulties encountered while inserting angiocath. If R.N.s who care for the patients afterwards are aware of specific difficulties, it will assist them in providing better patient care, avoid unnecessary pain for the patient, and save time.

With I.V. therapy lawsuits on the rise, it is very important to have complete documentation of I.V. angio placement including verbal and written consents obtained prior to the procedure. The consents should be obtained from the patient, the family, or the patient’s power of attorney.

A tip for nursing documentation. DON’T DOCUMENT WHAT YOU DON’T SEE. In other words do not use phrases such as “no swelling, no redness, no leakage observed”. These phrases have not held up in courts of law. Use instead, “No signs and symptoms of I.V. related complications observed,” if that is the case.

Site and Catheter Care

I.V. site checks should be made at least every two hours and every time the nurse sees the patient in-between. Chart these observations.

Angiocaths placed while the patient was in an ambulance or in the field should be changed within twelve hours of arrival at the hospital or as soon as the patient is stable. This also applies to re-accessing implantable port-a-caths. With each new admission, inquire about the place and time of the V.A.D. placement and document the findings.

Change an I.V. site every 72 hours or if redness, tenderness, swelling, pain, streaking, palpable cord, purulence, and/or leakage around the insertion site is observed. A large gauge cannula, placed pre-operatively, should be changed as soon as the patient is stable after the procedure. If a patient is immuno-compromised, the cannula should be changed every 48 hours or as needed (P.R.N.) Follow the facilities procedures. These patients are at risk for developing a potentially life threatening inflammation of the vein.

Dressing changes on peripheral lines should be done ONLY if the patient refuses to have the cannula site changed or if the patient is to be discharged the next day and if there is no sign of complications. If the patient refuses to have the I.V. site changed, the nurse must explain to the patient that there is risk of soreness and complications.

During site assessment, the R.N. should check for dressing and taping security, for date, angio length and gauge, for wet dressings, and for signs and symptoms of phlebitis, hematoma, and infiltration. The I.V. site should not be covered with tape, as tape does not allow moisture to evaporate (a greenhouse effect). When fluids that support the growth of bacteria collect under the tape, the patient may contract life threatening, blood borne infections. Use gauze over the insertion site.

An alert and oriented patient should be asked about soreness in the I.V. site and the site should be gently palpated during assessment.

Site Complications

Potential complications are many. Contributing factors for complications to occur are:

1. Age of patient 2. Patient’s medical condition 3. Skin integrity* 4. Site of infusion 5. Duration of infusion 6. Method of infusion 7. Line maintenance 8. Activity of the patient 9. Insertion technique

*The patient who is on steroids and who is a diabetic usually have compromised skin and veins. Thin skin impairs the local skin defenses.

Potential local complications are:

1. Hematoma 2. Phlebitis 3. Clotting 4. Thrombophlebitis 5. Infiltration 6. Extravasation

Hematoma is the most common complication of a routine venipuncture. A hematoma is due to leakage of the blood under the skin during or after a venipuncture. The cause is a through-the-vein venipuncture and because of needle displacement. A hematoma can also be a result of the re-application of a tourniquet after an unsuccessful stick. Symptoms of a hematoma are tenderness, ecchymosis, and inability to flush or advance the cannula. Treatment of a hematoma is to remove the catheter, to apply pressure, and warm soaks. Document circumstances leading up to the hematoma. Most malpractice suits related to I.V. therapy are due to hematomas.

Phlebitis is defined as an injury to the vessel wall. Transient mechanical phlebitis appears in the first 48 to 72 hours after insertion. The incidence is higher in women than in men by a ratio of 15 to 1. Phlebitis occurs more frequently with larger gauge needles, traumatic insertion, and with glove powder. To reduce the risk of phlebitis, the angiocath should be as small in diameter as possible, thus taking up less room in the vein and allows for better blood flow around the catheter. The area’s circulation is not compromised and medications get diluted as they enter the vein. Treatment is started with cool compresses to relieve pain, then warm compresses for twenty minutes every four hours until improvement is evident. Elevation and mild exercise are also recommended. Signs and symptoms of infusion phlebitis are redness, swelling, and tenderness. About 60% of all hospitalized patients develop infusion phlebitis between 8 to 16 hours after insertion. Presence of pain at insertion site may be the precursor to phlebitis and may require removal of cannula. Once and insertion site is sore, the soreness will only get worse if the cannula is left in place. Removal of cannula does not terminate the development of phlebitis. Monitor the I.V. site after removal of cannula and document your observations.

There are three types of phlebitis: mechanical, chemical, and bacterial.

The causes of mechanical phlebitis are the use of too large a size of cannula, improper taping, cannula’s location near area of flexion, size and condition of the vein, and the technique of the clinician. Tips to avoid the onset of mechanical phlebitis are:

1. Do not use area of flexion 2. Anchor cannula well 3. Use aseptic technique 4. Use cannula smaller than vein 5. Use a smooth insertion technique

The cause of chemical phlebitis is:

1. Using solutions of >300 mEq/liter 2. Solutions of a high pH 3. Solutions with a large amount of particulate matter

These solutions cause pain at insertion site and irritation to wall of vein. Sufficient dilution of medicine can help this type of phlebitis. The addition of lidocaine 1% to solution or medicine can help prevent irritation to the vein. A doctor’s order is required for this.

The most common cause of bacterial phlebitis is a contaminated catheter hub as well as add-on devices and a fibrin sheath. Bacterial infections in immuno-compromised patients can lead to septicemia. Septic phlebitis can be avoided by using a new cannula for each insertion attempt.

Follow the facilities policy and procedures as far as writing out incident reports should phlebitis, hematoma, or infiltrates occur. Phlebitic events can be reduced by changing I.V. sites every three days or P.R.N. and by performing an excellent skin preparation. Proper skin prep can reduce the growth of microorganisms and the formation of a fibrin sheath.

Some control measures in relation to phlebitis are:

1. Conformation to established policies and procedures 2. Hand washing 3. Proper site and device selection 4. Site preparation 5. Product integrity 6. Cannula placement 7. Occlusive dressing 8. Minimal handling of dressing and I.V. site 9. Frequent inspection 10. Catheter stabilization 11. Using sterile technique 12. Routine changes of dressing, site, and tubing

Thrombophlebitis is caused by injury to the vein during the venipuncture. It can also be cause by a sluggish flow rate as this allows a clot to form at the end of the catheter. Thrombophlebitis is a thrombus plus inflammation. Contributing factors are:

1. Duration of infusion 2. Osmolality and pH of infusate 3. Site of infusion, e.g. areas of flexion 4. Small veins 5. Venipuncture technique

Clotting is caused by any injury that roughens the endothelial cells of the venous wall. The anti-coagulant property of this endothelial layer gets destroyed. Endothelial damage causes inflammation through fibrin, protein, and platelet deposits (a thrombus forms) to which bacteria adhere. White blood count and anti-bodies “come to the rescue”. Bacteria secrete a slime to protect themselves. This layer of slime is called a biofilm. Bacteria will leave this biofilm and enter the blood stream, potentially causing septicemia.

Thrombosis occurs when a local thrombus obstructs the circulating blood. Thrombus prevention can be obtained through a smooth, efficient cannula insertion and removal technique.

Infiltration is caused by an inadvertent administration of a non-vesicant medication/solution into surrounding tissue through an improperly placed or dislodged cannula. Signs and symptoms of infiltration are swelling, tenderness, and decreased skin temperature. Treatment consists of removal of catheter, elevation, and cool/warm compresses.

Extravasation is an inadvertent administration of a vesicant medication/solution into surrounding tissues. A vesicant is an agent that is capable of causing pain, necrosis, and sloughing of tissue. The onset of symptoms can be immediate or delayed. Morbidity is dependent upon the type, amount, and concentration of the medication/solution and upon the location of the infiltrate. Signs and symptoms are discomfort, erythema, blistering, necrosis, swelling, burning/coolness, blanching, and ulceration. Call the pharmacy if there is a question whether the drug being administered is a vesicant and ask about the antidote available. Best results are achieved if treatment is administered within one hour of the acute extravasation occurrence. Treatment of extravasation consists of stopping the I.V. infusion, pulling back on tubing to extract as much of the medicine/fluid as possible. Then remove the I.V. catheter unless the needle is to be used as a path to infiltrate the tissue with an antidote. Estimate the amount of extravasated solution and notify the physician. Administer the appropriate antidote following the physician’s order and the pharmacist’s instructions. Elevate the extremity. Apply either ice packs or warm compresses to the affected area for a 20-minute period every 4 hours until improvement is evident. The choice of the latter should be discussed with the pharmacist. Take a photograph of the site if indicated. Document the site of extravasation, the drug, time and date, and approximate amount infused. Document the patient’s symptoms and complaints and the appearance of the site. Indicate nursing treatment and the doctor’s notification and outcome. An incident report should be filled out and acted upon per institutional policy.

Potential Systemic Complications

Systemic complications may develop quickly and insidiously. Septicemia, pulmonary edema, speed shock, allergic reactions, and occlusions are all potential systemic complications.

Septicemia has been previously covered.

Pulmonary edema is a result of too rapid infusion of fluids, which increases the venous pressure and dilates the cardiac muscle. Overloading the circulation is especially hazardous to the elderly patient and patients with impaired renal and cardiac functions. Signs and symptoms of pulmonary edema are venous dilation with engorged neck veins, increased blood pressure, rapid respiration, and shortness of breath. To correct the situation, slow down the infusion and notify the physician.

Speed shock is a term used to denote the systemic reaction that occurs when a substance, foreign to the body, is rapidly introduced into the circulation, flooding the organs rich in blood (heart and brain); as a result sycope shock and cardiac arrest may occur. It can be avoided by not playing catch-up and by avoiding free flow by gravity.

Allergic reactions to medications may occur from the first to the fifteenth dose. Treat as needed.

There are three types of occlusions: mechanical, thrombotic, and precipitate.

Mechanical occlusions are due to kinks in tubing. Trouble shoot the I.V. line from the insertion site to the I.V. bag.

Thrombotic occlusions can be avoided by eliminating irritation of the wall of the vein and by not allowing the I.V. bag to run dry.

Check I.V. solutions for precipitates and use filters when appropriate. A 0.2-mm filter is an absolute bacteria retentive and air eliminating filter. Particulate matter is a mobile, undissolved substance unintentionally present in parenteral fluids, such as rubber, glass, molds, and drug particles. Studies have shown that particulate contamination is present in all I.V. fluids and administration sets. The vascular route of infused particles is as follows:

Particles introduced into the vein -> right atrium of the heart -> tricuspid valve -> right ventricle of the heart -> pumped into pulmonary artery -> branches decreasing in sizeà particles trapped in massive capillary bed of lungs as well as the brain, kidneys, and eyes.

Infection Control by Handwashing

Infection control is achieved through hand washing. Gloves do not preclude hand washing. Gloves do not just prevent nosocomial infection, but they also protect the nurse from blood borne pathogens, such as HIV, Hepatitis B, and Hepatitis C.

The skin offers a fertile medium for bacterial growth. Staphylococcus Aureus cause one-third to one-half of all I.V. device infections. Gram-Negative Bacilli are rampant on the skin of hospitalized patients. Ten thousand organisms per square centimeter can be found on normal skin. Blood stream infections have tripled over the past ten years and nosocomial infections are the fourth leading cause of hospital deaths in America with annual costs exceeding $4.5 billion. Persons with a high probability of acquiring I.V. infections are: the elderly with less elastic skin, patients with heart disease, diabetes, and HIV, patients receiving steroids, and patients whose immune systems are compromised and who have received chemotherapy.

Sources of cannula related infection are the hands of medical personnel, hematogenous seeding from an established organ infection, contaminated disinfectants, and from the patient’s own skin contamination introduced into the vein via the catheter.

Termination of I.V. Cannula

Termination of an I.V. cannula occurs upon a doctor’s order, prior to discharge, with signs and symptoms of infection, after placement of a functioning central line, and after three days in the vein. Documentation should consist of writing down the following observations:

1. Catheter intact 2. Application of pressure dressing 3. Appearance of site after catheter removal

If upon removal, the cannula is not intact, apply a tourniquet above cannula site, call the doctor, and check the circulation of the extremity. If a cannula is to be sent to the laboratory for culture and sensitivity, the following action should be taken:

1. Scrub the insertion site around the cannula with alcohol to remove exudate 2. Quickly remove catheter onto a sterile gauze 3. Cut below hub with sterile scissors 4. Let drop in sterile container 5. Label per the facilities policies and procedures 6. Send to laboratory

Nursing Responsibilities Regarding I.V.Therapy

In general, the nursing responsibilities regarding I.V. therapy are:

1. Know the protocols and procedures related to access device used. Follow them. 2. Know the medication or solution to be infused, the desired actions, untoward actions, side effects, and normal dosage. Report the patient’s reactions and measures to prevent complications. 3. Be aware of osmolality, pH of drugs and solutions. 4. Make sure that medications and solutions are stored properly and are not outdated. 5. Make sure medications, which are infused simultaneously, are compatible. 6. Change I.V. tubing and central lines dressing per protocol. Label them. 7. DO NOT INFUSE MEDICINES SIMULTANEOUSLY WITH BLOOD TRANSFUSIONS! 8. Clarify unclear orders 9. Documentation is crucial–REMEMBER, IF YOU DIDN’T DOCUMENT, IT WAS NOT DONE! 10. Know your abilities and show confidence.

As you work to improve your I.V. skills, a few failures should not set you back. Practice leads to improvement. Good Luck!

Should You or Should You Not Be A Nurse?

2008-03-06T01:55:00.001-08:00

There are a lot of people taking nursing right now. As of this time, lots of nursing schools are sprouting all over the Philippines, and sadly not all are credible. Everywhere you go, you see nursing students that are first coursers, second coursers and sometimes every professionals from other fields. It's mind boggling how many people want to become nurses.

There are a lot of reasons why people are taking nursing. I'd like to think that those who are taking nursing right now are taking it for the reason of service and dedication to the public and promotion of health to the Philippines, but even I didn't think of that when I first entered into the nursing course.

Like tons of students out there, I am one such student that shifted to nursing because it was what my parents asked of me. I believe it took me 2 years to actually fit in to the nursing crowd. Two years of agonizing over why I took nursing. I'm sure there are a lot out there who feel that way right now and I sympathize with you on that matter.

But here's the thing, nursing is not a course to agonize about. It was only later around my 3rd year in nursing school that I realized what being a nurse is, and what being a nurse required.

Being a nurse means being open to service, all forms of service. Yes, there was a matter of theory, the books and procedures on diseases and techniques ,etc. but in all honesty, that was just secondary to the fact that being a nurse meant willingness to serve those who need us and those in pain.

I know many if not most of the nursing students decided to take nursing because they want to help their families, they want to go abroad, they want to earn more than the average Filipino income, and thats true, you nor I can't deny that because for a fact that is why my parents wanted me to take nursing. But the truth is, if your heart is not set on serving others, I'm sorry. all the books in the world will not help you get there. Potter and Perry can only do so much as to provide you with background theories. But the truth is, it is the heart and the will to serve that determines if you should be a nurse.

How can you judge if you made the right choice to become a nurse? For one thing, it is alright to be forced to take nursing (at first) but as long as you learn to love it. Love the feeling of being able to serve a person and and give relief to the person's pain. Otherwise, your four years of nursing will be useless.

Books, theories and techniques are just guidelines, it is service and the willingness to serve that makes one a real nurse. Sure, you may have the highest grade in your nursing class, sure you may have passed the local board exams, but what good is that if your not willing to serve? It will all go to waste. Believe me. Hospitals will not hire nurses just because of high grades, exceptional scores but when it comes to the willingness to serve you rate the lowest. That only equal zero to the dollars you thought you will be getting, which is too bad.

If you don't feel that way about service, then I suggest you get out of it while you still can because all the dreams of dollars and living the American dream will never ever materialize without the willingness to serve.

Ladies and gentlemen, I want to close this post by saying this: If you are meant to be a nurse you will be a nurse. But always remember that to be a nurse means to serve, not dollars, not visa grants. It is the willingness to serve. If you know that is not what you want to do, do not waste your time. And to parents please do not force your children to taking nursing just because you think this will help them prepare for the future. Listen to them first. Some may be swayed but others cannot. And the more you do force them, the more you will hurt them.

What is a Nurse?

2008-03-03T17:25:00.000-08:00

According to wikipedia.com a nurse is responsible—along with other health care professionals—for the treatment, safety, and recovery, or demise of acutely or chronically ill or injured people, health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings. Nurses may also be involved in medical and nursing research and perform a wide range of non-clinical functions necessary to the delivery of health care. Nurses are also quite essential in meeting end-of-life needs and assist in the grieving process associated with death and dying.

That my friends is the word for word definition of a nurse. Personally, if you were to ask me I only have a short definition for that. A nurse is a person who helps you in any problem that you have, either physically, mentally, or emotionally. A nurse can be a professional RN, she can be your mom, your "yaya" or simply your friend. Why do I say that?

Ofcourse in the hospital setting, it is the professsional RN that takes care of us, but at home, who is there to listen, and feel with us all kinds of pain? It's our mom mostly, sometimes our "yayas" and most often, it's our friends. This post is my dedication to all the people who have been "nurses" in my life that have been great influences in getting me to where I am today.

To All Passers of the December 2007 Philippine Nursing Licensure Examinations

2008-02-29T17:29:00.000-08:00

Congratulations to all those who passed the December 2007 Philippine Nursing Licensure Examinations!
Most Especially to my fellow Larmenians:
Sander James Alvarez,
Monica Panares,
Jennifer Fuentes,
Joseph Balmores,
Grace Ann Pag Ong,
Bong Gupana,
Jane Anoos,
Sandra Go Manzano, and
Joyce Astilla

and ofcourse, I would also want to congratulate my friends from Silliman University who also made it:
Barbara Alonzo Chantal Diao Mary Palarpalar
Sheriel Orcullo Diego Nochefrance Karl Bumanglag
Ciara Pasion Monique Carabuena Jacky Omandam
Michael Koppin Katherine Ampo Ivah Carvas
Joanna Dizon Elalyn Dagohoy Dexie Mosqueda

and all my other classmates from Silliman...sorry i cant name all of you, but anyway congratulations and good luck to us all, we did a great job...