ACHIEVE OPTIMAL LEVEL OF HEALTH & MAXIMUM LEVEL OF INDEPENDENCE

Insertion of Suprapubic Catheter

2011-10-29T10:10:00.000-07:00

Dissection at the base of the bladder to reach the anterior vaginal wall and uterine cervix creates edema, interrupts the small nerve pathways, and thereby sets up the physiologic changes that produce urinary bladder atony. Therefore, catheter drainage of the urinary bladder is an essential feature of many pelvic surgical procedures. Fortunately, in most cases, these conditions reverse themselves in 3-5 days, and catheter drainage is no longer needed.

Suprapubic bladder catheterization is superior to transurethral bladder catheterization because it is cleaner. It also leaves the urethra open for voiding when urinary function has returned. The use of an ordinary Foley catheter (No. 16 French with 5-mL bag) is preferable to the commercially available suprapubic catheter kits because a Foley catheter, when inserted as described in this section, is usually not dislodged from the bladder during sleep or activity. In addition, the Foley catheter is less costly and is available in all surgical clinics. The instrument used for insertion of the Foley catheter is an ordinary Randall stone forceps. The fulcrum of this instrument is toward the rear, which keeps the overall diameter of the axis virtually unchanged except at the jaws and gives it an advantage over a Kelly clamp.

The operation provides drainage of the urinary bladder through a clean surgical incision and ensures that the catheter does not slip out of the patient or become dislodged within the abdominal wall.

Physiologic Changes. The procedure reduces edema at the base of the bladder, allowing the return of normal vesical function.

Points of Caution. After grasping the catheter with the jaws of the Randall forceps (Fig. 4) and before inflating the Foley balloon, the catheter should be drawn through the bladder until the tip can be seen in the urethral meatus. This ensures that the catheter tip and balloon are in the bladder and not in the subcutaneous or subfascial space.

Technique

This procedure can be performed in the inpatient treatment rooms of a hospital, clinic, or doctor's office. Local anesthesia is adequate for most patients. The bladder does not have to be empty. The patient is placed in the dorsal lithotomy position. The periurethral area and suprapubic area are surgically prepped and draped. A routine pelvic examination is performed prior to placement of the suprapubic catheter. If local anesthesia is to be used, a 4 x 4 cm area around the insertion site is infiltrated with 1% lidocaine. Infiltration should include the fascia and, if at all possible, a small area of the bladder wall.

A Randall stone forceps is inserted through the urethral meatus and used to elevate the dome of the bladder from the inside, pushing the suprapubic abdominal wall upward to the palpating finger.

Upward pressure is maintained on the forceps, and a small incision is made in the suprapubic skin and fascia until the forceps can be felt with the blade of the knife.

A sudden upward thrust of the forceps pierces the bladder wall and pushes the forceps through the incision. The jaws of the forceps are opened and used to grasp the tip of the Foley catheter.

The Foley catheter is pulled through the bladder, and the forceps is withdrawn from the urethra until the tip of the Foley catheter can be seen in the urethral meatus.

Traction is placed on the Foley catheter from above while the balloon is simultaneously inflated. This draws the catheter back into the body of the bladder.

When 5 mL of sterile saline solution have completely filled the Foley balloon, the catheter is firmly retracted upward.
It is not necessary to suture the catheter to the abdominal skin. A sterile dressing is applied, and the Foley catheter is connected to straight drainage......http://www.atlasofpelvicsurgery.com

Communication Techniques in Nursing

2011-10-25T06:48:00.001-07:00

Communication techniques are very important in which ever profession you are, especially care giving professions. As such, communication techniques in nursing are very significant. The way in which a care giving professional communicates with the patient can bring about a sea change in how the patient feels. Hence, scroll down to know about therapeutic communication techniques for nursing.

he way you communicate with others in personal and public arenas reflects a lot about your personality. If you are communicating positively then you would obviously get a same kind of response and vibes (unless you encounter a jerk!). Pertaining to all this, since the past few years, communication skills and techniques have gained a lot of importance in almost all the professions. It is more so with professions where you meet numerous people like hospitality, public relations, human resources, health care, media and so on. But the field where communication has an impact which can really make the other person's life better is nursing within health care. The way a nurse deals with the patients is extremely important for the well-being of the patient, mentally and physically. The question which crops up here is, are there communication techniques in nursing? Well, yes there are. Find out what they are in the text below.

Techniques of Communication in Nursing

General Communication Techniques
Speaking or Verbal Communication: If most of us would not have been able to speak, I wonder what we all would have done. I mean, just try and gauge the amount of time we spend speaking and talking in a day! But coming back to nursing, nurses or any other type of care givers need to speak clearly first of all. Maintaining slow, even tone helps the patient to understand what they want to say. Once they put across the point, wait for the patient to respond. Nursing requires you to be slow and gentle, so not rushing thorough is one of the techniques for communicating effectively.

Non-Verbal Communication: When dealing with patients who cannot hear well, nurses ideally need to use hands along with speech to tell what they want to say. Further, they also need to look out for non verbal cues they are reflecting - the body language, voice and so on. Please say the things which you are convinced about. Use other methods like writing or drawing out pictures and the likes so that the patient gets to know what you want to say if he or she is unable to understand you. Even silence can work wonders when it is about non verbal communication. These are very important nursing communication strategies. Read more on qualities of a good nurse.

These and the few other techniques like helpful behavior and positive mentality are important components of communication skills for nursing practice. Now, lets take a look at therapeutic communication techniques for nursing.

Nursing Therapeutic Communication Techniques
Attention: To attract and hold the patient's attention and to add a personal touch, use the name of the patient. Similarly, just as you would call the patient by his or her name, it is always nice to introduce yourself too. It adds a comfort level to the interaction and lays the foundation for a good rapport. Other things which can ensure a nurse the optimum attention from a patient are: checking out on their basic needs, avoiding distractions, having an eye contact and few other seemingly insignificant things, which are, however, very crucial.

Behavior: While dealing with patients, a nurse should empathize and acknowledge the mentality of the patient. A nurse's behavior should reflect that and if that is not the case, it does communicate many things to the patient. Encouragement is another essential factor in case of communication techniques in nursing and patient care. Already the patient is sort of demoralized and if the nurse discourages the patient on top of it, the patient would have it. So, as therapeutic technique, encouragement works wonders. Generally being helpful, concerned, bright and friendly is the best therapeutic behavioral technique.

Help in Dealing with Disorientation: Hospitalization is a very traumatic experience for the elderly and thus they might tend to get disoriented. So, if they say something which is not true, just calmly tell them the truth in a normal tone, without challenging what they have said. If patients are dealing with memory loss, give them gentle and polite reminders all the time. Show them or tell them how to do a particular thing.

Be Interactive: Wherever and whenever possible, a patient should be included in decision-making. After all, it is about the patient. Let the patient be communicated as if he or she is in control. Avoid talking about patients to others as if they do not exist. Being interactive does not mean that you nag or pester the patient to open up. Let the patient open up and express his or her feelings only when they want to. Do not rush into that.

Communication techniques in nursing are umpteen if you delve even deeper into the scheme of things. The above was just a glimpse of what are the fundamentals in it. There are many more therapeutic communication techniques for nursing like being patient, being clear, listening to the patient and so on. As one gains experience, he or she imbibes these qualities.

To cut a long story short, the penultimate aim is to make the patient feel better and foster a feeling that he or she is going to be just fine. If you do that, there is nothing as satisfying as that for all the Florence Nightingales out there!

Post-power Syndrome

2011-10-10T00:04:00.000-07:00

Post-power syndrome is a psychiatric term for someone who lives in the shadow of the days past success (career, intelligence, or anything else), and could not accept the reality that exist today. Patients always want to express and show how great he was in the past.

Some of the factors that caused the post-power syndrome, among others.

1. Early retirement and work fired
When people are getting early retirement or who fired the work could not accept a state that energy is not used anymore, especially if he feels can still contribute significantly to the company it will be easy to occur post-power syndrome.

2. Condition that requires her to quit her career
Examples accidents experienced by a football player who led his leg was amputated, can cause post-power syndrome.

How to Help People with post-power syndrome

1. Understanding of their beloved ones
It would be very helpful person if the person is to see that their loved ones still can understand his situation or lack of ability to earn a living, he would be more receptive to think it could have a cold. This will restore the ability and productivity, rather than always sarcastic, grumbling, even mocked him.

2. Support from the environment
Families can be very helpful during this post-power syndrome. Understanding families and children must be very necessary in an effort to expedite passage of this period, with a wise way we as a family member can suggest something that could be used to do anything within its capabilities.

3. Creating a positive activity
If a post-power syndrome sufferers can find a place to channel capacity, would be very helpful. For example, an employee who has retired or been fired but he was able to do new business or other activities such as agribusiness, it's easier and faster to adapt quickly and can accept the current situation.

In some cases the post-power syndrome causes mental disorder severe enough suppose can not think rationally in a certain period, depression, and may cause health problems.

Insomnia

2010-03-05T12:00:00.000-08:00

Insomnia Overview

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30%-50% of the general population are affected by insomnia, and 10% have chronic insomnia.

Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is "difficulty initiating or maintaining sleep, or both" and it may be due to inadequate quality or quantity of sleep. Insomnia is not defined by a specific number of hours of sleep that one gets, since individuals vary widely in their sleep needs and practices. Although most of us know what insomnia is and how we feel and perform after one or more sleepless nights, few seek medical advice. Many people remain unaware of the behavioral and medical options available to treat insomnia.

Insomnia is generally classified based on the duration of the problem. Not everyone agrees on one definition, but generally:

* symptoms lasting less than one week are classified as transient insomnia,

* symptoms between one to three weeks are classified as short-term insomnia, and

* those longer than three weeks are classified as chronic insomnia.

Statistics on Insomnia

Insomnia affects all age groups. Among adults, insomnia affects women more often than men. The incidence tends to increase with age. It is typically more common in people in lower socioeconomic (income) groups, chronic alcoholics, and mental health patients. Stress most commonly triggers short-term or acute insomnia. If you do not address your insomnia, however, it may develop into chronic insomnia.

Insomnia Causes

Insomnia may be caused by a host of different reasons. These causes may be divided into situational factors, medical or psychiatric conditions, or primary sleep problems. Insomnia could also be classified by the duration of the symptoms into transient, short-term, or chronic. Transient insomnia generally last less than seven days; short-term insomnia usually lasts for about one to three weeks, and chronic insomnia lasts for more than three weeks.

Many of the causes of transient and short-term insomnia are similar and they include:

* Jet lag

* Changes in shift work

* Excessive or unpleasant noise

* Uncomfortable room temperature (too hot or too cold)

* Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce, or separation)

* Presence of an acute medical or surgical illness or hospitalization

* Withdrawal from drug, alcohol, sedative, or stimulant medications

* Insomnia related to high altitude (mountains)

Chronic or long-term insomnia

The majority of causes of chronic or long-term insomnia are usually linked to an underlying psychiatric or physiologic (medical) condition.

Psychological related insomnia

The most common psychological problems that may lead to insomnia include:

* anxiety,

* stress,

* schizophrenia,

* mania (bipolar disorder), and

* depression.

In fact, insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness.

Physiological related insomnia

Physiological causes span from circadian rhythm disorders (disturbance of the biological clock), sleep-wake imbalance, to a variety of medical conditions. The following are the most common medical conditions that trigger insomnia:

* Chronic pain syndromes

* Chronic fatigue syndrome

* Congestive heart failure

* Night time angina (chest pain) from heart disease

* Acid reflux disease (GERD)

* Chronic obstructive pulmonary disease (COPD)

* Nocturnal asthma (asthma with night time breathing symptoms)

* Obstructive sleep apnea

* Degenerative diseases, such as Parkinson's disease and Alzheimer's disease (Often insomnia is the deciding factor for nursing home placement.)

* Brain tumors, strokes, or trauma to the brain

High risk groups for insomnia

In addition to the above medical conditions, certain groups may be at higher risk for developing insomnia:

* travelers

* shift workers with frequent changing of shifts

* seniors

* adolescent or young adult students

* pregnant women, and

* menopausal women

Medication related insomnia

Certain medications have also been associated with insomnia. Among them are:

* Certain over-the-counter cold and asthma preparations.

* The prescription varieties of these medications may also contain stimulants and thus produce similar effects on sleep.

* Certain medications for high blood pressure have also been associated with poor sleep.

* Some medications used to treat depression, anxiety, and schizophrenia.

Other causes of insomnia

* Common stimulants associated with poor sleep include caffeine and nicotine. You should consider not only restricting caffeine and nicotine use in the hours immediately before bedtime but also limiting your total daily intake.

* People often use alcohol to help induce sleep, as a nightcap. However, it is a poor choice. Alcohol is associated with sleep disruption and creates a sense of nonrefreshed sleep in the morning.

* A disruptive bed partner with loud snoring or periodic leg movements also may impair your ability to get a good night's sleep.

Primary Sleep Disorders

In addition to the causes and conditions listed above, there are also a number of conditions that are associated with insomnia in the absence of another underlying condition. These are called primary sleep disorders, in which the sleep disorder is the main cause of insomnia. These conditions generally cause chronic or long-term insomnia. Some of the diseases are listed below:

* Idiopathic Insomnia (unknown cause) or childhood insomnia, which start early on in life and results in lifelong sleep problems. This may run in families.

* Central Sleep Apnea. This is a complex disorder. It can be the primary cause of the insomnia itself or it may be caused by other conditions, such as brain injury, heart failure, high altitude, and low oxygen levels.

* Restless leg syndrome (a condition associated with creeping sensations in the leg during sleep that are relieved by leg movement)

* Periodic limb movement disorder (a condition associated with involuntary repeated leg movement during sleep)

* Circadian rhythm disorders (disturbance of the biological clock) which are conditions with unusual timing of sleep (for example, going to sleep later and waking up late, or going to sleep very early and getting up very early).

* Sleep state misperception, in which the patient has a perception or feeling of not sleeping adequately, but there are no objective (polysomnographic or actigraphic) findings of any sleep disturbance.

* Insufficient sleep syndrome, in which the patient's sleep is insufficient because of environmental situations and lifestyle choices, such as sleeping in a bright or noisy room.

* Inadequate sleep hygiene, in which the individual has poor sleep or sleep preparation habits (described in the following treatment section.)

Insomnia Symptoms

Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms intertwine with those of other medical or mental conditions.

* Some people with insomnia may complain of difficulty falling asleep or waking up frequently during the night. The problem may begin with stress. Then, as you begin to associate the bed with your inability to sleep, the problem may become chronic.

* Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:

o Poor concentration and focus

o Difficulty with memory

o Impaired motor coordination (being uncoordinated)

o Irritability and impaired social interaction

o Motor vehicle accidents because of fatigued, sleep-deprived drivers

* People may worsen these daytime symptoms by their own attempts to treat the symptoms.

o Alcohol and antihistamines may compound the problems with sleep deprivation.

o Others have tried nonprescription sleep aids.

When to Seek Medical Care

When to call the doctor

* A person with insomnia needs a doctor's attention if it lasts longer than three to four weeks, or sooner if it interferes with a person's daytime activities and ability to function.

* Insomnia may be a symptom of another medical or psychological problem, which a patient may need to address first or at the same time.

When to go to the hospital

* Generally, a patient will not be hospitalized for most types of insomnia. However, accidents may result from poor coordination and attention lapse seen with sleep deprivation.

* Worsening pain or increased difficulty breathing at night also may indicate a person need to seek emergency medical care.

Exams and Tests

The doctor will begin an evaluation of insomnia with a good medical history.

* The doctor will seek to identify any medical or psychological illness that may be contributing to the patient's insomnia. A thorough medical history and examination including screening for psychiatric disorders and drug and alcohol use is paramount in evaluation of a patient with sleep problems.

o For example, the patient may be asked about chronic snoring and recent weight gain. This may direct an investigation into the possibility of obstructive sleep apnea. In such an instance, the doctor may request an overnight sleep test (polysomnogram). Sleep studies are frequently done in specialized "sleep labs" by doctors trained in sleep medicine, frequently working under pulmonary (lung) specialists. This test is not part of the routine initial workup for insomnia, however.

o The diary will include the patient's personal assessment of their alertness at various times of the day on two consecutive days within the two week period.

* The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness.

* Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity.

Insomnia Treatment

In general, transient insomnia resolves when the underlying trigger is removed or corrected. Most people seek medical attention when their insomnia becomes more chronic.

The main focus of treatment for insomnia should be directed towards finding the cause. Once a cause is identified, it is important to manage and control the underlying problem, as this alone may eliminate the insomnia. Treating the symptoms of insomnia without addressing the main cause is rarely successful.

The following therapies may be used in conjunction with therapies directed towards the underlying medical or psychiatric cause. They are also the recommended therapies for some of the primary insomnia disorders.

Generally, treatment of insomnia entails both non-pharmacologic (non-medical) and pharmacologic (medical) aspects. It is best to tailor treatment for individual patient based on the potential cause. Studies have shown that combining medical and non-medical treatments typically is more successful in treating insomnia than either one alone.

Non-medical treatment and behavioral therapy

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus control, and sleep restriction. These also referred to as cognitive behavioral therapies.

Sleep hygiene

Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps can be taken to improve a patient's sleep quality and quantity. These steps include:

* Sleep as much as you need to feel rested; do not oversleep.

* Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.

* Avoid forcing yourself to sleep.

* Keep a regular sleep and awakening schedule.

* Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.) Avoid "night caps," (alcoholic drinks prior to going to bed).

* Do not smoke, especially in the evening.

* Do not go to bed hungry.

* Adjust the environment in the room (lights, temperature, noise, etc.)

* Do not go to bed with your worries; try to resolve them before going to bed.

Relaxation therapy

Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.

Stimulus control

Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.

* Go to bed when you feel sleepy.

* Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep and sexual activity.

* If you do not fall asleep 30 minutes after going to bed, get up and go to another room and resume your relaxation techniques.

* Set your alarm clock to get up at a certain time each morning, even on weekends. Do not oversleep.

* Avoid taking long naps in the daytime.

Sleep restriction

Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is called sleep restriction. It is achieved by averaging the time in bed that the patient spends only sleeping. Rigid bedtime and rise time are set, and patient is forced to get up even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation for the previous night. Sleep restriction has been helpful in some cases.

Other simple measures that can be helpful to treat insomnia include:

* Avoid large meals and excessive fluids before bedtime

* Control your environment.

o Light, noise, and elevated room temperature can disrupt sleep. Shift workers and night workers especially must address these factors. Dimming the lights in the bedroom, relaxation, limiting the noise, and avoiding stressful tasks before going to bed may be beneficial. (Refer to sleep hygiene and relaxation therapy above.)

o Avoid doing work in the bedroom that should be done somewhere else. For example, do not work or operate your business out of your bedroom and avoid watching TV, reading books, and eating in your bed.

A person's body's circadian rhythm (biological clock) is particularly sensitive to light. Parents who need to sleep during the day may have to make child care arrangements to allow them to sleep.

Medications and Medical Therapies

There are numerous possible medications to treat insomnia. Generally, it is advised that they should not be used as the only therapy and that treatment is more successful if combined with non-medical therapies. In a study, it was noted that when sedatives were combined with behavioral therapy, more patients were likely to wean off the sedatives than if sedatives were used alone.

* Benzodiazepine sedatives: six of these sedative drugs have been used to treat insomnia. There are reports of subjective improvement of quality and quantity of sleep when using these medications. These include temazepam (Restoril), flurazepam (Dalmane), triazolam (Halcion), estazolam (ProSom, Eurodin), lorazepam (Ativan), and clonazepam (Klonopin).

* Nonbenzodiazepine sedatives: These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien).

* Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the center of your brain. Melatonin is produced during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. At night, melatonin is produced to help your body regulate your sleep-wake cycles. The amount of melatonin produced by your body seems to decrease as you get older. Melatonin may be beneficial in patients with circadian rhythm problems.

* Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for treatment of insomnia characterized by difficulty falling asleep.

* Some antidepressants [for example, amitriptyline (Elavil, Endep) and trazodone (Desyrel)] have been used for the treatment of insomnia in patients with co-existing depression because of some sedative properties. Generally, they may not be helpful for insomnia in people without depression.

* Antihistamines with sedative properties [for example, diphenhydramine (Benadryl) or doxylamine] have also been used in treating insomnia as they may induce drowsiness, but they do not improve sleep and should not be used to treat chronic insomnia.

* Valeriana officinalis (Valerian) is a popular herbal medication used in the United States for treating insomnia, however, to date there are no convincing studies to show any real benefit in patients with chronic insomnia.

Follow-up

Follow the doctor's recommendations for the patient's medical and psychological conditions. The patient will be asked to give their doctor feedback after they have followed a treatment plan.

Often the patient will have more than one option and more than one medication available to help them. A patient should not lose hope if the first medication does not give them the results they want or if they experience side effects or concerns. Report back to a doctor for advice.

Prevention

The following are suggestions to help anticipate and modify situations likely to be associated with insomnia. They are not foolproof, nor will they safeguard the patient from the consequences of sleep deprivation once it has occurred.

Insomnia from jet lag

* Behavioral and short-term drug therapy has been used.

* If you can anticipate a trip, begin to shift your bedtime to coincide with the time schedule in your destination.

* Short-acting tranquilizers (benzodiazepines) have been shown to be useful. Melatonin, a hormone secreted by the pineal gland that regulates our sleep-wake cycles, has also been used.

Insomnia from shift changes

* Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep deprivation in shift workers.

* You should shift your schedules forward in a clockwise direction - from days to evening to night shift - and allow sufficient time to adapt (at least one week) between shift changes.

* Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a rhythm synchronizer.

* Shift workers should stress the importance of good sleep habits with regular bedtime and awakening.

o Supplemental naps may be necessary to ensure work time alertness.

o Discuss the use of naps with a doctor.

o Some people promote using short-acting sedatives in the first few days following a shift change, but not everyone agrees.

Insomnia from acute stresses

* Stress may be positive or negative, and concerns about sleep may vary. Many stressors will go away with support and reassurance.

* Education about the importance of good sleep habits is also helpful.

* Some people may need short-term treatment with medications. A doctor will often work toward the lowest effective dose with a short-acting sedative to achieve proper sleep.

General recommendations include the following:

* Work to improve your sleep habits.

o Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often helpful.

o Control your environment. Avoid light, noise, and excessive temperatures. Use the bed only to sleep and avoid using it for reading and watching TV. Sexual activity is an exception.

o Establish a bedtime routine. Fix wake time.

* Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce the use of stimulants including caffeine and nicotine.

* If you do not fall asleep within 20-30 minutes, try a relaxing activity such as listening to soothing music or reading.

* Limit daytime naps to less than 15 minutes unless directed by your doctor.

o It is generally preferable to avoid naps whenever possible to help consolidate your night's sleep.

o There are certain sleep disorders, however, that will benefit from naps. Discuss this issue with your doctor.

http://www.emedicinehealth.com

Huntington's disease

2010-02-27T07:52:00.000-08:00

Huntington's disease is an inherited disorder that causes the degeneration of brain cells. This results in a progressive loss of the control of movement and mental ability, and changes in personality.

Around 4,800 people in the UK are living with Huntington's disease. It used to be called Huntington's chorea. Chorea means jerky, involuntary movements - a main symptom of the condition.

Huntington's disease usually develops between the ages of 30 and 50, but it can start at any age. Symptoms get worse gradually, sometimes over a period of up to 20 years. At the moment, there is no cure for the disease, but there are ways to help manage the symptoms.
Symptoms

The symptoms of Huntington's disease are sometimes overlooked. This is because they are mild at first and people without the disease can have the same symptoms. People who have Huntington's disease sometimes have problems for a long time before they find out that they have the condition.

Early symptoms include:

* mild tremor
* clumsiness
* lack of concentration and irritability
* difficulty remembering things
* mood changes, including depression
* aggressive antisocial behaviour

Over time the symptoms become progressively worse. Eventually, full-time nursing care will be needed. Later symptoms fall into three categories:
Physical symptoms

Physical symptoms include chorea (involuntary movements of the limbs, face and body). Chorea may lead to difficulty walking, speaking and swallowing. People often lose weight because of difficulty eating and by burning more calories due to the continuous movement. The ability to coordinate movement gets gradually worse as the disease progresses.
Emotional symptoms

Emotional symptoms include depression, not only because of the burden of having a progressive disorder, but as a direct result of the damage to certain brain cells. You may become frustrated at being unable to work or do previously simple tasks. You may behave stubbornly, and have mood swings. People with Huntington's may also become more irritable and antisocial than usual, or have less inhibitions.
Cognitive symptoms

Cognitive symptoms include a loss of drive and initiative. People with Huntington's may appear to be lazy or uninterested in life, spending days doing little or neglecting personal hygiene. You may also lose the ability to organise yourself. This is because planning skills and the ability to do more than one task at once deteriorate. In the later stages, you may get memory loss and be less able to understand speech.

The behavioural changes that occur are often the most distressing for you, your family and your carers. A previously full and active life may be lost with a gradual reduction in independence and mobility. At the same time, your personality can become gradually more self-centred and unmotivated, straining personal relationships.
Causes

Huntington's disease is caused by a faulty gene that runs in families. The gene, which was discovered in 1993, produces a protein called Huntingtin. Scientists are still researching how the faulty gene causes the disease.

Most genes in the body are present in two copies: one from your mother and one from your father. The gene that causes Huntington's disease is dominant. This means that if you inherit a copy of this gene from either parent, you will go on to develop the disease at some point in your life.

If you have one parent with Huntington's disease you have a 50 percent chance of inheriting the faulty gene. The risk is 50 percent for each child. It isn't altered by gender or whether brothers and sisters are affected. Only people who have the faulty gene can pass it on to their children.

Occasionally there is no family history of the condition. This may be because previous generations weren't diagnosed - either because of early death from other causes, or loss of contact through adoption.

Huntington's disease causes progressive damage to cells in areas of your brain called the basal ganglia and cerebral cortex. These areas are involved in the control of movement, planning, motivation and personality.
Juvenile Huntington's disease

A juvenile form of Huntington's disease, which develops before the age of 20, also exists. About five percent of people with Huntington's disease are affected by the condition when this young. The symptoms are similar to those of adult Huntington's, but muscular rigidity is more likely to occur. Epilepsy - which causes fits - is also more common among those with juvenile Huntington's disease compared with adults who have the condition.
Treatment

Although there is currently no cure for Huntington's disease, there are drugs to help manage some of your symptoms. There are medicines that can reduce the involuntary movements, and antidepressant medicines may alleviate depression. Mood stabilisers and antipsychotic drugs can help with some of the emotional disturbances.

Counselling can also be helpful, both for you and your family. Dieticians can advise on adequate calorie and nutrient intake to stop weight loss.
Future promise

Scientists are investigating several drug treatments to slow the progress of Huntington's disease. Some of these have shown promise and are planned to be tested in clinical trials. Examples include the antibiotic minocycline and coenzyme Q10. However, this research is speculative; more work is needed before any recommendations can be made.

Some clinical studies have used stem cells (the most basic form of cells from which others develop) to grow cells that can be transplanted into the brain of people affected by the disease. This approach may eventually improve the outlook for people with Huntington's disease. However, this research is still in the very early stages of development.
Genetic tests

There are tests available to find out whether you have the faulty gene. They fall into three categories: diagnostic, pre-symptomatic and antenatal.
Diagnostic tests

These are carried out if you have symptoms of Huntington's disease and you come from a family where others have the condition. The aim is to confirm the diagnosis.
Pre-symptomatic tests

These tests are carried out if you have no symptoms of Huntington's disease, but you have family members who are affected by it. The test tells you whether you will develop the disease, but not when it will happen.

The decision to take these tests is a serious one and shouldn't be rushed into. A positive result can be devastating since it may tell you that one day you will become severely ill. There are also issues surrounding testing when your parents have themselves not been tested. This is because a positive result means that one of your parents also has the faulty gene.

You should take advice from a genetic counsellor about the implications of taking the test before you go ahead. In the UK you can't have the test if you are under the age of 18.
Antenatal tests

These tests may be carried out early in pregnancy on the unborn children of couples from families affected by Huntington's disease. They can be used to calculate the risk of that child going on to develop the disease in their adult life.
Pre-implantation Genetic Diagnosis (PGD)

If you know that you carry the gene for Huntington's disease, you can opt for PGD. This is a type of in vitro fertilisation (IVF). Only embryos which are not carrying the faulty Huntington gene are used, so the baby is not at risk of having the disease.

Cardiac Marker Tests

2010-02-27T07:35:00.000-08:00

Definition

Cardiac marker tests identify blood analytes associated with myocardial infarction (MI), commonly known as a heart attack.
Purpose

Cardiac markers help physicians to assess acute coronary syndromes and to identify and manage high-risk patients. Creatine kinase-MB (CK-MB), myoglobin, homocysteine, C-reactive protein (CRP), troponin T (cTnT), and troponin I (cTnI) are all used for assessment of the suspected acute myocardial infarction. CK-MB, cTnT, and cTnI may also be used to identify and manage high-risk patients.

Precautions

C-reactive protein results may be affected by the use of oral contraceptives, NSAIDs, steroids, salicyltes, intrauterine devices (IUDs), and overnight sample refrigeration. Homocysteine levels may be affected by smoking, diabetes, and coffee.
Description
Creatine kinase (CK)

Creatine kinase is an enzyme responsible for transferring a phosphate group from ATP to creatine. It is composed of M and/or B subunits that form CK-MM, CKMB, and CK-BB isoenzymes. Total CK (the activity of the MM, MB, and BB isoenzymes) is not myocardial-specific. However, the MB isoenzyme (also called CK-2) comprises about 40% of the CK activity in cardiac muscle and 2% or less of the activity in most muscle groups and other tissues. In the proper clinical setting, MB is both a sensitive and specific marker for myocardial infarction. MB usually becomes abnormal three to four hours after an MI, peaks in 10 to 24 hours, and returns to normal within 72 hours. However, an elevated serum MB may occur in people with severe skeletal muscle damage (such as in muscular dystrophy or a crush injury) and renal failure. In such cases, the CK index (MB divided by total CK) is very helpful. If the index is under 4%, a nonmyocardial cause of a high MB should be suspected. C-MB is considered the benchmark for cardiac markers of myocardial injury. Measurement of CK-MB may be performed via electrophoresis or immunoassays; the latter demonstrates better analytical sensitivity and better precision.

CK-MB isoforms can be used to determine whether thrombolytic therapy (such as treatment with tissue plasminogen activator to dissolve a blood clot in the coronary artery) has succeeded. MB isoforms are different molecular forms of MB found in the circulation. When MB is released into the blood, the terminal lysine of the M sub-unit is removed by an enzyme in the plasma. This results in a molecule with faster electrophoretic mobility, called CK-21. This is the prevalent form of MB in the blood. The slower form, designated CK-22, is the unmodified cardiac form of MB. After successful thrombolytic therapy, the unmodified form of MB is rapidly flushed into the blood, causing it to become the dominant isoform.
Myoblobin

Myoglobin is a protein found in both skeletal and myocardial muscle. It is released rapidly after tissue injury and may be elevated as early as one hour after myocardial injury, though it may also be elevated due to skeletal muscle trauma. However, if myoglobin values do not rise within three to four hours after a person shows acute symptoms, it is highly unlikely that he or she had an MI. There are several measurement methods available, including fluorometric, nephelometric, and turbid-metric assays; plus immunochromatography-based tests designed for qualitative, point-of-care testing.
Troponin T and troponin I

Troponin C, I, and T are proteins that form the thin filaments of muscle fibers and regulate the movement of contractile proteins in muscle tissue. Skeletal and cardiac forms are structurally distinct, and antibodies can be produced that react only with the cardiac forms of troponin I and troponin T.

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are the newest additions to the list of cardiac markers. Troponins are specific to heart muscle. They have enabled the development of assays that can detect heart muscle injury with great sensitivity and specificity. While these markers have been used mainly to aid in the diagnosis of chest-pain patients with nondiagnostic electrocardiograms, they are also used as prognostic indicators of a MI. According to the American Heart Association, "Several studies have identified a measurable relationship between cardiac troponin levels and long-term outcome after an episode of chest discomfort. They suggest that these tests may be particularly useful to evaluate levels of risk. In other words, it's possible that the results of a troponin test could be used to identify people at either low risk or high risk for later, serious heart problems."

Several commercially available quantitative immunoassays are available for for the measurement of cTnI and cTnT. There is also a qualitative cTnI test, targeted at bedside testing.
C-reactive protein (CRP)

CRP is a protein found in serum or plasma at elevated levels during a inflammatory processes. The protein can be measured via a variety of methods, including EIA or ELISA, for the quantitative or semiquantitative determination of C-reactive protein in human serum, particle agglutination tests that provide semiquantitative results, and laser and rate nephelometery tests that measure antigen-antibody complexes by light dispersion.

CRP binds to the C polysaccharide of the capsule of Streptococcus pneumoniae. It is a sensitive marker of acute and chronic inflammation and infection, and in such cases is increased several hundred-fold. Several recent studies have demonstrated that CRP levels are useful in predicting the risk for a thrombotic event. These studies suggest that a high-sensitivity assay for CRP be used that is capable of measuring the very low level normally found in serum (0.1 to 2.5 mg/L). Heart patients who have persistent CRP levels between 4 and 10 mg/L, with clinical evidence of low-grade inflammation, should be considered to be at increased risk for thrombosis. People can be stratified into four groups of increased risk based upon the quartile in which their CRP levels fall.
Homocysteine

Homocysteine is an amino acid. According to the American Heart Association, studies have shown that too much homocysteine in the blood is related to a higher risk of coronary heart disease, stroke, and peripheral vascular disease; and that it may also have an effect on atherosclerosis. High levels of homocysteine are the result of inheritance or dietary excess and have been implicated in vascular-wall injury. One immunoassay is available for it. It is believed that laboratory testing for plasma homocysteine levels can improve the assessment of risk, particularly in patients with a personal or family history of cardiovascular disease, but in whom the well-established risk factors (smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity, and diabetes) do not exist. Homocysteine levels are obtained via high-performance chromatography with electrochemical detection.
Preparation

These assays require a sample of blood, which is typically obtained via a standard venipuncture procedure. Homocysteine tests require the patient to fast. Homocysteine is stable only in separated refrigerated or frozen plasma for 48 hours.
Aftercare

Discomfort or bruising may occur at the puncture site, or the person may feel dizzy or faint. Applying pressure to the puncture site until the bleeding stops reduces bruising. Warm packs to the puncture site relieve discomfort.
Complications

There are no complications associated with these tests.
Results

Normal results vary, based on the laboratory and method used. Unless otherwise specified, the following information is from the American College of Cardiology and the American Heart Association.

* Total CK: Reference value is 38 to 174 units/L for men and 96 to 140 units/L for women. The values begin to rise within four to six hours and peak at 24 hours. Values return to normal within three to four days.
* CK-MB: Reference value is 10 to 13 units/L. The values begin to rise within three to four hours and peak at 10 to 24 hours. Values return to normal within two to four days.
* Troponin T: Reference value is less than 0.1 ng/mL. The values begin to rise within two to four hours and peak at 10 to 24 hours. Values return to normal within five to 14 days.
* Troponin I: Reference value is less than 1.5 ng/mL. The values begin to rise within two to four hours and peak at 10 to 24 hours. Values return to normal within five to 10 days.
* CK-MB isoforms: Reference value is a ratio of 1.5 or greater. The values begin to rise within two to four hours and peak at six to 12 hours. Values return to normal within 12 to 24 hours.
* Myoglobin: Reference value is less than 110 ng/mL. The values begin to rise within one to two hours and peak at four to eight hours. Values return to normal within 12 to 24 hours.
* Homocysteine: The normal fasting level for plasma is five to 15 micromol/L. Moderate, intermediate, and severe hyperhomocysteinemia refer to concentrations between 16 and 30, between 31 and 100, and less than 100 micromol/L, respectively.
* C-reactive protein: According to the U.S. Food and Drug Administration, in healthy people, reference values are below 5 mg/dL; in various diseases, this threshold is often exceeded within four to eight hours after an acute inflammatory event, with CRP values reaching approximately 20 to 500 mg/dL.

Health care team roles

Cardiac marker tests are usually performed by clinical laboratory scientists, medical technologists, or clinical laboratory technicians.//enotes.com

Chest Physical Therapy

2010-02-27T07:33:00.000-08:00

Definition

Chest physical therapy (CPT) is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.
Purpose

The purpose of chest physical therapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body.

Chest physical therapy includes postural drainage, chest percussion, chest vibration, turning, breathing exercises, coughing, and incentive spirometry. CPT is usually done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administration of expectorant drugs.

Chest physical therapy can be used with newborns, infants, children, and adults. People who benefit from chest physical therapy exhibit a wide range of problems that make it difficult to clear secretions from their lungs.

Patients who may receive chest physical therapy include those with cystic fibrosis, neuromuscular diseases (such as Guillain-Barré syndrome), progressive muscle weakness (such as myasthenia gravis), or tetanus. People with lung diseases such as pneumonia, bronchitis, and some forms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis, also benefit from chest physical therapy. CPT should not be used in the treatment of patients diagnosed with asthma.

People without specific lung problems but who are likely to aspirate their mucous secretions because of diseases such as cerebral palsy or muscular dystrophy also receive chest physical therapy, as do those who are bedridden or confined to a wheelchair. In addition, CPT may be part of treatment after surgery for patients who develop difficulty taking deep breaths.
Precautions

While the doctor ultimately determines which type of therapy can be performed, health care professionals know that not all forms of chest physical therapy are appropriate for all patients. Postural drainage and percussion should not be administered to patients who:

* have just eaten or are vomiting
* have acute asthma or tuberculosis
* have brittle bones or broken ribs
* are bleeding from the lungs or are coughing up blood
* are experiencing intense pain
* have increased pressure in the skull
* have head or neck injuries
* have collapsed lungs or a damaged chest wall
* recently experienced a heart attack
* have a pulmonary embolism or lung abscess
* have an active hemorrhage
* have injuries to the spine
* have open wounds or burns
* have had recent surgery

Description

Chest physical therapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and in the patient's home. Depending on the circumstances, chest physical therapy may be performed by anyone ranging from a respiratory care therapist to a trained member of the patient's family. Patients can be taught to perform some therapies.

Lengths of therapies and their costs vary. Some therapies may be part of ongoing treatment for a chronic condition. Special equipment may be needed for some procedures, such as percussion, and may be covered by the patient's health plan.

Chest physical therapy encompasses a variety of procedures; which ones are applied depends on the patient's needs. Hospitalized patients are reevaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long term chest physical therapy are reevaluated about every three months.
Turning

Turning from side to side permits lung expansion. Patients who cannot turn themselves are turned by a care- giver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.
Coughing

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. However, for patients with conditions like COPD, it can be painful to cough normally. An important part of chest

physical therapy is teaching patients to clear their airways by gentler methods, such as with a controlled cough or by "huffing."

Before either technique, patients are advised to sit upright and drink a glass of water. For the controlled cough, patients purse their lips and take a deep breath. They hold their breath for several seconds and then make two brief, gentle coughs. Huffing also starts with pursing the lips and taking a deep breath. After holding the breath for several seconds, patients exhale by using the stomach muscles to push the air out. The vocal chords remain open so that the cough has almost a whispery sound. Coughing and huffing are repeated several times a day as needed.
Deep breathing exercises

Deep breathing helps expand the lungs and forces better distribution of the air into all areas. The patient may initially need to lie down to do these exercises, but eventually it is done while sitting upright, then while walking.

Patients may find it helpful to monitor their breathing by placing a hand on their abdomen to provide a sense of their regular breathing pattern. The patient then starts by taking a deep breath through the nose, then purses the lips as if to whistle. The patient then exhales the air slowly through pursed lips. The exhalation should take twice as long as the inhalation. A patient may start by inhaling for two seconds and then exhaling for four. After taking several deep breaths, the patient breathes at a normal rhythm and begins another cycle of deep breathing. The patient builds up to taking deeper breaths, following a schedule given by the health care team. Generally, COPD patients practice deep breathing exercises for 20 minutes each day.
Incentive spirometry

The incentive spirometer helps the patient improve lung function. This self-administered therapy involves inhaling into a tube attached to a device. The specific technique and goal depends on the type of spirometer. The patient receives directions from the doctor, nurse, or respiratory therapist.

With a breath flow-oriented device, the patient inhales through a tube to raise a ball inside the plastic spirometer chamber. The drop in pressure causes the ball to rise, and the goal is to keep the ball in the air for as long as possible.

For a volume-oriented device, the patient sets a pointer on the chamber at the desired breath volume level. The patient inhales into the tube and attempts to raise a piston inside the chamber so that the volume marker reaches that level.

Hybrid volume accumulators combine a flow-oriented device with a volume-oriented device. A piston inside a cylinder responds to negative pressure from the patient's inhalation.

Some devices have a component designed for exhalation. If the model does not include an exhaling function, the patient breathes out air naturally.

At the end of the session, the patient takes a deep breath and then coughs. The length of therapy and the number of exercises done depend on the patient's condition and is determined by a respiratory therapist or other health professional.
Postural drainage

Postural drainage uses gravity to assist in draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. This therapy generally lasts a maximum of 30 minutes. If various positions are tried to induce a cough, the patient may remain in one position for from five to 15 minutes. The health care team guides the patient in determining the amount of time needed. Each position reaches a specific area of the lungs. Chest drainage positions include:

* the patient seated with head back
* the patient seated with head bent forward
* the patient lying face up with feet higher than the head
* the patient lying face down with feet higher than the head
* the patient lying first on one side, then the other, with feet higher than the head

Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Patients at home are given schedules set by their doctor or respiratory therapist. Percussion and vibration may be performed in conjunction with postural drainage.
Percussion

Percussion, also called cupping or clapping, involves rhythmically striking the chest wall with cupped hands. Mechanical devices can also be used. Percussion results in breaking up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.
Vibration

Vibration therapy is done for one minute after percussion therapy or may be used instead of percussion therapy for patients who may be too sore or frail to tolerate percussion. The purpose is also to help break up lung secretions. Vibration can be performed either mechanically or manually. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.
Preparation

Preparation for chest physical therapy starts with an evaluation of the patient's condition to determine which chest physical therapy techniques would be most beneficial. Since most therapies are done at home, patient education is extremely important. The doctor, nurse, physical therapist, or respiratory therapist instructs the patient or caregiver in chest physical therapy techniques. The therapy should be explained and demonstrated by the health professional. Then the patient or caregiver should try the therapy. This will demonstrate whether the patient understands the therapy or if more instruction is needed.
Aftercare

Patients should be advised to practice oral hygiene procedures to lessen the bad taste and odor of the secretions that they spit out.
Complications

Risks and complications associated with chest physical therapy depend on the health of the patient. Although chest physical therapy usually poses few problems, the health care team should be aware that in some patients it may cause:• oxygen deficiency if the head is kept lowered for drainage

* increased intracranial pressure
* temporary low blood pressure
* bleeding in the lungs
* pain or injury to the ribs, muscles, or spine
* vomiting
* inhaling secretions into the lungs
* heart irregularities

Results

The health care team should tell patients that CPT is often an ongoing treatment, with some or all therapies done daily. A positive response to treatment can be assessed by:

* increased volume of sputum secretions
* ease in breathing
* changes in breath sounds
* improved vital signs
* improved chest x ray
* increased oxygen in the blood as measured by arterial blood gas values

Health care team roles

The doctor typically orders chest physical therapy for a patient. A nurse or respiratory therapist provides therapy when a patient is hospitalized. For people seen on an outpatient basis, the emphasis is generally on patient education.
Patient education

Effective patient education is vital because chest physical therapy is often performed at home. A doctor, nurse, or respiratory therapist explains and demonstrates techniques such as breathing, percussion, and incentive spirometry. The patient or caregiver performs the therapy under the health professional's observation to be sure it can be done correctly independently.

Nurses and respiratory therapists also participate in public awareness education, such as anti-smoking campaigns.
Training

Chest physical therapy is part of training for physicians and nurses specializing in cardiopulmonary treatment, and for respiratory therapists (also known as respiratory care practitioners). Therapists must have at least an associate degree, which is earned after completion of a two-year program. There are also four-year bachelor degree programs for this profession. Graduates with both types of degrees are certified after passing the examination given by the National Board for Respiratory Care.

Catheterization, Female

2010-01-15T12:04:00.000-08:00

http://www.enotes.com

Definition

Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose

Intermittent catheterization is used for the following reasons:• To obtain a sterile urine specimen for diagnostic evaluation; to empty bladder content when the patient is unable to void (urinate) due to urinary retention, bladder distention, and obstruction, or to measure residual urine after urination.

* To instill medication for a localized therapeutic effect and to instill contrast material (dye) into the bladder through the urethral catheter for cystourethralgraphy (x ray of the bladder and urethra).
* To empty the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery and during pelvic and abdominal surgery.
* To strictly monitor the urinary output and fluid balance of critically ill patients.

Indwelling catheterization is:

* Indicated as palliative care for terminally ill or severely impaired incontinent patients, for whom bed and clothing changes are uncomfortable, and as a way to manage skin ulceration caused or exacerbated by incontinence.
* Used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation, and for persons with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.
* Indicated for urologic surgery, bladder outlet obstruction, and for patients with an initial episode of acute urinary retention to allow the bladder to regain its tone.

Precautions

Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a urinary tract infection (UTI). The catheterization procedure must be sterile and the catheter must be free from bacteria.

Urinary catheterization aids or replaces the body's normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function, however frequent and continuous catheterization can lead to total dependency. Catheterization is invasive and has the potential of injuring the urethra and bladder, inviting urinary tract infections. Therefore aseptic techniques should be use in all catheter management activities.

The normal flow of urine from the kidneys through the ureters, bladder, urethra prevents the movement of bacteria up through the urinary system. The antibacterial properties of the bladder wall, urethra lining, and low urine pH also serve as protective barriers to urinary tract infections. Urinary tract infections occur when bacteria invade the protective barriers of one or more urinary structures.
Infection control

Every attempt should be made to keep the urinary drainage system closed. Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient's catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure.

The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

Frequent intermittent catheterization and long term use of indwelling catheterization predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus or urothelium (urinary lining) with catheters that are too large or inserted with insufficient use of lubricant. Patients with an indwelling catheter must be reassessed periodically to determine if alternative treatment will be more effective in treating the problem.
Description

The female urethral orifice is a vertical, slit-like or irregularly ovoid (egg shaped) opening, 4 or 5 mm in diameter, located between the clitoris and the vagina. The urinary meatus (opening) is concealed between the labia minora, which are the small folds of tissue that need to be separated in order to visualize the opening and insert the catheter. With proper positioning, good lighting and gloved hands, these anatomical landmarks can be identified. If necessary, provide perineal care to ensure a clean procedural environment.

Catheterization of the female patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion. But since there are no lubricating glands in the female urethra (as found in the male urethra), the risk of trauma from a simple catheter insertion is more likely; therefore, ample supply of an anesthetic or antibacterial lubricant should be used.
Preparation

Health care practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, trained in antiseptic techniques and in catheter insertion and catheter care.

Determine the primary purpose for the catheterization and give the patient and/or caregiver a detail explanation. Patients requiring self-catheterization should be instructed and trained in the technique by a qualified health professional.

Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, perineal drapes, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and drainage system may need to be added. It is always wise to review the content of the pre-packaged catheterization set while assembling the materials.
Catheter choices

TYPES. Silastic catheters have been recommended for short-term catheterization after surgery because they are known to decrease incidence of urethritis. However, due to lower cost and acceptable outcomes, latex is the catheter of choice for long-term catheterization. Silastic catheters should be used for patients who are allergic to latex products.

There are also additional types of catheters:

* PTFE-coated latex Foley catheters
* hydrogel-coated latex Foley catheters
* pure silicone Foley catheters
* silicone-coated latex Foley catheter

SIZE. The diameter of the catheter is measured in millimeters. Authorities recommend the "narrowest and softest tube" that will serve the purpose. Rarely is a catheter larger than size 18 F required, and sizes 14 or 16 F are used more often. Catheters greater than size 16 F have been associated with patient discomfort and urine bypassing. A size 12 catheter has been successfully used in children and female patients with urinary restriction.

LENGTH. Female adult patients should be given the choice of a short, female length or a standard length catheter for urethral catheterization.

BALLOON SIZE. Select a catheter with a balloon-filling volume of 0.33 fl oz (10 ml) for routine drainage. Sterile water must always be used to inflate the balloon as other fluids may contain particles, which could block the inflation channel. Some indwelling catheters are manufactured pre-filled with 0.33 fl oz (10 ml) of sterile water, ready for balloon inflation after catheter insertion.

DRAINAGE SYSTEM. Review the design, capacity, and emptying mechanism of the variety of urine drainage bags with the patient. Select the system that is most adaptable to the patient's lifestyle and her ability to manage the device independently. For women with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.
Procedure

The standard technique for catheter insertion is:

* Explain the procedure to the patient, position the patient and ensure privacy and good lighting.
* Wash hands, remove outer tray wrapper and put on sterile gloves before opening the sterile inner packet. Prepare a sterile field and place a specimen collection vessel between the patient's legs.
* Cleanse the labia according to established guidelines and identify the urethral meatus. If an anesthetic lubricating gel is used, instill approximately 0.16 fl oz (5 ml) of 2% lignocaine hydrochloride gel into the urethra or apply the gel to the meatus to achieve surface anesthesia within three to five minutes.
* Hold the catheter in the dominant hand and gently insert it into the urethral meatus; pass it slowly through the urethra and into the bladder. If the catheter is accidentally inserted into the vagina or the tip is contaminated, discard it and take new sterile catheter before proceeding.
* Once the urine starts to flow, collect the specimen and pass the catheter an additional 2 inches (5 cm) to ensure that the balloon is in the bladder before slowly inflating the balloon with 10 ml sterile water.

Aftercare

Patients using intermittent catheterization to manage incontinence may require a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake.

Antibiotics should not be prescribed as a preventative measure for patients at risk for urinary tract infections. Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Patients who practice intermittent self-catheterization can reduce their risks for UTI by using antiseptic techniques for insertion and catheter care.

Attach the indwelling catheter to the drainage system, slightly curve the tubing, and anchor it to prevent urethral traction. In women the catheter should be secured to the anteromedial thigh with non-allergenic adhesive.
Complications

Complications that are liable to occur include:

* Trauma and/or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
* Trauma to the urethra and/or bladder from incorrect insertion or removal of the catheter with the balloon inflated. Repeated trauma may cause scaring and/or stricture, or narrowing of the urethra.
* Bypassing of urine around the catheter. Inserting a smaller catheter size can minimize this problem.

Sexual activity and menopause can also compromise the sterility of the urinary tract. Irritation of the urethra during intercourse promotes the migration of perineal bacteria into the urethra and bladder, causing UTIs. Postmenopausal women may experience more UTIs than younger women. The presence of residual urine in the bladder secondary to incomplete voiding provides an ideal environment for bacterial growth.
Results

Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.

Catheters should not be changed routinely. When each patient is monitored for indication of obstruction, infection, or complications before the catheter is changed, some patients require catheter changes weekly, and others may need a change in several weeks. Fewer catheter changes will reduce trauma to the urethra and reduce incidence of UTI.
Health care team roles
Observation

Before commencing with the catheterization, the nurse should observe the patient's general condition, pal-pate the pubic area to note gross distension. The patient should be monitored for indications of infections and encourage adequate fluid intake.

The nurse should seek medical advice if the catheter cannot be inserted easily, or if the patient complains of undue pain or bleeding other than that associated with minor trauma.
Patient education

The patient and/or caregiver should be taught to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital and nursing homes and home care units.

The sexuality of the patient with an indwelling catheter for continuous urinary drainage is seldom considered. If a patient is sexually active, the practitioner must explain that intercourse can take place with the catheter in place. The patient or her partner can be taught to remove the catheter before, and replace it with a new one following intercourse.
KEY TERMS

Catheterization—A procedure of inserting a catheter through the urethra into the bladder to remove urine.

Catheter—A tube for evacuating or injecting fluid.

Contaminate—To make an item unsterile or unclean by direct contact.

Foley catheter—A double channel retention catheter. One channel provides for the inflow and outflow of bladder fluid, the second (smaller) channel is used to fill a balloon that holds the catheter in the bladder.

Intermittent catheterization—Periodic catheterization to facilitate urine flow. The catheter is removed when the bladder is sufficiently empty.

Perineal area—The genital area between the vulva and anus in a woman.

Urinary incontinence—The inability to retain urine or control one's urine flow.

Urinary retention—The inability to void (urinate) to discharge urine.

Urethritis—Inflammation of the urinary bladder.
Resources
BOOKS

Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.
PERIODICALS

Colley, Wendy. RGN, DNCret. FETC. "Know How." Nursing Times (July 2, 1997).

Cravens, David D., Steven Zweig. "Urinary Catheter Management." American Family Physicians 61, no. 2 (January 15, 2000): 369.

Sanyay Saint, Joann G. Elmore, Sean D. Sullivan, Scott S. Emerson, Thomas D. Koepsell, "The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis." American Journal of Medicine 105, no. 3 (September 1998): 236.

Aliene S. Linwood, B.S.N., RN, D.P.A., FACHE

Catheterization, Male

2010-01-15T12:02:00.000-08:00

http://www.enotes.com

Definition

Urinary catheterization is the procedure of inserting a catheter through the urethra into the bladder to remove urine. Intermittent catheterization is performed for periodic relief of bladder distension; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose

Intermittent catheterization is recommended to obtain a sterile urine specimen, to relieve urinary retention, for urologic surgery or surgery on contiguous structures, for critically ill patients requiring accurate measurement of intake and output, and for temporary obstruction of the bladder opening due to injury.

Indwelling catheterization is recommended for continuous drainage of urine when the bladder outlet obstruction can not be corrected by medical or surgical intervention; in cases of intractable skin ulceration caused or exacerbated by exposure to urine; and as palliative care for terminally ill or severely impaired incontinent patients.
Precautions

The urinary tract is normally a sterile system. The normal flow of urine from the kidneys through the ureters, bladder, and urethra prevents the migration of bacteria up through the urinary system. Antibacterial properties of the bladder wall, urethra, low pH of urine, and the prostatic fluid in men also inhibit bacteria growth. Urinary tract infections (UTI) usually result from bacterial invasion of the protective barriers of one or more urinary structures. As a result, urinary catheterization should be avoided whenever possible. Precautions must be taken to keep the procedure sterile and the catheter free from bacteria. The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

Frequent intermittent catheterization and long-term use of indwelling catheters predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus and urothelium (urinary lining) with catheters that are too large or inserted with an insufficient amount of lubricant. Further medical advice should be sought if the catheter cannot be inserted easily, or the patient complains of undue pain or bleeding other than that associated with minor trauma.

Every attempt should be made to keep the urinary drainage system closed. Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient's catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.
Description

Intermittent catheterization is preferable to chronic indwelling catheterization in certain patients with bladder dysfunction. It has become the standard care for patients with spinal cord injuries. Elderly patients, following surgical repair of hip fractures, regain the ability to control urination more quickly on a program of intermittent catheterization every six to eight hours compared to the use of indwelling catheters.

Intermittent catheterization may be performed four or five times a day by the health care practitioner or care-giver. Patients who are interested in self-catheterization should be instructed and trained by a qualified health professional. This is also true for patients who require indwelling catheterization, as the procedure for insertion is similar to that for intermittent catheterization, with added responsibility of inflating the balloon.
Preparation

Health care practitioner performing the catheterization should have a good understanding of the male urinary system anatomy and physiology and should be trained in aseptic technique, catheter insertion technique, and catheter care.

Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agents, perineal drapes, gloves, lubricant, specimen container, label, and adhesive strips. Local anesthetic gel, antibacterial lubricant, catheter, and drainage system may need to be added. It is wise to check the content of the pre-packaged catheterization set when assembling materials and supplies.
Catheter choices

Silastic catheters have a decreased incidence of urethritis and are recommended for short-term and intermittent catheterization. Latex is the catheter of choice for long-term catheterization. Silastic catheters are recommended for patients who are allergic to latex products.

There are additional types of Foley catheters:

* PTFE-coated latex
* hydrogel-coated latex
* silicone-coated latex
* pure silicone

Select the smallest and softest catheter available. Catheters larger than 18 F are seldom used. Catheters size 14 or 16 F are used more frequently. A size 12 F catheter has been used successfully in catheterizing men with acute urinary retention. When indwelling catheters are required, select a catheter that can be inflated with 5 to 10 ml of sterile water.

Review the design, capacity, and emptying mechanism of a variety of urine drainage systems available. Select the system that is most adaptable to the patient's lifestyle and ability to manage the device independently. For patients with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.
Procedural precautions

Before starting the catheterization, observe the patient's general condition and palpate the suprapubic area to detect gross distension. The genital area should be washed with a mild soap and warm water and patted dry.

Phimosis is constriction of the prepuce (foreskin) so that it cannot be drawn back over the glans penis. This may make it difficult to identify the external urethral meatus. Care should be taken when catheterizing men with phimosis to avoid trauma from forced retraction of the prepuce or by incorrect positioning of the catheter.

The male urethra is longer than the female urethra and has two curves in it as it passes through the penis to the bladder, which makes catheter insertion more difficult. One curve can be straightened out by lifting the penis; the other curve is fixed. The penis should be held upright, at right angle to the patient's body when the catheter is inserted. The male urinary meatus is located at the end of the penis and is exposed by retracting the prepuce in uncircumcised patients. Men with a retracted penis can be even more difficult to catheterize. Gentle finger pressure on both sides of the penis will often cause the penis to emerge and extend from the body to facilitate the catheterization.

To perform the procedure:

* Position the patient in a horizontal recumbent position.
* Place the opened catheterization tray on the bedside stand in comfortable reaching distance.
* Retract the foreskin. Using an aseptic technique, clean the prepuce and insert anesthetic gel to anesthetize the glans penis and dilate the prepuce exposing the meatus. Anesthetic gel can then be introduced into the urethra and catheterization can commence.
* Use two or three aseptic swabs to clean the meatus with circular motion, beginning with the center of the opening and rotating outwards.
* Lubricate about 8 inches (20 cm) of the catheter.
* Hold the penis in the dominant hand and pull it upward and slightly backward to straighten the urethra.
* Gently insert the catheter with a smooth continuous motion until urine begins to flow. Do not force.
* Once the urine starts to flow, collect the specimen. Advance the catheter an additional 5 cm before inflating the balloon with 5 to 10 ml of sterile solution to hold the catheter in place.
* Connect the indwelling catheter to the drainage system. Put a slight curve in the catheter and anchor it to the upper outer thigh with hypoallergenic adhesive to prevent urethral traction.

Aftercare

Patients using intermittent catheterization as treatment of incontinence or retention will have a period of adjustment as they try to establish a catheterization schedule adequate for their normal fluid intake. The urinary drainage system should be kept closed. Breaks in the drainage unit may result in an infection. Avoiding cross-contamination is important in controlling catheter-related UTIs. Practitioners and caretakers should always wash their hands before and after handling a patient's catheter or urine collection unit.

The extended portion of the catheter should be washed with a mild soap and warm water to remove accumulated debris. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.

Catheters should not be changed routinely. Each patient should be monitored for indication of obstruction or complications before changing the catheter. Some patients require catheter changes weekly, and others may need a change in several weeks.

In summary, the following guidelines are recommended for male catheterization:

* Catheterize the patient only when it is absolutely necessary.
* Secure the catheter properly.
* Maintain a closed sterile urine collection system and unobstructed urine flow.
* Avoid catheter irrigation unless it is needed to prevent or relieve bladder obstruction.
* Always use the smallest effective catheter.
* Do not change the catheter as an elective treatment option.
* Isolated minor episodes of UTI should not be treated with antibiotics. Antibiotic prophylaxis promotes emergence of drug-resistant bacteria.
* Provide continuing education in catheter care for practitioners and caretakers.

Complications

A few complications that may rise during the procedure are:

* urinary tract infections and catheter obstruction
* trauma and/or the introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia
* trauma to the bladder, urethra, and meatus caused by incorrect insertion of the catheter or forceful removal with the bladder inflated by confused patients
* scaring, stricture and/or narrowing of the urethra due to repeated trauma
* urine bypass around the catheter (A smaller catheter size may minimize leakage.)
* leakage around the catheter due to forceful bladder spasms that overwhelm the catheter's drainage capacity

Results

Urinary catheterization aids or replaces the body's normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function. However frequent and continuous catheterization can lead to total

dependency. Practically every patient with chronic catheterization and frequent intermittent catheterization will develop bacteriuria. Some physicians do not recommend antibiotic therapy for asymptomatic bacteriuria. When symptomatic infections are treated in patients with indwelling catheters, the catheter is removed and a fresh urine specimen is obtained for culture to determine the source of the infection and direct the medical therapy.
Health care team roles

The physician orders the catheter and a registered nurse performs the procedure and provides patient education. Catheterization is a rather simple procedure, but female nurses are sometimes reluctant to perform urethral catheterization on male patients despite established patient care guidelines and advice on the male catheterization procedure. However, both intermittent and indwelling male catheterization is required to achieve optimum quality of life; therefore nurses should make the best possible practice and techniques available. Before commencing with the catheterization, the health care professional observes the patient's general condition, palpates the pubic area to note gross distension, monitors the patient for indications of infections, and encourages adequate fluid intake.
Patient education

The nurse usually teaches the patient and/or caregiver to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital, nursing homes, and home care units.

The sexuality of the patient with an indwelling catheter for continuous urinary drainage is seldom considered. If a patient is sexually active, the patient or her partner can be taught to remove the catheter before inter-course, and replace it with a new one following inter-course.
KEY TERMS

Bacteriuria—Bacteria in the urine (asymptomatic or symptomatic).

Foley catheter—A double channel retention catheter. One channel provides for the inflow and outflow of fluid; the second and smaller channel is used to fill a balloon that holds the catheter in the bladder.

Phimosis—Tightness of the foreskin, which cannot be drawn back from the glans penis.

Prepuce—A fold of cutaneous tissue over the glans penis.

Urinary catheterization—The insertion of a catheter through the urethra into a patient's bladder.

Urinary incontinence—The inability to retain urine or control one's urine flow.

Urinary retention—The inability to void (urinate) to discharge urine.
Resources
BOOKS

Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.
PERIODICALS

Cravens, David D. and Steven Zweig. "Urinary Catheter Management." American Family Physician 16, no. 12 (January 15, 2000): 369.

Marchiondo, Kathleen. "A New Look at Urinary Tract Infection." American Journal of Nursing 98, no. 3 (March 1998):p34-39.

Pomfret, Ian. "Women at Work." Nursing Times 95, no. 6 (February 10, 1999): 59-60.

Aliene S. Linwood, BSN, RN, D.P.A., FACHE

Osteoporosis

2010-01-15T11:53:00.000-08:00

http://www.enotes.com

Definition

The word osteoporosis literally means "porous bones." It occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass, and therefore bone strength, is decreased. As a result, bones become fragile and break easily. Even a sneeze or a sudden movement may be enough to break a bone in someone with severe osteoporosis.

Description

Osteoporosis is a serious public health problem. Some 28 million people in the United States are affected by this potentially debilitating disease, which is responsible for 1.5 million fractures (broken bones) annually. These fractures, which are often the first sign of the disease, can affect any bone, but the most common locations are the hip, spine, and wrist. Breaks in the hip and spine are of special concern because they almost always require hospitalization and major surgery, and may lead to other serious consequences, including permanent disability and even death.

To understand osteoporosis, it is helpful to understand the basics of bone formation. Bone is living tissue that is constantly being renewed in a two-stage process (resorption and formation) that occurs throughout life. In the resorption stage, old bone is broken down and removed by cells called osteoclasts. In the formation stage, cells called osteoblasts build new bone to replace the old. During childhood and early adulthood, more bone is produced than removed, reaching its maximum mass and strength by the mid-30s. After that, bone is lost at a faster pace than it is formed, so the amount of bone in the skeleton begins to slowly decline. Most cases of osteoporosis occur as an acceleration of this normal aging process—a form referred to as primary osteoporosis. The condition can also be caused by other disease processes or prolonged use of certain medications that result in bone loss—a form called secondary osteoporosis.

Osteoporosis occurs most often in older people and in women after menopause. It affects nearly half of all men and women over the age of 75. Women, however, are five times more likely than men to develop the disease. They have smaller, thinner bones than men to begin with, and they lose bone mass more rapidly after menopause (usually around age 50), when they stop producing a bone-protecting hormone called estrogen. In the five to seven years following menopause, women can lose about 20% of their bone mass. By age 65 or 70, though, men and women lose bone mass at the same rate. As an increasing number of men reach an older age, they are becoming more aware that osteoporosis is an important health issue for them as well.
Causes and symptoms

A number of factors increase the risk of developing osteoporosis. They include:

* Age. Osteoporosis is more likely as people grow older and their bones lose tissue.
* Gender. Women are more likely to have osteoporosis because they are smaller and so start out with less bone. They also lose bone tissue more rapidly as they age. While women commonly lose 30–50% of their bone mass over their lifetimes, men lose only 20–33% of theirs.
* Race. Caucasian and Asian women are at higher risk for the disease than women of African or Hispanic ethnicities.
* Figure type. Women with small bones and those who are thin are more liable to have osteoporosis.
* Early menopause. Women who stop menstruating early because of heredity, surgery or a lot of physical exercise may lose large amounts of bone tissue early in life. Conditions such as anorexia and bulimia may also lead to early menopause and osteoporosis.
* Lifestyle. People who smoke or drink too much, or do not get enough exercise have an increased chance of getting osteoporosis.
* Diet. Those who do not get enough calcium or protein may be more likely to have osteoporosis. People who constantly diet are more prone to the disease. It has been shown that adolescent girls (but not boys) have insufficient calcium intake levels in the diet. This calcium deficiency occurs during a period of rapid bone growth, stunting the peak bone mass ultimately achieved; thus, these individuals are at greater risk of developing osteoporosis.
* Genetics. People with a family history of osteoporosis are more likely to contract the disease.
* Chronic use of medication. Certain types of medication, such as steroids, interfere with the body's ability to absorb calcium or accelerate calcium depletion, damaging bone density.

Osteoporosis is often called the "silent" disease, because bone loss occurs without symptoms. People often do not know they have the disease until a bone breaks, frequently in a minor fall that would not normally cause a fracture. A common occurrence is compression fractures of the spine. These can happen even after a seemingly normal activity, such as bending or twisting to pick up a light object. The fractures can cause severe back pain, but sometimes they go unnoticed—either way, the vertebrae collapse down on themselves, and the person actually loses height. The hunchback appearance of many elderly women, sometimes called "dowager's hump" or "widow's hump," is due to this effect of osteoporosis on the vertebrae.
Diagnosis

Certain types of doctors may have more training and experience than others in diagnosing and treating people with osteoporosis. These include geriatricians, who specialize in treating the aged; endocrinologists, who specialize in treating diseases of the body's endocrine system (glands and hormones); and orthopedic surgeons, who treat fractures, such as those caused by osteoporosis.

Before making a diagnosis of osteoporosis, the doctor usually takes a complete medical history, conducts a physical exam, and orders x-rays, as well as blood and urine tests, to rule out other diseases that cause loss of bone mass. The doctor may also recommend a bone density test. This is the only way to determine if osteoporosis is present. It can also show how far the disease has progressed.

Several diagnostic tools are available to measure the density of a bone. The most accurate and advanced of the densitometers uses a technique called DEXA (dual energy x-ray absorptiometry). With the DEXA scan, a double x-ray beam takes pictures of the spine, hip, or entire body. It takes about 20 minutes to do, is painless, and exposes the patient to only a small amount of radiation—about one-fiftieth that of a chest x ray. The ordinary x ray is one, though it is the least accurate for early detection of osteoporosis, because it does not reveal bone loss until the disease is advanced and most of the damage has already been done. Other tools that are more likely to catch osteoporosis at an early stage are computed tomography scans (CT scans) and machines called densitometers, which are designed specifically to measure bone density. The CT scan, which takes a large number of x rays of the same spot from different angles, is an accurate test, but uses higher levels of radiation than other methods.

People should talk to their doctors about their risk factors for osteoporosis and if, and when, they should get the test. A woman should have bone density measured at menopause, and periodically afterward, depending on the condition of their bones. Men should be tested around age 65. Men and women with additional risk factors, such as those who take certain medications, may need to be tested earlier.
Treatment

There are a number of good treatments for primary osteoporosis, most of them medications. In addition, calcium (0.5 to 2 g/day) and vitamin D (400 to 800 IU/day) supplementation can reduce the rate of bone loss in women who are more than five years postmenopausal. Fracture reduction efficacy of calcium and vitamin D supplementation, administered independently, has been demonstrated in women older than 75 years of age.

For people with secondary osteoporosis, treatment may focus on curing the underlying disease.
Drugs

For most women who have gone through menopause, the best treatment for osteoporosis is hormone replacement therapy (HRT). Many women participate in HRT when they undergo menopause, to alleviate symptoms such as hot flashes, but hormones have other important roles as well. They protect women against heart disease, the number one killer of women in the United States, and they help to relieve and prevent osteoporosis. HRT increases a woman's supply of estrogen, which helps build new bone, while preventing further bone loss.

Some women, however, do not want to take or are not candidates for hormones, because some studies show they are linked to an increased risk of breast cancer or uterine cancer. Other studies reveal that risk is due to increasing age. (Breast cancer tends to occur more often as women age.) Whether or not a woman takes hormones is a decision she should make carefully with her doctor. Women should talk to their doctors about personal risks for osteoporosis, as well as their risks for heart disease and breast cancer.

Novel delivery systems of HRT have been developed. For example, Vivelle is a estradiol transdermal system that is used for prevention of osteoporosis. It uses a "patch" to continously deliver the hormone estradiol through the skin.

Studies have shown women who started taking HRT within five years of menopause show significantly reduced rates of hip fractures than women who began HRT more than five years postmenopausal. However, even while taking HRT, 10 to 20% of women continue to lose bone density and therefore may require additional intervention.

For people who cannot or will not take estrogen, other agents can be good choices. These include:

* bisphosphonates
* calcitonin
* selective estrogen receptor modulators
* sodium fluoride
* androgens

Although there are a number of bisphosphonates used for the treatment of various forms of osteoporosis and resorptive bone diseases, alendronate (sold under the brand name Fosamax), etidronate (sold under the brand name Didronel), and risedronate (sold under the brand name Actonel) are some of the agents most commonly used for therapeutic treatment of postmenopausal osteoporosis. Biphosphonates act by decreasing bone resorption or breakdown. For example, alendronate attaches itself to bone that has been targeted by bone-eating osteoclasts. It protects the bone from these cells. Osteoclasts help the body break down old bone tissue.

Alendronate has shown to be an effective agent in preventing bone loss and building bone in recently post-menopausal women and is especially useful in women who have contraindications for HRT. It has been licensed for the treatment and prevention of vertebral and nonvertebral postmenopausal osteoporosis. Alendronate has proven safe in very large, multi-year studies, but not much is known about the effects of its long-term use. Side effects are generally minimal with abdominal pain, nausea, dyspepsia, constipation and diarrhea occurring in 3% to 7% of patients treated with alendronate. It can be taken daily, and now a new formulation has been developed that can be taken weekly.

Etidronate has been shown to reduce the rate of new vertebral and nonvertebral fractures. It appears to be well tolerated in clinical studies.

Calcitonin is a hormone that has been used as an injection for many years. It is also marketed as a nasal spray. It also slows down bone-eating osteoclasts. Side effects are minimal, but calcitonin builds bone by only 1.5% a year, which may not be enough for some women to recover the bone they lose.

Selective estrogen receptor modulators (SERMs) such as raloxifene, droloxifene, idoxifene, and tamoxifen are used as alternatives to hormone replacement therapy (HRT) which commonly use estrogen. SERMs have been shown to protect against postmenopausal bone loss without the estrogenic side effects. Raloxifene was the first SERM to be approved in the osteoporosis market for prevention and treatment of osteoporosis. Raloxifene binds to estrogen receptors and mimics estrogen's action on bone by preventing bone loss, and improving cholesterol metabolism, therefore acting as an agonist. It also acts as an estrogen antagonist in the uterus and the breasts, by not imitating the action of estrogen. These drugs may thus improve blood lipid profiles and protect against breast cancer. There is an enhanced risk of venous thromboembolic events during raloxifene therapy, especially during the first four months of therapy. It also has a propensity to induce hot flashes, and leg pain.

Sodium fluoride has been used as an anabolic agent to stimulate bone formation. However, a high incidence of side effects, mainly gastrointestinal symptoms and lower extremity pain syndrome have occurred in clinical trials.

Androgens have been used for reducing bone loss. Androgens are classified as anabolic steroids, which include nandrolone, stanozolol and testosterone, are used as antiresorptive agents. Androgens are important for postmenopausal women as they serve as a substrate for the peripheral production of estrogens.

The treatments currently available are antiresorptive, which limits the ability to increase bone mass. Other bone-building agents are under investigation including parathyroid hormone which has been clinically evaluated but is still awaiting FDA approval as of March 2001. The biphosphonates have demonstrated the most dramatic reduction in fracture rates and may be the best choice for women with severe osteoporosis. Estrogen's effect may be similar, but has not been established in large randomized trials. Raloxifene may be particularly useful in women who wish to benefit from a breast cancer risk reduction. Calcitonin may be the least potent but may be useful in women who cannot tolerate other therapies.
Surgery

Unfortunately, treatment for osteoporosis is usually tied to fractures that result from advanced stages of the disease. For complicated fractures, such as broken hips, hospitalization and a surgical procedure are required. In hip replacement surgery, the broken hip is removed and replaced with a new hip made of plastic, or metal and plastic. Though the surgery itself is usually successful, complications of the hip fracture can be serious. Those individuals have a 5%–20% greater risk of dying within the first year following that injury than do others in their age group. A large percentage of those who survive are unable to return to their previous level of activity, and many end up moving from self-care to a supervised living situation or nursing home. Getting early treatment and taking steps to reduce bone loss are vital.
Alternative treatment

Alternative treatments for osteoporosis focus on maintaining or building strong bones. A healthy diet low in fats and animal products and containing whole grains, fresh fruits and vegetables, and calcium-rich foods (such as dairy products, dark-green leafy vegetables, sardines, salmon, and almonds), along with nutritional supplements (such as calcium, magnesium, and vitamin D), and weight-bearing exercises are important components of both conventional prevention and treatment strategies and alternative approaches to the disease. In addition, alternative practitioners recommend a variety of botanical medicines or herbal supplements. Herbal supplements designed to help slow bone loss emphasize the use of calcium-containing plants, such as horsetail (Equisetum arvense), oat straw (Avena sativa), alfalfa (Medicago sativa), licorice (Glycyrrhiza galbra), marshmallow (Althaea officinalis), and yellow dock (Rumex crispus). Homeopathic remedies focus on treatments believed to help the body absorb calcium. These remedies are likely to include such substances as Calcarea carbonica (calcium carbonate) or silica. In traditional Chinese medicine,
KEY TERMS

Alendronate—A nonhormonal drug used to treat osteoporosis in postmenopausal women.

Anticonvulsants—Drugs used to control seizures, such as in epilepsy.

Biphosphonates—Compounds (like alendronate) that slow bone loss and increase bone density.

Calcitonin—A hormonal drug used to treat post-menopausal osteoporosis.

Estrogen—A female hormone that also keeps bones strong. After menopause, a woman may take hormonal drugs with estrogen to prevent bone loss.

Glucocorticoids—Any of a group of hormones (like cortisone) that influence many body functions and are widely used in medicine, such as for treatment of rheumatoid arthritis inflammation.

Hormone replacement therapy (HRT)—Also called estrogen replacement therapy, this controversial treatment is used to relieve the discomforts of menopause. Estrogen and another female hormone, progesterone, are usually taken together to replace the estrogen no longer made by the body. It has the added effect of stopping bone loss that occurs at menopause.

Menopause—The ending of a woman's menstrual cycle, when production of bone-protecting estrogen decreases.

Osteoblasts—Cells in the body that build new bone tissue.

Osteoclasts—Cells that break down and remove old bone tissue.

Selective estrogen receptor modulator—A hormonal preparation that offers the beneficial effects of hormone replacement therapy without the increased risk of breast and uterine cancer associated with HRT.

practitioners recommend herbs thought to slow or prevent bone loss, including dong quai (Angelica sinensis) and Asian ginseng (Panax ginseng). Natural hormone therapy, using plant estrogens (from soybeans) or progesterone (from wild yams), may be recommended for women who cannot or choose not to take synthetic hormones.

It should be noted, however, that very few clinical trials are conducted on alternate therapies and therefore efficacy cannot be established.
Prognosis

There is no cure for osteoporosis, but it can be controlled. Most people who have osteoporosis fare well once they get treatment. The medicines available now build bone, protect against bone loss, and halt the progress of this disease.
Health care team roles

Doctors, nurses, physical therapists, radiation technologists, and dietitians all play roles in the process of controlling osteoporosis. Because osteoporosis is treatable but not curable, the main responsibility for controlling the progress of the disease rests with the patient. All of these team members play an important role in identifying risk of osteoporosis before it strikes and in convincing the patient to take appropriate steps (including lifestyle modification) to minimize the dangers of fracturing major bones.
Prevention

Building strong bones, especially before the age of 35, and maintaining a healthy lifestyle are the best ways of preventing osteoporosis. To build as much bone mass as early as possible in life, and to help slow the rate of bone loss later in life:
Get calcium in foods

Experts recommend 1,500 milligrams (mg) of calcium per day for adolescents, pregnant or breast-feeding women, older adults (over 65), and postmenopausal women not using hormone replacement therapy. All others should get 1,000 mg per day. Foods are the best source for this important mineral. Milk, cheese, and yogurt have the highest amounts. Other foods that are high in calcium are green leafy vegetables, tofu, shell-fish, Brazil nuts, sardines, and almonds.
Take calcium supplements

Many people, especially those who do not like or cannot eat dairy foods, do not get enough calcium in their diets and may need to take a calcium supplement. Supplements vary in the amount of calcium they contain. Those with calcium carbonate have the most amount of useful calcium. Supplements should be taken with meals and accompanied by six to eight glasses of water a day. Calcium supplements and antacids interfere with absorption of alendronate and should be taken at least one half hour later.
Get vitamin D

Vitamin D helps the body absorb calcium. People can get vitamin D from sunshine with a quick (15–20 minutes) walk each day or from foods such as liver, fish oil, and vitamin-D fortified milk. During the winter months it may be necessary to take supplements (400–800 IU/day).
Avoid smoking and alcohol

Smoking reduces bone mass, as does heavy drinking. To reduce risk, do not smoke and limit alcoholic drinks to no more than two per day. An alcoholic drink is1.5 oz (44 mL) of hard liquor, 12 oz (355 mL) of beer, or 5 oz (148 mL) of wine.
Exercise

Exercising regularly builds and strengthens bones. Weight-bearing exercises—where bones and muscles work against gravity—are best. These include aerobics, dancing, jogging, stair climbing, tennis, walking, and lifting weights. People who have osteoporosis may want to attempt gentle exercise, such as walking, rather than jogging or fast-paced aerobics, which increase the chance of falling. Try to exercise three to four times per week for 20–30 minutes each time. As physical activity improves muscle strength and coordination it may also aid in reducing the risk of fall-related fractures.

Those at risk should avoid medications known to compromise bone density, such as glucocorticoids, thyroid hormones and chronic heparin therapy.
Resources
BOOKS

Adams, John S. and Barbara P. Lukertet. Osteoporosis: Genetics, Prevention and Treatment. Boston: Kluwer Academic, 1999.

Kessler, George J., et al. The Bone Density Diet: 6 Weeks to a Strong Body and Mind. New York: Ballantine Books, 2000.

Krane, Stephen M., and Michael F. Holick. "Metabolic Bone Disease: Osteoporosis." In Harrison's Principles of Internal Medicine. 14th ed. Ed. by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.

Lane, Nancy E., ed. The Osteoporosis Book. New York: Oxford University Press, 1998.

McIlwain, Harris, et al. Osteoporosis Cure: Reverse the Crippling Effects With New Treatment. New York: Avon Books, 1998.

Notelovits, Morris, et al. Stand Tall! Every Woman's Guide to Preventing and Treating Osteoporosis. 2nd ed. Gainesville, FL: Triad Publishing Co., 1998.
PERIODICALS

Feder, G., et al. "Guidelines for the Prevention of Falls in People over 65." British Medical Journal 321 (2000): 1007-1011.

McClung, Michael R., et al. "Effect of Risedronate on the Risk of Hip Fracture in Elderly Women." The New England Journal of Medicine 344, no. 5 (2001): 333-40.
ORGANIZATIONS

Arthritis Foundation, 1330 W. Peachtree St., PO Box 7669, Atlanta, GA 30357-0669. (800) 283-7800. .

National Center for Complementary and Alternative Medicine (NCCAM), 31 Center Dr., Room #5B-58, Bethesda, MD 20892-2182. (800) NIH-NCAM. Fax: (301) 495-4957. .

National Osteoporosis Foundation, 1150 17th Street, Suite 500 NW, Washington, DC 20036-4603. (800) 223-9994. .

Osteoporosis and Related Bone Diseases-National Resource Center. 1150 17th St., NW, Ste. 500, Washington, DC 20036-4603. (800) 624-BONE. .

Alzheimer's Disease

2010-01-15T11:51:00.000-08:00

http://www.enotes.com

Definition

Alzheimer's disease (AD) is the most common form of dementia, a neurologic disease characterized by a progressive loss of mental ability severe enough to interfere with normal activities of daily living, lasting at least six months, and not present from birth. AD usually occurs in old age and is marked by a decline in cognitive functions such as remembering, reasoning, and planning.

Description

A person with AD usually has a gradual decline in mental functions, often beginning with slight memory loss, followed by losses in the ability to maintain employment, to plan and execute familiar tasks, and to reason and exercise judgment. Communication ability, mood, and personality may also be affected. Most people who have AD die within eight years of their diagnosis, although that interval may be as short as one year or as long as 20 years. AD is the fourth leading cause of death in adults after heart disease, cancer, and stroke.

In 2001, four million Americans have been diagnosed with AD. That number is expected to grow to as many as 14 million by the middle of the twenty-first century as the baby-boomer population ages. These numbers may be seriously underestimated due to new research that suggests mild cognitive impairment may be early stages of AD.

While a small number of people in their 40s and 50s develop the disease (called early-onset AD), AD predominantly affects the elderly. AD affects about 10% of all people over the age of 65 and nearly half of those over85. Slightly more women than men are affected with AD, since women tend to live longer and occupy a larger proportion of the most affected age groups.

The costs for caring for loved ones with AD is considerable, and has been estimated at approximately $174,000 per person over the course of the disease. More than 70% of people with AD are cared for at home at an estimated annual cost of $196 billion. These costs are not supplemented by outside sources. If patients are cared for by paid home caregivers or are placed in nursing homes, the total annual out-of-pocket costs by families or third party payees account for $83 billion and $32 billion respectively.
Causes and symptoms
Causes

The cause of Alzheimer's disease is unknown. Some strong leads have been found through recent research, however, and these have also given some theoretical support to several new experimental treatments.

AD affects brain cells responsible for learning, reasoning, and memory. Autopsies of people with AD indicate that these regions of the brain become clogged with two abnormal structures, neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells (neurons). Senile plaques are composed of parts of neurons surrounding a group of brain proteins called beta-amyloid deposits. While it is not clear exactly how these structures cause problems, some researchers now believe that their formation is responsible for the mental changes of AD, presumably by interfering with the normal communication between neurons in the brain. Drugs approved by the Food and Drug Administration (FDA) increase the level of chemical signaling molecules in the brain, known as neurotransmitters, to make up for this decreased communication ability.

What triggers the formation of plaques and tangles is unknown, although there are several possible candidates. Restriction of blood flow may be part of the problem, perhaps accounting for the beneficial effects of estrogen, which increases blood flow in the brain. However, studies in 2001 do not show estrogen as a protection against the development of AD.

Highly reactive molecular fragments called free radicals damage cells of all kinds, especially brain cells, which have smaller supplies of protective antioxidants thought to protect against free radical damage. Vitamin E is one such antioxidant, and its use in AD is showing some benefit.

Several genes have been implicated in AD, including the gene for amyloid precursor protein (APP) responsible for producing amyloid. Mutations in this gene are linked to some cases of the relatively uncommon earlyonset forms of AD. Other cases of early-onset AD are caused by mutations in the gene for another protein, presenilin. AD eventually affects nearly everyone with Down syndrome, caused by an extra copy of chromosome 21. Other mutations on other chromosomes have been linked to other early-onset cases.

Potentially the most important genetic link was discovered in the early 1990s on chromosome 19. A gene on this chromosome, apoE, codes for a protein involved in transporting lipids into neurons. ApoE occurs in at least three forms: apoE2, apoE3, and apoE4. Each person inherits one apoE from each parent, and therefore can either have one copy of two different forms or two copies of one. Compared to those without ApoE4, people with one copy are about three times as likely to develop lateonset AD, and those with two copies are almost four times as likely to do so. Despite this important link, not everyone with apoE4 develops AD, and people without it can still have the disease. Why apoE4 increases the chances of developing AD is not known.

Promising research in 2001 has discovered a protein, apoptosis-inducing factor, that kills cells by disrupting the genetic material at their cores. This discovery could lead to drugs that could turn off this protein that triggers apoptosis or biologically regulated cell death, which is important in fetal development but is also implicated in stroke, heart disease, and AD. It is thought that this protein runs out of control and shuts off otherwise healthy cells.

There are several risk factors that seem to increase a person's likelihood of developing the disease. The most significant one is, of course, age; older people develop AD at much higher rates than younger ones. Another risk factor is having a family history of AD, Down syndrome, or Parkinson's disease. People who have had head trauma or hypothyroidism may manifest the symptoms of AD sooner.

Many environmental factors have been suspected of contributing to AD, but population studies generally have not borne these out. A study in early 2001, however, showed a specific link between aluminum in drinking water and the incidence of AD. Other suspected risk factors were other pollutants in drinking water, aluminum in any form, and mercury in dental fillings. To date, none of these other factors has been shown to cause AD or to increase its likelihood.

Lifestyle factors, moreover, may prove to be better indicators of risk. Lack of stimulation, mentally and physically, between the ages of 20 and 60 seems linked to the incidence of AD. Studies have not shown, though, that a sedentary lifestyle early in life causes AD or whether it is a marker for the incidence of the disease.

Another study of African Americans and their Nigerian counterparts shows AD appearing more often in the American population than the African one. Researchers suggest that environmental or cultural factors may play a role in the formation of AD. Here, physical activity or diet may play a part.
Symptoms

The symptoms of Alzheimer's disease begin gradually, usually with memory lapses. Occasional memory lapses are common to everyone and do not, by themselves, signify any change in cognitive function. The person with AD may begin with only the routine sort of memory lapse—forgetting where the car keys are—but progresses to more profound or disturbing losses such as forgetting how to even drive a car. Being lost or disoriented on a walk around the neighborhood becomes more likely as the disease progresses. A person with AD may forget the names of family members, or forget what was said at the beginning of a sentence by the end of the sentence.

As AD progresses, other symptoms appear, including inability to perform routine tasks, loss of judgment, and personality or behavior changes. Some patients have trouble sleeping and may suffer from confusion or agitation in the evening, known as sunsetting. In some cases, people with AD repeat the same ideas, movements, words, or thoughts, a behavior known as perseveration. There may be delusional thinking or even hallucinations. In the final stages people may have severe problems with eating, communicating, and controlling their bladder and bowel functions.

The Alzheimer's Association has developed a list of 10 warning signs of AD. A person with several of these symptoms should see a physician for a thorough evaluation:

* memory loss that affects job skills
* difficulty performing familiar tasks
* problems with language, as in word-find problems or inappropriate word substitutions
* disorientation about time and place
* poor or decreased judgment
* problems with abstract thinking
* misplacing things
* changes in mood or behavior
* changes in personality
* loss of initiative

Other types of dementia, including some that are reversible, can cause similar symptoms. It is important for the person with these symptoms to be evaluated by a professional who can weigh the possibility that the symptoms may have another cause. Approximately 20% of those originally suspected of having AD actually have some other disorder; about half of these cases are treatable.
Diagnosis

Diagnosis of Alzheimer's disease is complex and may require visits to several different specialists over several months before a determination can be made. With new diagnostic tools and criteria, it is possible to make a provisional diagnosis that is about 90% accurate. A positive confirmation of these findings can be made only through autopsy.

Early diagnosis is essential in helping the patient and the family make decisions about treatment, long-term care, and financial matters. Finding out that a loved one's behavior is based on a degenerative mental disease can help a family avoid unnecessary anger and feelings of impotence when dealing with the progression of the disease.

There are two diagnoses the clinical team can make for a patient. They are probable AD or possible AD. Probable AD is determined when physicians and psychiatrists rule out all other disorders that might produce similar symptoms. A diagnosis of possible AD is made when AD is considered the primary reason for the symptoms but is complicated with the presence of another disorder that might confuse the general progression of the disease.

Diagnosis for AD begins with the elimination of other physical and psychological causes for the patient's behavior. This is done through a multi-step process that tests for other disorders and measures the amount of deficit the patient is experiencing.
Patient history

A detailed medical history should be taken, noting a list of the patient's medicines (prescription and over the counter), vitamins, and herbs. Since there are many pharmaceuticals that can cause the same mental changes as AD, a careful review of the patient's medication, alcohol, and herbal use is important. If the patient's symptoms are related to any of these, most likely the condition can be reversed through adjustments in the patient's medications or herbal use. Any illicit drugs should also be reported.

Next, the physician should take a detailed report of any changes in the patient's mental functioning and memory. This will determine the mode of onset of symptoms, the progression of the deficits, and the impact of the impairment on daily functioning.
Physical exam and lab tests

AD-like symptoms can also be provoked by other medical conditions, including tumors, infection, thyroid malfunctioning, and dementia caused by mild strokes (multi-infarct dementia). These possibilities must be ruled out through blood screens, urine tests, electroencephalographs (EEGs), and a variety of imaging techniques.

A genetic test for the ApoE4 gene is available, but is not used for diagnosis, since possessing even two copies does not ensure that a person will develop AD.
Cognitive functioning evaluation

Several types of oral and written tests are used in AD diagnosis and disease progression, including tests of mental status, language ability, functional ability, memory, and concentration. In the early stages of the disease, the results of these tests are usually normal. It should be noted that the widely-used Mini-Mental State Examination (MMSE) may not be accurate for highly educated or poorly educated individuals, or cultural minorities.
Neuropsychiatric evaluation

A detailed cognitive evaluation can be done by a psychologist or psychiatrist. These tests of memory and mental functioning provide a quantitative measure of the patient's deficits.

One of the most important parts of the diagnostic process is the evaluation of depression and delirium, since these can be present with AD or may be mistaken for it. (Delirium involves a decreased consciousness or awareness of one's environment.) Depression and memory loss are both common in the elderly, and the combination of the two can often be mistaken for AD. Depression can be treated with drugs, although some antidepressants can worsen dementia if it is present, further complicating both diagnosis and treatment.
Imaging studies

Several imaging techniques can assess brain function and pathology, thus eliminating these as causes of the patient's symptoms. Most frequently used imaging scans are magnetic resonance imaging (MRI) or computed tomography (CT) scans, which detect structural changes in the brain. Brain function can be assessed through MRI, positron emission tomography (PET), and single-photon emission CT (SPECT). These tests help rule out stroke, subdural hematoma, and brain tumor as possible causes for the patient's symptoms.
Treatment

Alzheimer's disease is currently incurable, though a number of pharmaceuticals and home care strategies can mange the disease. The mainstay of AD treatment continues to be good nursing care, providing both physical and emotional support, as the patient gradually is able to do less independently and whose behavior becomes more erratic. Modifications of the home to increase safety are often necessary. Creative strategies to help the patient stay as independent as possible are also indicated. The caregiver also needs support to minimize anger, despair, and burnout.
Drugs

Donepezil hydrochloride (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) have been approved for use in AD treatment. These drugs increase the levels of the neurotransmitter acetylcholine in the brain, thereby increasing the communication ability of the remaining neurons. They do this by inhibiting the enzymes, acetylcholinesterase and butylcholinesterase, which normally break down acetylcholine and butylcholine released by neurons. These drugs modestly increase attention span, concentration, mental acuity, and information processing. Tacrine (Cognex), the first drug used, is no longer used due to the risk of liver toxicity. All cholinesterase inhibitors have mild gastric side effects such as nausea and vomiting.

The antioxidant, vitamin E, is also thought to delay AD onset because it prevents neuron damage caused by free radicals. Vitamin E therapy, in combination with cholinesterase inhibitors, has become a practice standard in the treatment of AD.

Drugs that have been found ineffective are Selegiline (used in the treatment of Parkinson's disease), prednisone, and the anti-inflammatory NSAID diclofenac. Estrogen, once thought to be the keystone in treatment and prevention of AD in women, was found to be ineffective in mitigating symptoms in 2001. There is still some discussion about estrogen's ability to delay the onset of AD.

Depression may be treated with selective serotonin reuptake inhibitors (SSRIs) such as citalopram and sertraline. Physicians may also prescribe typical antipsychotics for agitation, aggression, or hallucinations, such as olanzapine, quetiapine, or risperidone. It should be noted that AD patients have more side effects from most medications, especially psychoactive drugs, and care should be taken in their selection.
Alternative treatment

Several substances are currently being tested for their ability to slow the progress of Alzheimer's disease. Among them are gingko extract, derived from the leaves of the Gingko biloba tree, and huperzine A, from the moss Huperzia serrata. Gingko extract has antioxidant, anti-inflammatory, and neuroprotective effects and has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. It has been shown to modestly improve cognitive function. Huperzine A is a natural cholinesterase inhibitor. It is reported to produce greater improvement than the synthetic cholinesterase inhibitors and has few side effects. Since neither herbal is regulated, they may have inconsistent levels of their active ingredients per dosage.
Nursing care and safety

The person with Alzheimer's disease will gradually lose the ability to dress, groom, feed, bathe, or use the toilet without help; in the late stages of the disease, the individual may be unable to move or speak. In addition, the person's behavior becomes increasing erratic. A tendency to wander may make it difficult to leave the patient unattended for even a few minutes, which would make even the home a potentially dangerous place. In addition, some patients may exhibit inappropriate sexual behaviors.

Nursing care required for AD patients is simple enough to learn. The difficulty for many caregivers comes in the constant but unpredictable nature of the demands put on them. Additionally, the personality changes presented in AD can be heartbreaking for family members as a loved one deteriorates, seeming to become a different person. Not all AD patients develop negative behaviors: some become gentle, spending increasing amounts of time in dream-like states.

A loss of grooming skills may be one of the early symptoms of AD. Mismatched clothing, unkempt hair, and decreased interest in personal hygiene become more common. Caregivers, especially spouses, may find these changes socially embarrassing and difficult to cope with. The caregiver will begin to assume more and more grooming duties for the patient as the disease progresses.

Ensuring proper nutrition for the AD patient may require using a colored plate to focus the patient's attention on the food. Finger foods may be preferable to those foods requiring utensils. Later, the caregiver may need to feed the patient. As movement and swallowing become difficult, a feeding tube may be placed into the stomach through the abdominal wall, which will require special attention.

For many caregivers, incontinence becomes the most difficult problem to deal with at home, and is a principal reason for pursuing nursing home care. In the early stages, limiting fluid intake and increasing the frequency of toileting can help. Careful attention to hygiene is important to prevent skin irritation and infection from soiled clothing.

Safety will become of prime importance. In all cases, a person diagnosed with AD should not be allowed to drive, because of the increased potential for accidents and the increased likelihood of wandering far from home while disoriented. In the home, grab bars in the bathroom, bed rails on the bed, and clutter-free passageways can greatly increase safety. Electrical appliances should be unplugged and put away when not in use, and matches, lighters, knives, or weapons should be stored out of reach. The hot water heater temperature should be set lower to prevent accidental scalding. A list of emergency numbers, including the poison control center and the hospital emergency room, should be posted by the phone.

A calm, structured environment with simple orientation aids such as calendars and clocks may reduce anxiety and increase safety. Labeling cabinets and drawers may keep the patient's attention focused. Scheduling meals, bathing, and other activities at regular times and places will provide emotional security and routine, since unfamiliar places and activities can be disorienting for the patient. Sleep disturbances may be minimized by keeping the patient engaged in activities during the day, offering structure and providing physical activities.
Care for the caregiver

Family members or others caring for a person with AD have a difficult and stressful job, which becomes harder still as the disease progresses. It is common for caregivers to develop feelings of anger, resentment, guilt, and hopelessness, in addition to the sorrow they feel for their loved one and for themselves. Depression is an extremely common consequence of being a full-time caregiver for an AD patient. Support groups are an important way to deal with the stress of caregiving. The location and contact numbers for AD caregiver support groups are available from the Alzheimer's Association; they may also be available through a local social service agency, the patient's physician, or pharmaceutical companies that manufacture the drugs used to treat AD. Medical treatment for depression may be an important adjunct to group support.
Outside help, nursing homes, and governmental assistance

Most families eventually need outside help to relieve some of the burden of around-the-clock care for an AD patient. Personal care assistants, either volunteer or paid, may be available through local social service agencies. Adult daycare facilities are becoming increasingly common. Meal delivery, shopping assistance, or respite care may be available as well.

Providing the total care required by a person with late-stage AD can become an overwhelming burden for a family, even with outside help. At this stage, many families consider nursing home care. This decision is often one of the most difficult for the family, since it is often considered an abandonment of the loved one and a failure of the family. Counseling with a physician, clergy, or other trusted adviser may ease the difficulties of this transition. Selecting a nursing home may require a difficult balancing of cost, services, location, and availability. Keeping the entire family involved in the decision may help prevent further stress from developing later on.

Several federal government programs may ease the cost of caring for a person with AD, including Social Security Disability, Medicare, and Supplemental Security Income. Each of these programs provides some assistance for care, medication, or other costs, but none of them will pay for nursing home care indefinitely. Medicaid is a state-funded program that may provide for some or all of the cost of nursing home care, although there are important restrictions. Details of the benefits and eligibility requirements of these programs are available through the local Social Security or Medicaid office, or from local social service agencies. Long-term care insurance can also be another option, if taken out prior to the diagnosis.
Prognosis

Alzheimer's disease can weaken the aging body, making it more susceptible to life-threatening infections such as pneumonia. In the late stages of the disease, autonomic body functions may be impaired, the patient falling into a coma, and death following. In addition, other diseases common in old age—cancer, stroke, and heart disease—may lead to more severe consequences in a person with AD. On average, people with AD live eight years past their diagnosis, with a range from one to 20 years.
Health care team roles

Treatment of AD is a team effort, involving primary care physicians, nurses, imaging and laboratory technicians, gerontology specialists, psychiatrists, psychologists, nursing staff, and caregivers. Physicians order tests that aid in the diagnosis and treatment of AD. These experts must educate the patient and the caregivers in the nature of the disease and its progression, although this burden usually falls on the nursing staff. Nurses are also the first line of access to medical care and support groups. Social workers, counselors, and support group facilitators may also provide emotional support, practical advice, and information about community resources. Special Alzheimer's disease facilities may be used for either respite day care or as permanent long-term care placements.
Prevention

There is currently no proven way to prevent Alzheimer's disease, though some of the drug treatments may delay the development of the disease. The most likely current candidate is estrogen. However, staying active mentally and physically throughout life may be key to prevention.
KEY TERMS

Acetylcholine—One of the substances in the body that helps transmit nerve impulses.

Dementia—Impaired intellectual function that interferes with normal social and work activities.

Donepezil hydrochloride (Aricept)—A drug that increases the brain level of the neurotransmitter acetylcholine, which is given once a day to treat AD.

Ginko—An herb from the Ginko biloba tree that some alternative practitioners recommend for the treatment of AD.

Neurofibrillary tangle—Twisted masses of protein inside nerve cells that develop in the brains of people with AD.

Senile plaque—Structures composed of parts of neurons surrounding brain proteins called beta-amyloid deposits and found in the brains of people with AD.

Sunsetting—Confusion or agitation in the evening.

Tacrine (Cognex)—A drug that may help improve memory in people with mild to moderate cases of AD.
Resources
BOOKS

Castleman, Michael, Dolores Gallagher-Thompson, and Matthew Naythons. There's Still a Person in There: The Complete Guide to Treating and Coping with Alzheimer's. New York: G. P. Putnam's Sons, 1999.

Gray-Davidson, Frena. The Alzheimer's Sourcebook for Caregivers: A Practical Guide for Getting through the Day. Los Angeles: Lowell House, 1999.

Khatchaturian, Zaven S., and M. Marcel Mesulam, eds. Alzheimer's Disease: A Compendium of Current Theories. New York: New York Academy of Sciences, 2000.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day. Baltimore: The John Hopkins University Press, 1999.

Tanzi, Rudolph E. Decoding Darkness: The Search for the Genetic Causes of Alzheimer's Disease. Cambridge, MA: Perseus Publishing, 2000.
PERIODICALS

Glaser, Vicki. "Strategies for Early Diagnosis." Patient Care 35 no. 3 (February 15, 2001): 22.

Hines, Silvia E. "Contemporary Drug Treatment." Patient Care 35 no. 3 (February 15, 2001): 54.

Nichols, Mark. "On the Trail of a Killer: Researchers Discover a Key to the Mystery of Why Cells Die." Maclean's (April 9, 2001): 40.
ORGANIZATIONS

Alzheimer's Association. 919 North Michigan Ave., Suite 1100, Chicago, IL 60611. (800) 272-3900. (312) 335-8700). .

National Institute of Aging, Alzheimer's Education, and Referral Center. (800) 438-4380.
OTHER

Alzheimer's Disease Books and Videotapes. .

Author unspecified. "Ten Warning Signs." Alzheimer's Association. .

Advanced Practice Nurse

2010-01-15T11:49:00.000-08:00

Definition

Advanced practice nurses are typically those nurses prepared at the master's or doctoral level, and they fall into four categories of clinicians: clinical nurse specialists, certified registered nurse anesthetists, nurse practitioners, and certified nurse-midwives.

Description
Clinical nurse specialists

Clinical nurse specialists (CNSs) are licensed registered nurses (RNs) with additional master's or doctorate-level training in CNS. These advanced practice nurses are clinical experts in theory-based or research-based nursing, focusing on specific specialty areas.

CNSs have broadened patient care roles because of their advanced training. In some states, they have the authority to prescribe medications.

CNSs assume many roles within the health care delivery system. While many are in the clinical setting, others work as educators, administrators, consultants, researchers, change agents, and case managers. CNSs can become specialized in the areas of adult psychiatry, child psychology, community health, home health, gerontology, and medical-surgical, as well as oncology, perinatal critical care, critical care, and rehabilitation. Some nurses in areas of specialty certification classify themselves as CNSs, others use the umbrella term of advanced practice nursing

In March 2000, the number of RNs prepared to practice in at least one advanced practice role was estimated to be about 7.3% of the total RN population. The largest group among the advanced practice nurses was the nurse practitioners, followed by the CNSs. These two groups together made up about 80% of all advanced practice nurses. Although about 36.9% of the CNSs were employed in nursing, only about 24% were practicing under the position title of CNS. Nearly 25% of CNSs reported working in nursing education positions.
Certified registered nurse anesthetist

Nurse anesthesia is the oldest of the advanced nursing specialties. These advanced clinical nurses, called certified registered nurse anesthetists (CRNAs), administer about 65% of the anesthetics given to patients annually in the United States.

Nurse anesthetists make up the third largest group of advanced practice nurses, and were the first professional group in the United States to provide anesthesia services in the 1800s. Their role in surgery is to keep patients as comfortable, pain free, and safe as possible. Nurse anesthetists perform patient physical assessments; take part in preoperative teaching; develop, prepare, and implement the anesthesia plan; select, obtain, and administer anesthesia and other medications and fluids needed to manage the anesthetic; maintain anesthesia throughout the operation and manage the patient's airway and pulmonary status; respond as necessary to emergency situations ensuring airway management, administering emergency fluids or medications, and performing cardiac life support techniques; and follow patients through recovery and into the patient care unit. Essentially, they take care of patients before, during, and after having surgery or giving birth.

CRNAs can sub-specialize in pediatric, obstetric, cardiovascular, plastic, dental, or neurosurgical anesthesia. Some have credentials in critical care nursing and respiratory care.
Nurse practitioner

Nurse practitioners (NPs) are registered nurses who have advanced academic and clinical experience. Because of this additional training, NPs can diagnose and manage common and chronic illnesses, independently or as part of a health care team. Nurse practitioners often can provide primary care previously offered only by doctors and, in many states, they prescribe medications. While in many cases NPs work in collaboration with physicians, NPs have the authority to practice without a physician collaboration or supervision in 18 states.

NPs perform physical exams; diagnose and treat many acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic conditions; order and interpret x rays and other lab tests; and counsel and educate patients about how they can live healthy lifestyles. NPs focus much of their practice on health maintenance, disease prevention, patient education, and counseling. While they have a strong emphasis on primary care, NPs practice in a wide variety of specialties, including neonatology, obgyn, pediatrics, school health, family and adult health, mental health, home care, geriatrics, and acute care.
Certified nurse-midwife

Certified nurse-midwives (CNMs) focus on the independent management of women's health care, particularly on pregnancy, childbirth, the postpartum period, care of the newborn and the family planning, and gynecological needs of women. They have the authority to write prescriptions. CNMs deliver babies in all types of health care settings, as well as in private homes, and provide primary health care to women, often helping them to realize personal fulfillment through labor and birth. CNMs work independently and in collaboration with other health care providers. They also teach and conduct research.

The trend seems to be that more people are choosing CNMs. As of 1998, there were nearly 278,000 CNM-attended births in the United States. About 400 nurse-midwives pass the national certification exam each year. The practice of nurse-midwifery is legal in all states and the District of Columbia. These advanced practice nurses have prescription-writing ability in 50 states and jurisdictions. Ninety percent of all visits to CNMs are for primary and preventive care. Seventy percent of that was for care during pregnancy and after birth, while 20% was for care outside of the maternity cycle.
Work settings
Clinical nurse specialists

CNSs work in the acute care, long-term care, and intermediate care settings. They work in clinical education within health care facilities, as well as in nursing education programs as faculty teaching nursing. Other settings in which CNSs work include outpatient and ambulatory care, private practice, home health, physician office practice, sub-acute care, government or military service, community health centers, health care administration, private industry (working for drug companies or manufacturers, in managed care and other areas of the private sector), and nurse-managed centers. Within these categories, CNSs work in assisted living facilities; specialized hospital areas, such as cardiac catheterization labs; correctional facilities; dialysis units; parish nursing; and psychiatric hospitals.
Certified registered nurse anesthetist

Nurse anesthetists can work with an physician anesthesiologist, independently or in groups as providers of anesthetics. They work as part of a medical team or independently in any setting in which anesthesia is given, including doctors' and dentists' offices, pain clinics, operating rooms of hospitals, and ambulatory surgery settings. CRNAs who work independently or in groups might have contracts with physicians or hospitals. Some CRNAs work in private practices, while others choose the public sector or the U.S. military. They work in universities as instructors and in research settings as investigators, collaborators, consultants, assistants, interpreters, and researchers. CRNAs also work in surgical and obstetric environments in MRI units, cardiac catheterization labs, and lithotripsy units. In these environments, they provide consultation and implementation of respiratory and ventilatory care, manage emergency situations, and start or participate in airway maintenance, ventilation, and tracheal intubation during CPR.
Nurse practitioner

Nurse practitioners work in metropolitan area clinics and hospitals, as well as in rural areas, inner cities, and medically underserved locations. They work in schools, caring for children, and in nursing homes and assisted living facilities, caring for the elderly and others. NPs work in pediatric, family health, women's health, and other specialty settings. Some work in private practices or in nurse-run group practices.
Certified nurse-midwife

CNMs work in clinical practice in public, university, and military hospitals. They also work in health maintenance organizations, private practices, and birthing centers. Many practice in public heath clinic, and some provide home birth services. More than 50% of CNMs work most often in the office or clinic environment, listing a hospital or physician practice as their employer.
Education and training
Clinical nurse specialists

Nurses must have a baccalaureate degree or its equivalent to enroll in a CNS program. To use the title of CNS, the CNS must have a minimum of a master's degree from an education program that prepares CNSs. The training is graduate-level education. Some universities have a fast track program whereby they will accept individuals who do not have a baccalaureate and move them into a master's program. CNSs also take a certification exam in a specialty, offered by one of the nationally recognized certification entities.

CNS students go through advanced theory and practice training, revolving around the three areas of influence that impact on direct patient care, supervising direct patient care, and patient care systems.

The American Nurses Credentialing Center certifies CNSs as adult psychiatric, child psychology, community health, home health, gerontology, and medical-surgical CNSs. There also are other certifying bodies, including the Rehabilitation Nursing Certification Board, Oncology Nursing Certification Corporation, and American Association of Critical Care Nurses Certification.

The doctoral-level CNS typically focuses on research.
Certified registered nurse anesthetist

Nurse anesthetists are registered nurses who complete two to three years of higher education, beyond the bachelor's of nursing degree or other appropriate baccalaureate degree. They attend accredited nurse anesthesia educations programs, covering all areas of anesthesia. After completing an accredited program, nurse anesthetists must pass a national certification exam to obtain the CRNA designation.

The education for a nurse anesthetist involves about 24 to 36 months of graduate course work. It includes classroom and clinical experience.

In most cases, to be accepted into an accredited school, those who aspire to become nurse anesthetists must have an appropriate four-year degree, an RN license, and at least one year of acute care nursing experience, which varies by program.
Nurse practitioner

NPs receive their advanced educations through programs that award master's degrees. RNs who aspire to become NPs should have extensive clinical experience before applying to an NP program. NP programs include the components of an intensive preceptorship under the direct supervision of a physician or experienced NP and instruction in nursing theory. An increasing number of nurses are becoming prepared as both NPs and CNSs. Those prepared in both roles are more likely to function as nurse practitioners.
Certified nurse-midwife

CNMs are educated in the two disciplines of nursing and midwifery. They must possess evidence of certification according to the requirements of the American College of Nurse-Midwives. Being an RN is a requirement to become a certified nurse-midwife. In some cases, those with baccalaureate degrees in other fields are considered. Upon graduation, CNMs can receive MS (master's of science), MSN (master's of science in nursing), MPH (master's of public health) degrees or a doctoral degree. About 68% of CNMs have master's degrees, while 4% have doctoral degrees. There are also those who graduate with a certificate or from a nurse-midwifery education program. However, the number of states and employers who require master's-prepared CNMs is increasing. Once in the program, student CNMs receive labor and delivery experience in different types of settings. They must pass a national certification exam to call themselves CNMs.
Advanced education and training

All advanced practice nurses with master's degree can go on to get their doctorate degrees. Often, those with doctorate-level training go into research, administration, or teaching at the university level.
Future outlook

The outlook is good for all types of nurses, especially those at the RN level or higher. It is projected that if current trends continue, demand will exceed supply of RNs by about 2010. It is possible that as many as 114,000 jobs for full-time-equivalent RNs are going to go unfilled nationwide by 2015. This is due to a growing elderly population with mounting health care needs, an aging RN workforce, the expansion of primary care, and technological advances that require more highly trained nurses.

There is a growing demand for RNs with advanced clinical skills. Almost all who graduate have jobs waiting for them.
Resources
ORGANIZATIONS

American Association of Colleges of Nursing. One Dupont Circle, NW, Suite 530, Washington, DC 20036. (202) 463-6930. .

American Association of Nurse Anesthetists. 222 South Prospect Avenue, Park Ridge, IL 60068-4001. (847) 692-7050. .

American College of Nurse-Midwives. 818 Connecticut Ave. NW, Suite 900, Washington, DC 20006. (202) 738-9860. .

American College of Nurse Practitioners. 503 Capitol Ct. NE, #300, Washington, DC 20002. (202) 546-4825. .

American Nurses Association. 600 Maryland Avenue, SW, Suite 100 West, Washington, DC 20024. (800) 274-4ANA. .

National Association of Clinical Nurse Specialists. 3969 Green Street, Harrisburg, PA 17110-1575. (717) 234-6799. .
OTHER

The Registered Nurse Population National Sample Survey of Registered Nurses—March 2000. U.S. Department of Health and Human Services, Health Resources and Services administration. Bureau of Health Professions. Division of Nursing. .

http://www.enotes.com

Acute Kidney Failure

2010-01-15T11:46:00.000-08:00

http://www.enotes.com

Definition

Acute kidney failure (AKF) occurs when there is a sudden reduction in kidney function that results in nitrogenous wastes accumulating in the blood (azotemia).
Description

The kidneys are the body's natural filtration system. They perform the critical task of processing approximately 200 quarts of fluid in the bloodstream every 24 hours. Waste products like urea and toxins, along with excess fluids, are removed from the bloodstream in the form of urine. Kidney (or renal) failure occurs when kidney functioning becomes impaired somehow.

Fluids and toxins begin to accumulate in the bloodstream. As fluids build up in the bloodstream, the patient with AKF may become puffy and swollen (edematous) in the face, hands, and feet. Their blood pressure typically begins to rise, and they may experience fatigue and nausea. Often urine output decreases drastically or is not produced at all.

Unlike chronic kidney failure, which is long term and irreversible, acute kidney failure is often a temporary condition. With proper and timely treatment, it can many times be reversed, leaving no permanent or serious damage to the kidneys.
Causes and symptoms

Acute kidney failure appears most frequently as a complication of serious illness, like heart and/or liver failure, serious infection, dehydration, severe burns, and excessive bleeding (hemorrhage). It may also be caused by an obstruction to the urinary tract or as a direct result of kidney disease, injury, or an adverse reaction to medicine. These conditions divide AKF into three main categories: prerenal, postrenal, and intrinsic (inside) conditions.

Prerenal AKF does not damage the kidney, but can cause diminished kidney function and significantly decreased renal (kidney) blood flow. It is the most common type of acute renal failure, and is often the result of:

* dehydration
* extracellular fluid (ECF) volume depletion (or other acute fluid loss from the gastrointestinal tract, kidneys, or skin)
* drugs (NSAIDS, cyclosporine, radiopaque contrast materials, or any substance toxic to the kidneys)
* hemorrhage
* septicemia, or sepsis
* congestive heart failure (CHF)
* liver failure
* burns
* decreased intravascular volume (referred to as third spacing, also found in the presence of pancreatitis, post surgical patients, and patients with a nephrotic syndrome)

Postrenal AKF is the result of an obstruction of some kind somewhere in the urinary tract, often in the bladder or ureters (the tubes leading from the kidney to the bladder). The kidneys compensate to such a degree that one kidney can be completely obstructed and the other will maintain nearly normal kidney function for the body. The conditions that often cause postrenal AKF are:

* inflammation of the prostate gland in men (prostatitis)
* enlargement of the prostate gland (benign prostatic hypertrophy)
* bladder or pelvic tumors
* kidney stones (calculi)

Intrinsic AKF involves a type of kidney disease or direct injury to the kidneys. This type of AKF accounts for 20-30% of AKF reported among hospitalized patients. Intrinsic AKF can result from:

* lack of blood supply to the kidneys (ischemia)
* use of radiocontrast agents in patients with kidney problems
* drug abuse or overdose
* long-term use of nephrotoxic medications, like certain pain medicines
* acute inflammation of the glomeruli, or filters, of the kidney (glomerulonephritis)
* kidney infections (pyelitis or pyelonephritis)
* infiltration by lymphoma, leukemia, or sarcoid carcinomas

Common symptoms of AKF include:

* Anemia. The kidneys are responsible for producing erythropoietin (EPO), a hormone that stimulates red blood cell production. If kidney disease causes shrinking of the kidney, red blood cell production is reduced, leading to anemia.
* Bad breath or bad taste in mouth. Urea in the saliva may cause an ammonia-like taste in the mouth.
* Bone and joint problems. The kidneys produce vitamin D, which helps the body absorb calcium and keeps bones strong. For patients with kidney failure, bones may become brittle. In children, normal growth may be stunted. Joint pain may also occur as a result of high phosphate levels in the blood. Retention of uric acid may cause gout.
* Edema. Puffiness or swelling in the arms, hands, feet, and around the eyes.
* Frequent urination.
* Foamy or bloody urine. Protein in the urine may cause it to foam significantly. Blood in the urine may indicate bleeding from diseased or obstructed kidneys, bladder, or ureters.
* Cola-colored urine followed by oliguria (decreased urine output) or anuria (no urine output)
* Headaches. High blood pressure may trigger headaches.
* Hypertension, or high blood pressure. The retention of fluids and wastes causes blood volume to increase. This makes blood pressure rise.
* Increased fatigue. Toxic substances in the blood and the presence of anemia may cause the patient to feel exhausted.
* Itching. Phosphorus, normally eliminated in the urine, accumulates in the blood of patients with kidney failure. An increased phosphorus level may cause the skin to itch.
* Lower back pain. Patients suffering from certain kidney problems (like kidney stones and other obstructions) may have pain where the kidneys are located, in the small of the back below the ribs.
* Nausea. Urea in the gastric juices may cause upset stomach.

Diagnosis

Kidney failure is diagnosed by a doctor, whether the patient is in the hospital or seen as an outpatient. He or she will take a complete medical history and make a thorough review of the patient's medical record, looking for exposure to nephrotoxic (medicines that can be hard on the kidneys) drugs or other clues to the patient's condition. The physician will then conduct a thorough physical examination, making a careful assessment of the patient's ECF volume and effective circulating blood volume (EBV). A nephrologist, a doctor that specializes in the kidney, may be consulted to confirm the diagnosis and recommend treatment options. He or she will look for a recent history of changes in body weight and try and determine whether the patient is taking in much more fluid than he or she is excreting. Capillary wedge pressure and cardiac output values are also effective tools in pinpointing the cause and extent of the AKF.

The patient that is suspected of having AKF will have blood and urine tests to determine the level of kidney function. A blood test will assess the levels of creatinine, blood urea nitrogen (BUN), uric acid, phosphate, sodium, and potassium. The kidney regulates these agents in the blood. Urine samples will also be collected, usually over a 24-hour period, to assess protein loss and/or creatinine clearance.

Determining the cause of kidney failure is critical to proper treatment. Prerenal or obstructive causes are often looked into first because they are the quickest types of AKF to treat. A full assessment of the kidneys is necessary to determine if the underlying disease is treatable and if the kidney failure is chronic or acute. X rays, magnetic resonance imaging (MRI), computed tomography scan (CT), ultrasound, renal biopsy, and/or arteriogram of the kidneys may be used to determine the cause of kidney failure and level of remaining kidney function. X rays and ultrasound of the bladder and/or ureters may also be needed.
Treatment

Treatment for AKF varies, since it is directed to the underlying, primary medical condition that triggered thekidney failure. Prerenal conditions may be treated with replacement fluids given through a vein, diuretics, blood transfusion, restricted salt intake, or medications. Postrenal conditions and intrarenal conditions may require surgery and/or medication.

Frequently, patients in AKF require hemodialysis, hemofiltration, or peritoneal dialysis to filter fluids and wastes from the bloodstream until the primary medical condition can be controlled.
Hemodialysis

Hemodialysis involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. The ECC is made up of plastic blood tubing, a filter known as a dialyzer (or artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. The patient's blood leaves the body through the vein and travels through the ECC and the dialyzer, where fluid removal takes place.

During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body.

A dialysis "run" typically lasts three to four hours, depending on the type of dialyzer used and the physical condition of the patient. Dialysis is used several times a week until AKF has resolved.

Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases.
Hemofiltration

Hemofiltration, also called continuous renal replacement therapy (CRRT), is a slow, continuous blood filtration therapy used to control acute kidney failure in critically ill patients. These patients are typically very sick and may have heart problems or circulatory problems. They cannot endure the rapid filtration rates of hemodialysis. They also frequently need antibiotics, nutrition, vasopressors, and other fluids given through a vein to treat their primary condition. Because hemofiltration is continuous, prescription fluids can be given to patients in kidney failure without the risk of fluid overload.

Like hemodialysis, hemofiltration uses an ECC. A hollow fiber hemofilter is used instead of a dialyzer to remove fluids and toxins. Instead of a dialysis machine, a blood pump makes the blood flow through the ECC. The volume of blood circulating through the ECC in hemofiltration is less than that in hemodialysis. Filtration rates are slower and gentler on the circulatory system. Hemofiltration treatment will generally be used until kidney failure is reversed.
Peritoneal dialysis

Peritoneal dialysis may be used if the patient in AKF is stable and not in immediate crisis. In peritoneal dialysis (PD), the lining of the patient's abdomen, the peritoneum, acts as a blood filter. A flexible tube-like instrument (catheter) is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a certain time period, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate. There are three types of peritoneal dialysis, which vary according to treatment time and administration method.

Peritoneal dialysis is often the best treatment option for infants and children. Their small size can make vein access difficult to maintain. It is not recommended for patients with abdominal adhesions or other abdominal defects (like a hernia) that might reduce the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of an inflammation of the small pouches in the intestinal tract (diverticulitis).
Prognosis

Because many of the illnesses and underlying conditions that often trigger AKF are critical, the prognosis for these patients many times is not good. Studies have estimated overall death rates for AKF at 42-88%. Many people, however, die because of the primary disease that has caused the kidney failure. These figures may also be misleading because patients who experience kidney failure as a result of less serious illnesses (like kidney stones or dehydration) have an excellent chance of complete recovery. Early recognition and prompt, appropriate treatment are key to patient recovery.

Survival statistics also depend on the type of AKF the patient has, age at time of onset, and general health. If the patient has prerenal AKF, there is a good recovery prognosis, but the mortality rate is higher among those who fail to respond to diuretics and vasodilator therapy. Since 1980, age has become a risk factor that increased mortality in patients with acute tubular necrosis (ATN), an intrinsic form of AKF.

Up to 10% of patients who experience AKF will suffer irreversible kidney damage. They will eventually go on to develop chronic kidney failure or end-stage renal

disease. These patients will require long-term dialysis or kidney transplantation to replace their lost renal functioning.
Health care team roles

The patient who suffers from AKF will come in contact with a number of different health care professionals during both the diagnosis and treatment phase of the illness. Patients will require (according to the type and severity of their condition) laboratory work, diagnostic radiology services, pharmaceutical and nutritional interventions, dialysis (in some cases), nursing care, and disease management by a nephrologist.

The medical history, taken by a physician in the emergency room, the patient's family doctor, a fellow nurse practitioner, physician's assistant (PA), or a nephrologist is the most essential tool in determining the cause and type of AKF. The admitting physician or nephrologist will conduct a thorough physical, looking at the following areas for specific clues.

Skin. Checking the patient for areas of small, purple or red spots (petechiae), hemorrhage beneath the skin (purpura), and bluish discoloration of a fairly large area of the skin (ecchymosis) can lead to a diagnosis of an inflammatory or vascular cause for the AKF.

Eyes. Certain conditions in the eyes can point to a diagnosis of interstitial nephritis (inflammation between the cells and tissues of the kidney) or necrotizing vasculitis (inflammed blood vessels).

Cardiovascular and volume status. Evaluating the condition of the heart and the rest of the circulatory system plus volume status (fluid balance) is the most important part of diagnosing and managing AKF. Nurses and nurses' aides will measure and chart daily intake and output (measuring how much fluid the patient takes in and how much he or she excretes in a 24-hour period of time). This is one of the best ways to get a good estimate of volume status. The pulse rate and blood pressure will be taken by the physician, nurses, and nurses' aides often in both the upright (standing or sitting on the side of the bed with legs dangling down) and supine (lying down) positions. The physician will also check the pulse in the neck, examine the heart and lungs, and check for edema (fluid buildup) in the arms and legs. Different combinations of the results of these assessments point to different causes for and types of AKF.

Abdomen. The physician will feel for signs of urinary tract obstruction by palpating (pressing) on the bladder and the upper corners of the abdomen that may reveal an obstruction in the ureter (tube between the kidney and the bladder) somewhere. If the entire abdomen is unusually swollen and filled with fluid (ascites), the AKF may be the result of liver failure.

Arms and legs (extremities). The physican and nursing staff will check the patients arms and legs for edema at the time of diagnosis and throughout treatment. Edema in the arms and legs is a sign of a decrease in oxygenated blood (ischemia), muscle tenderness from rhabdomyolysis (disease of the skeletal muscle), or arthritis. The presence and degree of edema is helpful in pinpointing the cause of AKF and in measuring the patient's progress with treatment.

Nervous system. The physician will assess the patient's degree of mental clarity and nerve responses, as abnormalities in these areas of the nervous system are often common symptoms of AKF. The nursing staff also monitors the patient's mental status during the course of treatment.

Laboratory personnel will draw blood and collect urine samples to help diagnose AKF and later, to evaluate treatment. Increases in BUN (blood urea nitrogen) and creatinine (substance formed from the metabolism of creatine) are indicators of AKF.

The urinalysis is the most important test run in the early stage of AKF evaluation. Significant color changes point to an intrinsic cause for AKF. Urine dipstick tests that prove positive for proteinuria (too much protein) and blood are helpful in diagnosing many causes of AKF. The different types of sediment readings from spun urine samples can further help to distinguish the cause and type of AKF. Urine electrolytes indicate how well the tubules (part of the kidney's nephron) are working.

Nurses and nurses' aides will keep track of fluids the patient takes in (intake) and eliminates (output) to help determine the type of AKF the patient is in and to help the physician manage the patient's course of treatment. Fluid management is critical in the patient with AKF, regardless of the cause.

Patients in AKF may undergo further evaluation in the Radiology Department to determine the cause of their disease and to plan an appropriate plan of treatment. They may undergo an ultrasound examination, doppler scan, nuclear scan, MRI, renal angiography, or a renal biopsy. The ultrasound, doppler scan, and MRI are the least invasive of the procedures. Contrast material is injected for the angiogram and the renal biopsy requires taking tissue samples from the kidney itself. These procedures are performed by trained and licensed radiologic technologists and radiologists.

Nutrition is crucial to the effective management of the patient in AKF. The dietician will work closely with the patient, physician, nursing staff, and pharmacist to ensure proper electrolyte balance, whether the patient eats regular foods or is nourished by total parenteral nutrition (TPN, nutrients mixed and fed through a tube).

Some patients will require kidney dialysis that will be performed by nurses and technicians from the renal or urology department.

Since many different medications are eliminated through the kidneys, the physician works closely with the pharmacist to modify dosing and minimize the use of medications that are toxic to the kidneys.
Prevention

Since AKF can be caused by many things, prevention is difficult. Medications that may impair kidney function should be given cautiously. Patients with preexisting kidney conditions who are hospitalized for other illnesses or injuries should be carefully monitored for kidney failure complications. Treatments and procedures that may put them at risk for kidney failure (like diagnostic tests requiring radiocontrast agents or dyes) should be used with extreme caution.
KEY TERMS

Anuria—When the body ceases to make urine entirely or falls below 100 mls.

Azotemia—Too many nitrogenous compounds in the blood caused by the kidneys' failure to remove urea from the blood.

Blood urea nitrogen (BUN)—A waste product that is formed in the liver and collects in the bloodstream; patients with kidney failure have high BUN levels.

Capillary wedge pressure—The blood pressure inside of a capillary.

Cardiac output—The volume of blood pushed out by the ventricles.

Creatinine—A protein produced by muscle that healthy kidneys filter out.

Edema—The abnormal accumulation of fluid in the interstitial spaces of tissue.

Electrolytes—An element or a compound that can break into ions and conduct electrical current when melted or dissolved in water.

Erythropoietin (EPO)—A glycoprotein hormone made in the kidneys.

Extracellular fluid (ECF)—That part of body fluid made of interstitial fluid and blood plasma.

Extracorporeal—Outside of, or unrelated to, the body.

Glomeruli—The tiny structures that perform the actual mechanical filtering in the kidney.

Gout—A condition caused by error in uric acid metabolism.

Interstitial—The space between cells.

Intravascular volume—The volume of fluid inside a blood vessel.

Intrinsic—Starting from or situated inside an organ or tissue.

Ischemia—A lack of blood supply to an organ or tissue.

Lymphoma—Cancer of the lymph tissue.

Nephritis—Inflammation and abnormal functioning of the kidney.

Nephrologist—A physician who specializes in treating diseases of the kidney.

Nephrotoxic—Toxic, or damaging, to the kidney.

NSAIDS—Non-steroidal, antiinflammatory drug.

Oliguria—Abnormally low urine production.

Radiocontrast agents—Dyes administered to a patient for the purposes of a radiologic study.

Sepsis—A bacterial infection of the bloodstream.

Urea—A systemic diuretic.

Vasopressors—Medications that constrict the blood vessels.
Resources
BOOKS

Anderson, Kenneth N., Anderson, Lois, E., and Glanze, Walter D., eds. Mosby's Medical, Nursing, & Allied Health Dictionary, 5th edition. New York: Mosby, 1998.

Beers, Mark H., M.D., and Berkow, Robert M.D., eds. The Merck Manual, 17th edition. New Jersey: Merck Research Laboratories, 1999.

Faubert, Pierre F., and Porush, Jerome G. Renal Disease in the Elderly. New York: Marcel Dekker, Inc., 1999.

Gennari, F. John, ed. Medical Management of Kidney and Electrolyte Disorders. New York: Marcel Dekker, Inc.,2001.

Greenberg, Arthur, Cheung, Alfred K., Coffmann, Thomas M., Falk, Ronald J., and J. Charles, Jeanette, eds. Primer on Kidney Diseases, Second Edition - National Kidney Foundation. New York: Academic Press, 1999.
PERIODICALS

Andreucci, M., Federico, S., and Andreucci, V.E. "Edema and Acute Renal Failure." Seminars in Nephrology 21, 3(May 2001): 251-6.

Forbes, J.M., Hewitson, T.D., Becker, G.J., and Jones, C.L. "Simultaneous Blockade of Endothelin A and B Receptors in Ischemic Acute Renal Failure is Detrimental to Long-term Kidney Function." Kidney International 59, 4(April 2001): 1333-41.

Gruberg, L., Mehran, R., Dangas, G., Mintz, G.S., Waksman, R., Kent, K.M., Pichard, A.D., Satler, L.F., Wu, H., and Leon, M.B. "Acute Renal Failure Requiring Dialysis After Percutaneous Coronary Interventions." Catheter Cardiovascular Interventions 59, 4(April 2001): 409-16.

Knoll, T., Schult, S., Birck, R., Braun, C., Michel, M.S., Bross, S., Juenemann, K.P., Kirchengast, M., and Rohmeiss, P. "Therapeutic Administration of an Endothelin-A Receptor Antagonist After Acute Ischemic Renal Failure Dose-Dependently Improves Recovery of Renal Function." Journal of Cardiovascular Pharmacology 37, 4(April 2001): 483-8.

Rana, A., Sathyanarayana, P., and Lieberthal, W. "Role of Apoptosis of Renal Tubular Cells in Acute Renal Failure: Therapeutic Implications." Apoptosis 6,1-2(February-April 2001): 83-102

Airway Management

2009-12-29T08:13:00.000-08:00

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Definition

Airway management involves ensuring that the patient has a patent airway through which effective ventilation can take place.

Purpose

An obstructed airway means that the body is deprived of oxygen. If ventilation is not reestablished, brain death will occur within minutes. The primary purpose of airway management is to provide a continuously open airway along with a continuous source of oxygen. When a patient is critically ill and requires an artificial airway and mechanical ventilation, it is the responsibility of the healthcare professionals caring for the patient to ensure that the airway is secure.

Another goal of airway management is to provide an artificial airway that is as close to the patient's natural airway as possible. This may mean mechanically performing physiological functions such as humidifying inspired air and removing secretions.
Precautions

Airway management is a necessity for any patient who has an artificial airway. If the patient is restless or agitated, it is recommended that activities such as suctioning or endotracheal tube care be postponed until either the patient is calm or a sedative has been given. This is to avoid inadvertent removal of the airway. However, if the patient's respiratory status is unstable, suctioning or repositioning the endotracheal tube should be done if it will stabilize the patient.
Description

Airway management consists of much more than just keeping the breathing tube in the correct position. The tube must be managed so that it allows optimal ventilation with the fewest complications.
Humidification

Humidification of inspired air normally takes place in the upper respiratory tract. When this area is bypassed by an artificial airway (such as an endotracheal or tracheostomy tube), humidification must be performed out-side the body. If supplemental oxygen is used, it will require humidification to prevent drying and irritation of the respiratory tract and to facilitate removal of secretions. There are humidification devices available that can be attached to oxygen flow meters or ventilators.
Suctioning

Suctioning consists of inserting a sterile catheter into the endotracheal or tracheostomy tube in order to remove secretions. This is an extremely important part of caring for a patient with an artificial airway, since the reflex of coughing, which would normally remove these secretions, is not effective. The patient will experience respiratory distress if the tube is obstructed by sputum. Suctioning should be performed only when the patient

needs it; however, the need should be assessed at least every two hours.

A number of studies have been done to find ways to minimize the complications of suctioning. Equipment should be sterilized to decrease the risk of infection. There are now closed suction systems available that are attached to the ventilator tubing on one end and to the artificial airway on the other. The catheter remains protected inside a sterile plastic sleeve that is changed every 24 hours. This system limits the amount of times the tubing must be disconnected from the airway, thus reducing exposure of the trachea to environmental contaminants.

Suctioning causes oxygen deprivation for the time that the suction is applied. Hypoxemia can be minimized by preoxygenating the patient with 100% oxygen prior to suctioning and between each pass of the suction catheter. (This can be done by either pushing the 100% oxygen button on the ventilator or by using a bag-valve-mask device.) The patient's pulse oximetry should be monitored while suctioning. The duration of each suction pass should be limited to 10 seconds and the number of passes should be limited to three or less if possible. This decreases hypoxemia and airway trauma. Studies have shown that using intermittent suction is no more beneficial than continuous suction.

Installation of a small amount of saline prior to suctioning was a common procedure in the past. It was thought that saline helped to loosen secretions and to facilitate their removal, but studies have shown this is not the case. On the contrary, saline installation has been shown to increase infection rates and to cause decreased oxygen levels for longer periods than suctioning without saline use. This procedure is no longer regarded as beneficial.
Preparation

Preparation for airway management includes explaining all procedures that will be performed to the patient. Often, patients who are receiving mechanical ventilation are kept sedated or even paralyzed to facilitate optimal ventilation. The level of sedation should be assessed. If patients are not receiving continuous infusions of a sedating drug, they may have a physician's order for sedation as needed. If they are agitated, they should be given the prescribed dose of sedation prior to performing any airway-related procedures, to ensure that the airway is not inadvertently removed.

Patients receiving mechanical ventilation also often have bilateral soft wrist restraints applied to prevent accidental removal of the artificial airway. It is recommended that these be securely fastened before starting an airway-related procedure, or that another healthcare professional be at the bedside to help calm and hold the patient. Also, all needed supplies should be at the bedside prior to starting a procedure, so as to not cause excess discomfort or stress for the patient.
Aftercare

After the procedure is finished, the patient should be reassured if necessary and their respiratory status should be reassessed. The insertion point of the airway should be confirmed to be at the same place as prior to the procedure, unless the purpose was to change the depth of the tube. If the airway has been manipulated since suctioning, the patient may require suctioning again. Any waste should be disposed of in the garbage or in a biohazard container if there is a large amount of blood. Prior to the healthcare professional leaving the room, the patient should be made comfortable, further sedation or pain medication should be administered as needed and the patient should be confirmed to be stable.
Complications

The greatest risk of airway management is that the airway may be inadvertently removed, causing the patient to have respiratory distress. Procedures that require manipulating the airway may cause fear or agitation for patients if they feel that they do not have control over their breathing. If the patient becomes combative, it can be very difficult to finish the procedure without disturbing the airway.
Results

The anticipated outcomes of airway management are a continuously open airway through which effective ventilation can take place, and prevention of infection.
Health care team roles

The nurse and respiratory therapist are equally responsible for monitoring and managing artificial airways. Both perform sterile suctioning and both document their assessment of the patient's respiratory status. The respiratory therapist is generally responsible for managing the ventilator, adding humidification, and changing ventilator tubing.

If the patient is accidentally extubated (the airway is removed), both the nurse and respiratory therapist must assist in reinsertion. This is usually done by an anesthesiologist, a certified registered nurse anesthetist (CRNA), a medical resident, or another physician. The respiratory therapist is generally responsible for ventilating the patient with a bag-valve-mask device until reintubation (reinsertion of the airway), while the nurse gathers equipment, administers medications, and monitors the patient's pulse oximetry, vital signs, and cardiac rhythm.

The nurse and respiratory therapist are also responsible for finding alternative means for the patient to communicate. Artificial airways are inserted through the vocal cords, making speaking impossible. The patient should be encouraged to try alternative methods such as mouthing words, writing, or pointing to letters, words, or pictures on a communication board. Communicating with these patients takes great patience and creativity, as well as dedication to helping them feel like their needs are being met.
KEY TERMS

Bag-valve-mask device—Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.

Endotracheal tube—Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.

Hypoxemia—Abnormal deficiency of oxygen in the arterial blood.

Oxygen flow meter—Meter attached to a oxygen source that controls the amount of supplemental oxygen the patient receives.

Pulse oximeter—Noninvasive machine that measures the amount of hemoglobin that is saturated with oxygen.

Tracheostomy tube—Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.

Ventilator (mechanical ventilation)—Device used to provide assisted respiration and positive pressure breathing.

Activities of Daily Living Evaluation

2009-12-29T08:10:00.000-08:00

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Definition

An activities of daily living (ADL) evaluation is an assessment of an individual's physical and sometimes mental skills. In the area of physical or occupational therapy, it reflects how well a disabled patient or someone recovering from disease or accident can function in daily life. It is also used to determine how well patients relate to and participate in their environment.

Purpose

ADL evaluations help practitioners determine how independent patients are and what skills they can accomplish on their own, as well as to gauge how independent each individual can become after intervention by a health professional. The goal of practitioners performing ADL evaluations is to help patients become as independent as possible, using appropriate adaptations if needed.
Description

Many ADL indexes exist, such as the Katz Index, Revised Kenny Self-Care Evaluation, and the Barthel Index. These indexes typically evaluate patients on their self-care skills and rate each individual according to how functional they are. Scoring is based on how independently a task can be performed and whether supervision or assistance is needed in performing the task.
Basic ADL versus Instrumental ADL

Basic activities of daily living are those skills needed in typical daily self care. An evaluation would, in part, consist of bathing, dressing, feeding, and toileting. The evaluator would examine various activities in each category to determine the patient's skill. Afterward it can be determined what, if any, changes will be necessary to allow the patient to function as independently as possible.

Instrumental activities of daily living refer to skills beyond basic self care that evaluate how individuals function within their homes, workplaces, and social environments. Instrumental ADLs may include typical domestic tasks, such as driving, cleaning, cooking, and shopping, as well as other less physically demanding tasks such as operating electronic appliances and handling budgets. In the work environment, an ADL evaluation assesses the qualities necessary to perform a job, such as strength, endurance, manual dexterity, and pain management.

If a person is being treated following an injury or disorder diagnosis, whether an intervention is needed depends upon how severe his or her functional ability has been affected. If an individual's ADL function is not restored, a health care professional will perform an intervention, which entails helping the individual adapt to permanent dysfunction or regain meaningful function. How well an individual must be able to perform these tasks depends upon the living setting he or she is returning to, whether it is a full custodial facility, assisted living community, or living at home on his or her own.
Complications

Returning a client to full meaningful function can be problematic for individuals who do not have the motivation to do so. A holistic approach to treatment is most important in cases such as these, and physical and occupation therapists are trained to evaluate not only the physical disability or dysfunction of an individual, but also the person's mental health and well-being. Occupational therapists can address mental health issues resulting from injury or disorder diagnosis, such as depression. However, in cases where a patient has sustained a permanent cognitive disability and is learning-impaired, it is more effective and appropriate for the occupational therapist to teach family members or a caretaker how to perform daily tasks for the patient.
Results

Interventions implemented to increase function include adaptations and home modification. Adaptations are devices that can enhance the usability of everyday items for individuals who have a limited range of motion. Home modification involves the process of making one's living environment more functional for ADL.
Adaptations

There are several ways that adaptations can be used to make common household items more functional. For example, patients commonly have a weakened grasp that is insufficient to hold heavy or small objects, so enhancements such as easily gripped handles could be added to small objects, such as eating utensils or personal grooming items. Other adaptations may involve the use of unique tools to facilitate tasks, such as using a long rod with a hook at one end, known as a dressing stick, to pull on pants or socks. Adaptations may involve altering the environment to aid in other tasks, such as providing adequate lighting or magnifying lenses to compensate for a vision impairment.
Home modifications

Home modification has become a major area for occupational therapists to practice. In order for patients to return home or go to a group setting, the physical environment of the house or facility may have to be altered to make ADL function better. Common examples of home modifications include the installation of grab bars in the shower, toilet area and hallways; lower kitchen counters for easier access to wheelchair-bound individuals; and the elimination of potential trip points, such as loose throw rugs and slight changes in floor elevation.
Health care team roles

Occupational therapists and physical therapists are the two primary disciplines most qualified to assess ADL function and recommend the appropriate intervention and modifications in one's home and work environment. Physical therapists might focus primarily on a patient's mobility and ambulation, while the occupational therapist might focus on more specific tasks described above.
KEY TERMS

Adaptation—Altering a tool used in performing a task so that the patient is better able to function independently or with minimal assistance.

Dressing stick—A long rod with a hook attached to the end that a patient uses in place of the hands. Typically a dressing rod would be used to pull on a pair of pants or socks.

Home modification—Altering the physical environment of the home so as to remove hazards and provide an environment that is more functional for the patient. Examples of home modification include installing grab bars and no-slip foot mats in the bathroom to prevent falls.

Cervical Spondylosis and Spondylotic Cervical Myelopathy

2009-12-29T08:07:00.000-08:00

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Cervical spondylosis is osteoarthritis of the cervical spine causing stenosis of the canal and sometimes cervical myelopathy due to encroachment of bony osteoarthritic growths (osteophytes) on the lower cervical spinal cord, sometimes with involvement of lower cervical nerve roots (radiculomyelopathy).

Cervical spondylosis due to osteoarthritis is common. Occasionally, particularly when the spinal canal is congenitally narrow (< 10 mm), osteoarthritis leads to stenosis of the canal and bony impingement on the cord, causing compression and myelopathy (functional disturbance of the spinal cord). Hypertrophy of the ligamentum flavum can aggravate this effect. Osteophytes in the neural foramina, most commonly between C5 and C6 or C6 and C7, can cause radiculopathy (a nerve root disorder—see also Peripheral Nervous System and Motor Unit Disorders: Nerve Root Disorders). Manifestations vary according to the neural structures involved but commonly include pain.

Symptoms and Signs

Cord compression commonly causes gradual spastic paresis, paresthesias, or both in the hands and feet and may cause hyperreflexia. Neurologic deficits may be asymmetric, nonsegmental, and aggravated by cough or Valsalva maneuvers. After trauma, people with cervical spondylosis may develop central cord syndrome. Eventually, muscle atrophy and flaccid paresis may develop in the upper extremities at the level of the lesion, with spasticity below the level of the lesion.

Nerve root compression commonly causes early radicular pain; later there may be weakness, hyporeflexia, and muscle atrophy.

Diagnosis

*
MRI or CT

Cervical spondylosis is suspected when characteristic neurologic deficits occur in patients who are elderly, have osteoarthritis, or have radicular pain at the C5 or C6 levels. Diagnosis is by MRI or CT.

Treatment

* For radiculopathy only, NSAIDS and soft cervical collar
* For cord involvement or refractory radiculopathy, cervical laminectomy

For patients with cord involvement, cervical laminectomy is usually needed; a posterior approach can relieve the compression but leaves anterior compressive osteophytes and may result in spinal instability and kyphosis. Thus, an anterior approach with spinal fusion is generally preferred. Patients with only radiculopathy may try nonsurgical treatment with NSAIDs and a soft cervical collar; if this approach is ineffective, surgical decompression may be required.

Administration of Medication

2009-12-18T07:46:00.000-08:00

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Purpose

The administration of medication is often a chief responsibility of the nurse. The practice of administering medication involves providing the patient with a substance prescribed and intended for the diagnosis, treatment, or prevention of a medical illness or condition.

Description

The central action of medication administration involves actual and complete conveyance of a medication to the patient. However, there is a wider set of practices required to achieve safe, effective patient outcomes and to prepare for and evaluate the outcome of medication administration.

Laws regarding medication administration vary from state to state. Doctors, physicians, physician assistants, nurse practitioners, and nurses are generally trained and authorized to administer medication, while other medical disciplines may have a limited responsibility in this area. In certain circumstances, unlicensed personnel may be trained and authorized to administer medication in residential care settings. State and federal laws also restrict the distribution of and access to medications that can be abused (called controlled substances). Responsibility for controlled substances includes accountability for any discarded substances, double-locked storage, and counting of medication supply at regular intervals by clinician teams.

Preparation for medication administration begins with the order for medication, in most circumstances written by the physician. Nurse practitioners and physician assistants are also often authorized to write prescriptions. State laws vary regarding these privileges. A record of orders for medication and other treatments is kept in the medical chart. Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. Common routes of administration are discussed below.

The most common route of administration is the oral route, or swallowing of medication. This is the easiest and safest route. The physical position and swallowing abilities of the patient should be evaluated to avoid choking. Patients may also receive medication by the buccal route (through the inner cheek or gum) or the sublingual route (under the tongue).

Administration involving a needle or syringe occurs with several drug routes. These routes are referred to as parenteral. Care must be taken to maintain asepsis with all injections and injection sites. Intramuscular medications are injected into the muscle. A special injection technique called Z-track can be used when administering intramuscular medications that can be damaging to the tissue. All intramuscular injections involve the practice of landmarking, or identifying anatomical markers that indicate the correct injection site and avoid damage to bone or nerves. Subcutaneous injections are administered under the skin. Insulin is a common medication that is usually given subcutaneously. Intradermal medications are used much less frequently than subcutaneous or intramuscular injections. They are injected into the skin. Intravenous medications are given through an intravenous line into the vein. These medications may be mixed with a large amount of solution that is being infused, given in a small solution through a port in the intravenous tubing (bolus), or attached in smaller infusion containers to the larger infusion (piggyback). In all cases of administration with a needle or syringe, rotation of injection sites is required to prevent damage to tissue. It is also important that the size of the needle is selected based on the thickness of the medication to be given and the depth of the injection, while maximizing the patients level of comfort during insertion. Needle sticks with contaminated needles are a hazard to both health professional and patient. Care is taken to dispose of needles and syringes rapidly in impervious containers. Protective systems that sheath the needle after use are commonly used to prevent inadvertent needle sticks.

Medication can also be instilled via the mucous membranes. Asepsis must be used to avoid introduction of infection. Rectal or vaginal medications are most often given in suppository form and must be introduced gently to avoid tearing or bleeding of tissue. Nasal medications are often instilled via spray or drops and often involve closing one nostril and asking the patient to inhale gently. The head should be tilted back to avoid aspiration. Ear or otic medications are given in liquid form. The patient's head is tilted to the side. Instruments should never enter the ear. If the medication is not instilled correctly, the patient may experience nausea or vertigo. Eye or ophthalmic medications may be given via drops or ointment. The container for the medication should not touch the eye, and drops are introduced into the inner canthus or corner of the eye.

Inhalational medications are inhaled via the respiratory tract, most often to treat respiratory conditions. Metered dose inhalers (MDI) are often used. MDIs involve pressing a specially designed canister to release a mist.

Topical medications are applied to the surface of the skin. The skin needs to be cleansed and assessed for breaks before administering topical medications. Topical patches that gradually release medication need to be labeled with date and time in case a second patch is inadvertently applied without removal of the first. Ointments are applied evenly. The clinician should avoid touching the topical medication, as medications that are absorbed into the system via the skin, such as nitroglycerin paste, may affect the clinician. As with all medication techniques, asepsis must be maintained to avoid introduction of microorganisms.

Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (give as needed) order. Standing orders are routine hospital orders that doctors in specialized areas prescribe on admission.

Many abbreviations are used in writing medication orders. Other common abbreviations include:

* p.o.: by mouth
* IM: intramuscular injection
* SC: subcutaneous injection
* IV: intravenous
* PR: per rectum
* h.s.: at hour of sleep (bedtime)
* ac: before meals
* pc: after meals
* q: every, ie, q 8 h means every 8 hours
* q.d.: every day
* b.i.d.: twice/day
* t.i.d.: three times/day
* q.i.d.: four times/day
* q.o.d.: every other day

Some examples of medication orders using these abbreviations are:

* digoxin 0.25 mg p.o. q.d.
* diphenhydramine 25 mg p.o. q h.s. prn.

If orders are illegible, ambiguous, or confusing, the author of the order should be consulted to clarify the order before any medication administration occurs. When the order is clear, it often needs to be transcribed to another document reserved for recording administration of medications. Health care institutions have specific policies regarding methods with which to check medication orders and ensure proper transcription. Policies also dictate parameters for order renewal or medication discontinuation. Poor penmanship, misunderstanding of penmanship, and errors in transcription often contribute to medication errors. It is increasingly common for medical facilities to use a computerized system that lowers the risk of error by reducing steps in the process and validating information automatically.

Once the order has been read and verified, the care-giver needs to evaluate the order in the context of the individual patient. Some factors to consider include:

* pharmacodynamics: how the drug works in the body
* interactions: possible effects of other medication or food on the ordered medication
* allergies: patient history of hypersensitivity to drug or drug class
* contraindications: medical conditions that preclude the use of the ordered drug
* side effects: potential adverse reactions to the drug
* toxic effects: dangerous effects that often occur due to build up of drug in body or impaired metabolism
* tolerance: certain drugs require increasing doses over time to achieve the same effect
* physiological variables: sex, age, size, and physical condition may alter how a drug is processed in the body
* diet: certain foods, liquids, or nutritional states may alter the drug's effect on the body

Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication. The package insert that comes with every medication is also a good resource. Pharmacists are knowledgeable resources and can answer many questions regarding medication. It is important to be familiar with the medication ordered before attempting to administer it. Procedural manuals by the institution or medical reference publishers detail the step-by-step techniques for administering various types of medication.

The patient should be notified of the order for the drug and provided with education about the medication they are to receive. Before administration, five factors often referred to as the "five rights" should be addressed. Medication records should be on hand at time of administration to ensure safe administration.

Right patient. Identify patient by name badge or bracelet. Avoid simply asking patient's name or checking the name on the door as miscommunications can sometimes occur.

Right drug. Check record for name of drug and compare with drug on hand. As many drugs have similar spellings, this needs to be checked carefully. For prevention of error, it is often recommended that three checks of the drug to be administered are made: when reaching for the package that contains the drug, when opening the drug, and when returning the packaging to its storage area. It is also recommended that clinicians only administer drugs that they have prepared, versus those prepared by another clinician.

Right route. Check medication record for how to administer the drug and check labeling of drug to ensure it matches prescribed route.

Right dose. Compare ordered dose to dose on hand. At times, calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams.

The formula for this calculation can be applied to many situations:

* dose ordered/dose on hand × amount on hand = amount to administer

Using the above medication question, 25 mg/100 mg × 2 ml = 0.5 ml (amount to administer)

Intravenous medications also require frequent calculation. For example, an intravenous anticoagulant such as heparin may be ordered as "1000 units per hour," and the clinician may need to calculate how many drops are needed per minute or hour based on how the intravenous solution is prepared. These calculations may vary according to the infusion equipment used, for example, varying drop factor ratings or use of a device called a buretrol that carefully measures infused medication. Often a mechanical pump is used to control intravenous infusion rates.

Right time. Verify that frequency or time ordered matches current time.

All medications should be handled to ensure that they do not come into contact with potentially contaminated objects or surfaces. Medications of any sort should not be left unattended, and patients should be observed taking the medication. This avoids the disposal, hoarding, abuse, or misuse of the medication, and assures the safety of the patient.

Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document. Various institutions have policies and procedures regarding documentation. The initials of the administering nurse or other health care provider and the time and date should be documented on the record next to the appropriate order. Other information may be required, such as location and severity of pain when administering a pain medicine (analgesic) or pulse rate when administering certain heart medications (i.e., digoxin). Patient refusals of medication also need to be documented, and the prescribing clinician should be informed.

Medication errors need to be documented as well. The prescribing clinician should be notified of errors. Institutional policies usually require filing a separate form to document errors. Errors can include administering the wrong drug, wrong dose, at the wrong time, or via the wrong route. Omissions of medication are also considered errors.

It is important to evaluate the patient following medication administration and document effect. For example, many hospitals dictate that a note be written regarding pain relief within several hours after analgesic administration. Any adverse effects from medication should be reported.
Preparation

Preparation for safe medication administration requires a background of education and hands-on training. New nurses and other professionals should be supervised until they demonstrate an appropriate level of knowledge and competent skills for independent medication administration.
Aftercare

The patient should be monitored to make sure the medication has had the desired effect.
Health care team roles

In addition to the clinician who administers medication, other members of the health care team play vital roles surrounding the medication administration process. Doctors or other prescribing clinicians are responsible for writing clear, legible orders and for monitoring the response of the patient to medication. They are also responsible for responding to potential adverse effects and concerns by the patient or other clinicians. Pharmacists are responsible for evaluating the medication order for potential problems, correctly filling the order, and monitoring the medication supply. All health care professionals are responsible for complying with medication-related policies designed to protect the patient and/or staff and for maintaining current knowledge regarding medication and medication administration.
Resources

Abdominal Ultrasound

2009-12-18T07:43:00.000-08:00

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Definition

Abdominal ultrasound uses high frequency sound waves to produce two-dimensional images of the body's soft tissues, which are used for a variety of clinical applications, including diagnosis and guidance of treatment procedures. Ultrasound does not use ionizing radiation to produce images, and in comparison to other diagnostic imaging modalities, it is low cost, safe, fast, and versatile.

Purpose

Abdominal ultrasound is used in the hospital radiology department and emergency department, as well as in physician offices for a number of clinical applications. Ultrasound has a great advantage over x-ray imaging technologies in that it does not damage tissues with ionizing radiation. Ultrasound is also generally far better than plain x-rays at distinguishing the subtle variations of soft tissue structures, and can be used in any of several modes, depending on the area of interest.

As an imaging tool, abdominal ultrasound generally is indicated for patients afflicted with chronic or acute abdominal pain; abdominal trauma; an obvious or suspected abdominal mass; symptoms of liver disease, pancreatic disease, gallstones, spleen disease, kidney disease and urinary blockage; or symptoms of an abdominal aortic aneurysm.

Specifically:

* Abdominal pain. Whether acute or chronic, pain can signal a serious problem—from organ malfunction or injury to the presence of malignant growths. Ultrasound scanning can help doctors quickly sort through potential causes when presented with general or ambiguous symptoms. All of the major abdominal organs can be studied for signs of disease that appear as changes in size, shape, and internal structure.
* Abdominal trauma. After a serious accident, such as a car crash or a fall, internal bleeding from injured abdominal organs is often the most serious threat to survival. Neither the injuries nor the bleeding may be immediately apparent. Ultrasound is very useful as an initial scan when abdominal trauma is suspected, and it can be used to pinpoint the location, cause, and severity of hemorrhaging. In the case of puncture wounds, from a bullet for example, ultrasound can locate the foreign object and provide a preliminary survey of the damage. (CT scans are sometimes used in trauma settings.)
* Abdominal mass. Abnormal growths—tumors, cysts, abscesses, scar tissue, and accessory organs—can be located and tentatively identified with ultrasound. In particular, potentially malignant solid tumors can be distinguished from benign fluid-filled cysts. Masses and malformations in any organ or part of the abdomen can be found.
* Liver disease. The types and underlying causes of liver disease are numerous, though jaundice tends to be a general symptom. Ultrasound can differentiate between many of the types and causes of liver malfunction, and is particularly good at identifying obstruction of the bile ducts and cirrhosis, which is characterized by abnormal fibrous growths and reduced blood flow.
* Pancreatic disease. Inflammation and malformation of the pancreas are readily identified by ultrasound, as are pancreatic stones (calculi), which can disrupt proper functioning.
* Gallstones. Gallstones are an extremely common cause of hospital admissions. These calculi can cause painful inflammation of the gallbladder and also obstruct the bile ducts that carry digestive enzymes from the gall-bladder bladder and liver to the intestines. Gallstones are readily identifiable with ultrasound.
* Spleen disease. The spleen is particularly prone to injury during abdominal trauma. It may also become painfully inflamed when infected or cancerous.
* Kidney disease. The kidneys are also prone to traumatic injury and are the organs most likely to form calculi, which can block the flow of urine and cause further systemic problems. A variety of diseases causing distinct changes in kidney morphology can also lead to complete kidney failure. Ultrasound imaging has proven extremely useful in diagnosing kidney disorders, including blockage or obstruction.
* Abdominal aortic aneurysm. This is a bulging weak spot in the abdominal aorta, which supplies blood directly from the heart to the entire lower body. A ruptured aortic aneurysm is imminently life-threatening. However, it can be readily identified and monitored with ultrasound before acute complications result.
* Appendicitis. Ultrasound is useful in diagnosing appendicitis, which causes abdominal pain.

Ultrasound technology can also be used for treatment purposes, most frequently as a visual aid during surgical procedures—such as guiding needle placement to drain fluid from a cyst, or to guide biopsies.
Precautions

Ultrasound waves of appropriate frequency and intensity are not known to cause or aggravate any medical condition.

The value of ultrasound imaging as a medical tool, however, depends greatly on the quality of the equipment used and the skill of the medical personnel operating it. More accurate results are obtained when ultrasound is performed by a clinician skilled in sonography. Basic ultrasound equipment is relatively inexpensive to obtain, and any physician with the equipment can perform the procedure whether specifically trained in ultrasound scanning and interpretation or not. Patients should not hesitate to verify the credentials of technologists and physicians performing ultrasound scanning, as well as the quality of the equipment used and the benefits of the proposed procedure.

In cases where ultrasound is used as a treatment tool, patients should educate themselves about the proposed procedure with the help of their doctors—as is appropriate before any surgical procedure. Also, any abdominal ultrasound procedure, diagnostic or therapeutic, may be hampered by a patient's body type or other factors, such as the presence of excessive bowel gas (which is opaque to ultrasound). In particular, very obese people are often not good candidates for abdominal ultrasound.
Description

Ultrasound includes all sound waves above the frequency of human hearing—about 20 thousand hertz, or cycles per second. Medical ultrasound generally uses frequencies between one and 10 megahertz (1-10 MHz). Higher frequency ultrasound waves produce more detailed images, but are also more readily absorbed and so cannot penetrate as deeply into the body. Abdominal ultrasound imaging is generally performed at frequencies between 2-5 MHz.

An ultrasound scanner consists of two parts: the transducer and the data processing unit. The transducer both produces the sound waves that penetrate the body and receives the reflected echoes. Transducers are built around piezoelectric ceramic chips. (Piezoelectric refers to electricity that is produced when you put pressure on certain crystals such as quartz.) These ceramic chips react to electric pulses by producing sound waves (they are transmitting waves) and react to sound waves by producing electric pulses (receiving). Bursts of high-frequency electric pulses supplied to the transducer cause it to produce the scanning sound waves. The transducer then receives the returning echoes, translates them back into electric pulses, and sends them to the data processing unit—a computer that organizes the data into an image on a television screen.

Because sound waves travel through all the body's tissues at nearly the same speed—about 3,400 miles per hour—the microseconds it takes for each echo to be received can be plotted on the screen as a distance into the body. The relative strength of each echo, a function of the specific tissue or organ boundary that produced it, can be plotted as a point of varying brightness. In this way, the echoes are translated into an image.

Four different modes of ultrasound are used in medical imaging:

* A-mode. This is the simplest type of ultrasound in which a single transducer scans a line through the body with the echoes plotted on screen as a function of depth. This method is used to measure distances within the body and the size of internal organs.
* B-mode. In B-mode ultrasound, a linear array of transducers simultaneously scans a plane through the body that can be viewed as a two-dimensional image on screen.
* M-Mode. The M stands for motion. A rapid sequence of B-mode scans whose images follow each other in sequence on screen enables doctors to see and measure range of motion, as the organ boundaries that produce reflections move relative to the probe. M-mode ultrasound has been put to particular use in studying heart motion.

* Doppler mode. Doppler ultrasonography includes the capability of accurately measuring velocities of moving material, such as blood in arteries and veins. The principle is the same as that used in radar guns that measure the speed of a car on the highway. Doppler capability is most often combined with B-mode scanning to produce images of blood vessels from which blood flow can be directly measured. This technique is used extensively to investigate valve defects, arteriosclerosis, and hypertension, particularly in the heart, but also in the abdominal aorta and the portal vein of the liver.

The actual procedure for a patient undergoing an abdominal ultrasound is relatively simple, regardless of the type of scan or its purpose. Fasting for at least eight hours prior to the procedure ensures that the stomach is empty and as small as possible, and that the intestines and bowels are relatively inactive. This also helps the gallbladder become more visible. Prior to scanning, an acoustic gel is applied to the skin of the patient's abdomen to allow the ultrasound probe to glide easily across the skin and also to better transmit and receive ultrasonic pulses. The probe is moved around the abdomen's surface to obtain different views of the target areas. The patient will likely be asked to change positions from side to side and to hold the breath as necessary to obtain the desired views. Usually, a scan will take from 20 to 45 minutes, depending on the patient's condition and anatomical area being scanned.

Ultrasound scanners are available in different configurations, with different scanning features. Portable units, which weigh only a few pounds and can be carried by hand, are available for bedside use, office use, or use outside the hospital, such as at sporting events and in ambulances. Portable scanners range in cost from $10,000 to $50,000. Mobile ultrasound scanners, which can be pushed to the patient bedside and between hospital departments, are the most common comfiguration and range in cost from $100,000 to over $250,000, depending on the scanning features purchased.
Preparation

A patient undergoing abdominal ultrasound will be advised by the physician about what to expect and how to prepare. As mentioned above, preparations generally include fasting.
Aftercare

In general, no aftercare related to the abdominal ultrasound procedure itself is required. Discomfort during the procedure is minimal.
Complications

Properly performed, ultrasound imaging is virtually without risk or side effects. Some patients report feeling a slight tingling and/or warmth while being scanned, but most feel nothing at all.
Results

As a diagnostic imaging technique, a normal abdominal ultrasound is one that indicates the absence of the suspected condition that prompted the scan. For example, symptoms such as abdominal pain radiating to the back suggest the possibility of, among other things, an abdominal aortic aneurysm. An ultrasound scan that indicates the absence of an aneurysm would rule out this life-threatening condition and point to other, less serious causes.

Because abdominal ultrasound imaging is generally undertaken to confirm a suspected condition, the results of a scan often will confirm the diagnosis, be it kidney stones, cirrhosis of the liver, or an aortic aneurysm. At that point, appropriate medical treatment as prescribed by a patient's physician is in order.
Health care team roles

Ultrasound scanning should be performed by a registered and trained ultrasonographer, either a technologist and/or a physician (radiologist, obstetrician/gynecologist). Ultrasound scanning in the emergency department may be performed by an emergency medicine physician, who should have appropriate training and experience in ultrasonography.

Nephrostomy Tube Care

2009-12-18T07:38:00.000-08:00

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Definition

A percutaneous nephrostomy tube (PNT) is a urinary diversion system comprised of a collection bag, a nephrostomy tube at an exit site (usually in the skin over the flank area), and a nephrostomy tube that enters and ends in the renal pelvis of the kidney. This allows for direct drainage of urine from the kidney when normal urinary flow is impeded. The PNT is most often used for a urinary obstruction such as a calculus.

Purpose

The purpose of PNT care is to prevent complications when a PNT is in use.
Precautions

Aspiration of fluid from the nephrostomy tube is prohibited as such action will damage the renal pelvis. Gravity drainage is used to collect specimens, and the nurse should never use force when irrigating the tube. A tube should never be irrigated with more than 5 ml of solution, since the capacity of the renal pelvis is between 4 and 8 ml. The nurse must avoid dislodging the tube while removing the dressing.
Preparation

The nurse should wash hands prior to beginning the procedure, then assemble all of the following equipment:

* disposable underpad
* clean gloves
* measuring tape
* sterile gloves
* sterile cotton tip applicators (4)
* sterile 0.9% NaCl or povidone-iodine solution or sponges
* sterile 4×4 pad or transparent dressing
* sterile 2×2 pads
* tape
* pouch belt

Description

The nurse should provide privacy for the patient in preparation for the procedure. He or she should position the patient on the side opposite the tube site with the nephrostomy site up. This provides better viewing of the tube and allows an easier dressing change.

The nurse should put on clean gloves and place a disposable underpad beneath to the patient to absorb any drainage. To minimize tension at the site and to prevent dislodging, the nephrostomy tube should be anchored with a small piece of tape. The collection bag must be emptied. The old dressing can be removed by carefully loosening the edges, and then moving to the center of dressing. Care should be taken to avoid dislodging the tube while removing the dressing. A sterile cotton-tip applicator placed on the catheter will help stabilize the catheter while removing the dressing. The site is then assessed for signs of infection, any moisture, or other drainage. The PNT is then measured from exit site to tip. If the PNT length is longer than the measurement at time of insertion, the catheter may have migrated out, and the physician should be notified at that point. The nurse should remove the soiled gloves at this time and replace with sterile ones. The exit site should be cleansed with the agent of choice (0.9% saline or povidone-iodine solution), using sterile 2×2 pads. Each pad can only be used once. Cleansing should start at the exit site and work outward in a circular motion; this action should be repeated twice. If there is any crusted matter at the site, this must be loosened and removed by using a cotton-tip applicator moistened with 0.9% saline. Then, sterile dressing should be applied. After removing the old tape, the tube must be secured with new tape to the skin below the dressing, approximately 2.5 inches (6.5 cm) from the exit site. The patient will need to be assisted in the application of the pouch belt. Anchoring the PNT with tape reduces trauma and minimizes the possibility of dislodging or kinking the tubing; adding the belt further secures the PNT. The nurse may remove gloves at this point and wash hands. The patient's dressing needs to be dated and initialed, and will need to be changed daily, or more often if necessary.
Aftercare

The used equipment needs to be disposed of properly. Upon completion of the procedure, the nurse should again wash hands. Then the nurse will need to document observations and the techniques used, including the assessment of the site, the external catheter length, the type of dressing applied, and the devices used to secure the PNT.
Complications

There is an increased risk of infection because the PNT provides a direct pathway to the kidney. There is also a risk for dislodging the PNT during this procedure.
Patient education

The patient may shower 48 hours post-insertion. The patient should be given all of the following instructions:

* Cover the dressing and exit site with a waterproof covering before showering.
* Empty the collection bag prior to showering.

* Securely tape the PNT at the exit site and use a belt for the collection bag in the shower to prevent tube migration.
* Generally, after 14 days, if there are no complications, the site may be left uncovered when showering.

The patient should notify the doctor if any problems arise such as:

* signs of infection at the exit site of the PNT, including warmth, redness, swelling, tenderness, and discharge
* drainage from the PNT
* decreased urine output
* inability to flush the PNT
* presence of any bleeding, clots, stones, sediment, and odor
* incontinence or inadequate bladder emptying
* inadequate pain control, nausea, or vomiting
* fever
* accidental dislodgement of the PNT, or suspected migration of the PNT

Results

The site should not display any signs of infection. PNT measurement should be consistent with the baseline value. Abnormal findings are signs of infection, suspected migration, or a dislodged PNT. In the collection bag, any bleeding, clots, stones, sediment, and odor are all abnormal findings.
Health care team roles

Registered nurses (RNs) and licensed practical nurses (LPNs) may perform this procedure. After returning home, the patient may simply cleanse the insertion site with soap and water, and change the dressing daily. In an inpatient setting, an aseptic technique must be maintained.

Nurses are responsible for:

* dressing changes
* proper disposal of equipment
* documentation of the procedure
* patient education

Upper GI Endoscopy

2009-12-12T09:23:00.000-08:00

www.gicare.com

Upper GI endoscopy, sometimes called EGD (esophagogastroduodenoscopy), is a visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or video endoscope. The upper gastrointestinal tract begins with the mouth and continues with the esophagus (food tube) which carries food to the stomach. The

J-shaped stomach secretes a potent acid and churns food into small particles. The food then enters the duodenum, or small bowel, where bile from the liver and digestive juices from the pancreas mix with it to help the digestive process.

Equipment

The flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the gastrointestinal tract. Endoscopes now come in two types. The original pure fiberoptic instrument has a flexible bundle of glass fibers that collect the lighted image at one end and transfer the image to the eye piece. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in these scopes allows other instruments to be passed through in order to take tissue samples, remove polyps and perform other exams.

Reasons for the Exam

Due to factors related to diet, environment and heredity, the upper GI tract is the site of numerous disorders. These can develop into a variety of diseases and/or symptoms. Upper GI endoscopy helps in diagnosing and often in treating these conditions:

ulcers --which can develop in the esophagus, stomach, or duodenum; occasionally ulcers can be malignant tumors of the stomach or esophagus difficulty in swallowing upper abdominal pain or indigestion

intestinal bleeding -- hidden or massive bleeding can occur for various reasons

esophagitis and heartburn -- chronic inflammation of the esophagus due to reflux of stomach acid and digestive juices

gastritis -- inflammation of the lining of the stomach

Preparation

It is important not to eat or drink anything for at least eight hours before the exam. The physician instructs the patient about the use of regular medications, including blood thinners, before the exam.

The Procedure
Upper GI endoscopy is usually performed on an outpatient basis. The throat is often anesthetized by a spray or liquid. Intravenous sedation is usually given to relax the patient, deaden the gag reflex and cause short-term amnesia. For some individuals who can relax on their own and whose gagging can be controlled, the exam is done without intravenous medications. The endoscope is then gently inserted into the upper esophagus. The patient can breath easily throughout the exam. Other instruments can be passed through the endoscope to perform additional procedures if necessary. For example, a biopsy can be done in which a small tissue specimen is obtained for microscopic analysis. A polyp or tumor can be removed using a thin wire snare and electrocautery (electrical heat). The exam takes from 15 to 30 minutes, after which the patient is taken to the recovery area. There is no pain with the procedure and patients seldom remember much about it.

Results

After the exam, the physician will explain the results to the patient and family. If the effects of the sedatives are prolonged, the physician may suggest an interview at a later date when the results can be fully understood. If a biopsy has been performed or a polyp removed, the results are not available for three to seven days.

Benefits
An upper GI endoscopy is performed primarily to identify and/or correct a problem in the upper gastrointestinal tract. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a bleeding site is identified, treatment can stop the bleeding, or if a polyp is found, it can be removed without a major operation. Other treatments can be given through the endoscope when necessary.

Alternative Testing

Alternative tests to upper GI endoscopy include a barium x-ray and ultrasound (sonogram) to study the organs in the upper abdomen. Study of the stools, blood and stomach juice can provide indirect information about a gastrointestinal condition. These exams, however, do not allow for a direct viewing of the esophagus, stomach and duodenum, removal of polyps or biopsies.

Side Effects and Risks

A temporary, mild throat irritation sometimes occurs after the exam. Serious risks with upper GI endoscopy, however, are very uncommon. One such risk is excessive bleeding, especially with removal of a large polyp. In extremely rare instances, a perforation, or tear, in the esophagus or stomach wall can occur. These complications may require hospitalization and, rarely, surgery. Quite uncommonly, a diagnostic error or oversight may occur. Due to the mild sedation, the patient should not drive or operate machinery following the exam. For this reason, someone else should be available to drive the patient home.

Summary

Upper GI endoscopy is a simple outpatient exam that is often performed with the patient lightly sedated. The procedure provides significant information upon which specific treatment can be given. In certain cases, therapy can be administered directly through the endoscope. Serious complications rarely occur from upper GI endoscopy. The physician can answer any question the patient has.

Gastro Esophageal Reflux Disease

2009-12-12T09:20:00.001-08:00

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Almost everyone has experienced heartburn. About 25 million American adults suffer daily from heartburn. It is that burning sensation felt behind the breastbone and sometimes in the neck and throat. Heartburn is caused by stomach acid refluxing or splashing up into the esophagus, the muscular tube that connects the throat to the stomach. Occasional heartburn is nothing to be concerned about; however, anyone who has heartburn on a regular basis should consult a physician. Constant exposure to stomach acid can irritate the lining of the esophagus and cause other medical problems. Serious heartburn is known as gastroesophageal reflux disease or GERD.

What is GERD?

The esophagus carries food and liquid into the stomach. At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the lower esophageal sphincter (LES). The LES should remain tightly closed, except to allow food and liquid to pass into the stomach. Reflux occurs when the LES is not working properly. It may relax for periods of time throughout the day and night, or it may be constantly too weak to function effectively. This allows the stomach's acid juices to flow into the esophagus. How severe the disease becomes depends on how weakened the LES is, and the amount and duration of acid refluxed into the esophagus.

It is also common to find a hiatal hernia complicating GERD. With a hiatal hernia, the upper part of the stomach actually pushes up into the chest through a weakness in the diaphragm. The diaphragm is the thin, flat muscle that separates the lungs from the abdomen. When part of the upper stomach is stuck above the diaphragm, stomach acid is retained there for a longer period and is more likely to reflux into the esophagus.

Symptoms and Causes of GERD

Frequent heartburn is the most common symptom. However, patients may also experience some of the following:

* sour or bitter taste
* bitter stomach fluid coming into the mouth, especially during sleep
* hoarseness
* repeatedly feeling a need to clear the throat
* difficulty swallowing food or liquid
* wheezing or coughing at night
* worsening of symptoms after eating, or when bending over or lying down.

Certain diet and lifestyle choices can contribute to the condition. For example, certain foods increase acid production, and fatty foods increase the time food remains in the stomach. Chocolate, peppermint, coffee, alcoholic beverages, and especially nicotine in cigarette smoke weaken or relax the LES. Obesity places added pressure on the upper abdomen, and during pregnancy the LES weakens for unknown reasons.

Complications

Complications occur when GERD is severe or long-standing. Constant irritation of the esophagus by stomach acid can lead to inflammation, ulcers, and bleeding. Anemia or low blood count may develop. Over time, scarring and narrowing of the esophagus can also develop, making it difficult to swallow foods and liquids. This narrowing is called a stricture. Some patients develop a condition called Barrett's esophagus, which is a serious change in the cells lining the esophagus. Barrett's esophagus may be a forerunner of esophageal cancer.

Diagnosis of GERD

The diagnosis can usually be suspected by the physician, simply by taking the medical history. Beyond that, the physician may order an x-ray examination of the esophagus and stomach. For this x-ray, the patient swallows a liquid containing barium. This makes it possible to see the reflux and a hiatal hernia on the x-ray. Endoscopy is the most important test for patients with GERD. It is done with the patient under sedation. The physician examines the lining of the esophagus and stomach with a thin, lighted, flexible tube called an endoscope. This exam is helpful in determining how severe the disease is, how much tissue damage there is, and if there are any complications. Certain conditions, such as narrowing or stricture in the esophagus, can usually be corrected during this procedure. During an endoscopy, the physician can also look for signs of Barrett's esophagus, and perform a biopsy to see if precancerous changes have occurred.

There are other tests that are helpful. A pressure recording of the esophagus is called esophageal manometry. It measures the pressure in the LES and any abnormal muscle contractions in the main part of the esophagus. Finally, a 12 to 24 hour recording of the acidity in the esophagus is often helpful.

What is the treatment?

Treatment is aimed at reducing reflux and damage to the lining of the esophagus. Initial treatment is with lifestyle changes. Patients with GERD should follow these recommendations:

* Avoid eating anything within three hours before bedtime.
* Stop smoking. Nicotine in the blood weakens the LES.
* Avoid fatty foods, milk, chocolate, spearmint, peppermint, caffeine, citrus fruits and juices, tomato products, pepper seasoning, and alcohol -- especially red wine.
* Decrease portions of food at mealtime, and avoid tight clothing or bending over after eating.
* Review all medications with the physician. Certain drugs can weaken the LES, allowing acid irritation of the esophagus.
* Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach by gravity when sleeping. Extra pillows by themselves are not very helpful.
* Lose weight if overweight. This may relieve upward pressure on the stomach and LES.

Lifestyle changes are often all that is needed to correct mild forms of GERD. When symptoms are bad or GERD is moderate to severe, the physician will prescribe medications. Some that reduce stomach acid include Tagamet, Zantac, Pepcid and Axid. Certain potent newer drugs, such as Prilosec and Prevacid, can almost eliminate stomach acid entirely. These two drugs are most frequently used when GERD is severe. Other medications, such as Reglan (generic: metoclopramide) tighten the LES. These may be especially useful at night when reflux often occurs.

A number of patients with GERD may need surgery to strengthen the LES. This procedure is called fundoplication. Previously, this surgery required a major operation, often through the chest. It is a difficult operation for the patient, with a long recovery. It is now usually done by laparoscopy. This is a new type of minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen. The patient usually returns home 1-2 days after surgery, with few problems. Surgery, however, should not be considered until all other measures have been tried. Surgery is often seriously considered for an otherwise healthy patient when the disease is severe, or the patient does not want to face the expense or regimen of long-term treatment with medications.

Summary

GERD is a common problem that requires medical attention when symptoms and tissue damage become troublesome. Fortunately, there is a great deal that can now be done about GERD. Lifestyle changes can help, and there are many medications and even surgery to treat and correct GERD. Working together with the physician, a good medical program can almost always be developed to successfully treat the patient with GERD.

Hiatus Hernia

2009-12-12T09:14:00.000-08:00

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The hiatus hernia is one of the most misunderstood and maligned conditions in medicine. People blame this hernia for more symptoms than it usually causes. Patients with a hiatus hernia need to understand what it is and what might occur with it. Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.

Anatomy

The diaphragm is a sheet of muscle that separates the lungs from the abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens. In doing this, the diaphragm pulls air into the lungs. The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach. Normally this hole, called a hiatus, is small and fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm.

What Causes a Hiatus Hernia?

In some people, the hiatus or hole in the diaphragm weakens and enlarges. It is not known why this occurs. It may be due to heredity, obesity, exercises such as weightlifting, or straining at stool. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole. A hiatus hernia is now present. Hiatus hernias are very common, occurring in up to 60 percent of people by age 60.

What Are the Different Types of Hiatus Hernia?

1. Sliding Hiatus Hernia -- In this most common type of hiatus hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. These hernias are normally small and usually cause no problems or even symptoms.
2. Fixed Hiatus Hernia -- In this case, the upper part of the stomach is caught up in the chest. With this hernia, there may be few symptoms, but the potential for problems in the esophagus is increased.
3. Complicated or Serious Hiatus Hernia -- Fortunately, this type of hernia is uncommon. It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest. There is a high likelihood that medical problems will occur with this hernia and treatment, frequently involving surgery, will be required. Complicated hernias are uncommon.

Symptoms

In most patients, hiatus hernias cause no symptoms. This is especially true of sliding hernias. When symptoms occur, they usually take the form of heartburn and regurgitation, when stomach acid refluxes back into the esophagus. Some patients with fixed hiatus hernias experience chronic reflux of acid into the esophagus, which may cause injury and bleeding. Anemia, or low red blood cell count, can result. Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area. This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

Does Hiatus Hernia Cause Pain and Indigestion?

It is wrong to always blame a hiatus hernia for pain and indigestion. Hiatus hernias generally do not cause acute pain. This symptom may result from other disorders, such as peptic ulcers or even heart disease. Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatus hernia. If upper-abdominal pain or indigestion occurs, people should not mislead themselves into thinking the cause is a hiatus hernia. Instead, the patient should seek medical advice.

Diagnosis

Diagnosis of a hiatus hernia is typically made through an upper GI barium x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.

What Are the Complications?
The complications of hiatus hernia are:

* Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis
* Anemia due to chronic bleeding from the lower esophagus
* Scarring and narrowing of the lower esophagus causing difficulty in swallowing
* While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia

In addition, the complicated hernia can cause serious problems such as difficulty in breathing or severe chest pain, especially in the elderly.

Treatment

Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing. Acid inflammation and ulceration of the lower esophagus also require treatment.

General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are:

* Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as:
o nicotine (cigarettes)
o caffeine
o chocolate
o fatty foods
o peppermint
o alcohol
o spearmint
* Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.
* Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux.
* If overweight, lose weight. Obesity also increases abdominal pressure.
* Prescription medications. Certain drugs, such as intestinal antispasmodics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower espohagus.
* Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the esophagus while sleeping.

Other Treatments

Drugs -- Some medicines effectively reduce the secretion of stomach acid, while others increase the muscle strength of the lower esophagus, thereby reducing acid reflux.

Surgery -- The complicated hiatus hernia occasionally requires surgery on an emergency basis. Surgery is otherwise reserved for those patients with complications that cannot be handled with medications. The mere presence of a hiatus hernia is not a reason for surgery.

Summary

A hiatus hernia is an extremely common condition which usually does not cause symptoms or problems. When symptoms do occur, the physician can frequently treat the problem effectively with a well-planned program. Surgery is infrequently required to treat a hiatus hernia.

Antihypertensive drugs

2009-12-09T23:34:00.000-08:00

Antihypertensive drugs are medicines that help lower blood pressure in peoplewhose blood pressure is too high. Blood pressure is a measurement of the force with which blood moves through the body's system of blood vessels. Although everyone's blood pressure goes up and down in the course of a typical day,some people have blood pressure that stays high all the time.

This conditionis known as hypertension. Hypertension is not the same as nervous tension. People who have high blood pressure are not necessarily tense, high-strung, ornervous. They may not even be aware of their condition. Being aware of high blood pressure and doing something to control it are extremely important, however. Untreated, high blood pressure can lead to diseases of the heart and arteries, kidney damage, or stroke, and can shorten life expectancy.

Treatments for high blood pressure depend on the type of hypertension. Most cases of high blood pressure are called essential or primary hypertension, meaning that the high blood pressure is not caused by some other medical condition. For most people with primary hypertension, it is difficult to figure outthe exact cause of the problem. However, such hypertension usually can be controlled by some combination of antihypertensive drugs and changes in daily habits(such as diet, exercise, and weight control). Controlling primary hypertension is however a lifelong commitment. Although people may be able to reducethe amount of medicine they take as their blood pressure improves, they usually must continue taking it for the rest of their lives.

In people with secondary hypertension, the high blood pressure may be due tomedical problems such as kidney disease, narrowing of certain arteries, or tumors of the adrenal glands. Correcting these problems often cures the high blood pressure, and no further treatment is needed.

Many different types of drugs are used, alone or in combination with other drugs, to treat high blood pressure. The major categories are:

* Angiotensin-converting enzyme (ACE) inhibitors, such as benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril), quinapril(Accupril), and ramipril (Altace). ACE inhibitors work by preventing a chemical in the blood, angiotensin I, from being converted into a substance that increases salt and water retention in the body. These drugs also make blood vessels relax, which further reduces blood pressure.
* Angiotensin II receptor antagonists, such as losartan (Cozaar) and losartan with hydrochlorothiazide (Hyzaar). These drugs act at a later step in the same process that ACE inhibitors affect. Like ACE inhibitors, they lower blood pressure by relaxingblood vessels.
* Beta blockers, such as atenolol (Tenormin), metoprolol(Lopressor), nadolol (Corgard), propranolol (Inderal), and timolol (Blocadren). Beta blockers affect the body's response to certain nerve impulses. This,in turn, decreases the force and rate of the heart's contractions, which lowers blood pressure.
* Blood vessel dilators (vasodilators), such as hydralazine (Apresoline) and minoxidil (Loniten). These drugs lower blood pressure by relaxing muscles in the blood vessel walls.
* Calcium channel blockers, such as amlopidine (Norvasc), diltiazem (Cardizem), isradipine (DynaCirc), nifedipine (Adalat, Procardia), and verapamil (Calan, Isoptin, Verelan).Drugs in this group slow the movement of calcium into the cells of blood vessels. This relaxes the blood vessels and lowers blood pressure.
* Diuretics, such as chlorthalidone (Hygroton), furosemide (Lasix), hydrochlorothiazide (Esidrix, HydroDIURIL), and metolazone (Zaroxolyn). These drugs control blood pressure by eliminating excess salt and water from the body.
* Nerve blockers, such as alpha methyldopa (Aldomet), clonidine (Catapres), guanabenz (Wytensin), guanadrel (Hylorel), guanethidine (Ismelin), prazosin(Minipress), rauwolfia derivatives (Reserpine), and terazosin (Hytrin). These drugs control nerve impulses along certain nerve pathways. This allows blood vesselsto relax and lowers blood pressure.

The recommended dosage depends on the type, strength, and form of antihypertensive drug. Check with the physician who prescribed the drug or the pharmacist who filled the prescription for the correct dosage. Always take antihypertensive drugs exactly as directed. Never take larger or more frequent doses, and do not miss any doses. Some antihypertensive drugs may take several weeks to noticeably lower blood pressure. Once it begins to work and symptoms improve, continuing to take the medicine is just as important. Stopping some hypertensive drugs suddenly may cause serious problems. Check with the physician who prescribed the medicine to find out if it is necessary to gradually taper down before stopping the medicine completely.

Antihypertensive drugs will not cure high blood pressure, but will help control the condition. To avoid the serious health problems that high blood pressure can cause, patients may have to take medicine for the rest of their lives.Furthermore, medicine alone may not be enough. People with high blood pressure also may need to avoid certain foods and keep their weight under control.The health care professional who is treating the condition can offer advice on what measures may be necessary.

Anyone taking antihypertensive drugs should not take any other prescription or over-the-counter medicine without first checking with his or her physician.Some medicines may increase blood pressure. Most patients who take antihypertensive drugs are not bothered by side effects. However, antihypertensive drugs may interact with many other medicines. When this happens, the effects ofone or both of the drugs may change or the risk of side effects may be greater. Anyone taking antihypertensive drugs should not take any other prescription or nonprescription (over-the-counter)medicine without first checking with his or her physician.

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Urodynamic study

2009-12-05T08:03:00.001-08:00

About urodynamic study

Urodynamic study can help find what's causing urinary incontinence (involuntary leakage) or retention (difficulty in passing urine). It checks how your bladder, the muscle around the neck of your bladder (sphincter) and the tube through which urine flows out of the body (urethra) are working.

The purpose of urodynamic study is to find out whether your:

* symptoms are due to involuntary contractions (squeezing) of your bladder muscles
* bladder pressure is normal during filling and emptying
* bladder capacity is normal

What are the alternatives?

Your doctor may suggest alternative imaging tests, such as plain X-rays of the urinary system, CT (computed tomography) scan or renal ultrasound. Urodynamic study is usually only done if an obvious cause of incontinence or voiding problems isn't found.
Preparing for your procedure

Urodynamic study is usually done as an out-patient procedure. This means you have the test and go home the same day.

You may be asked to keep a record of how much you urinate (called a voiding diary) over three days. You will need to record what type of fluid you drink, when and how much, and the timing and volume of urine output each day. You will need to record when you feel urgency or leak urine. The hospital will give you detailed advice about how to complete a voiding diary beforehand. This diary helps your doctor better understand your bladder problem. You may also be asked to stop any current bladder medication for at least a week beforehand.

You can eat and drink as usual before having urodynamic study. You may be asked to come to your appointment with a full bladder.

At the hospital your nurse may check your heart rate and blood pressure, and test your urine for infection. If you have a urinary infection (known as a urinary tract infection, UTI) your doctor may decide not to proceed with the test and ask you to come back after the infection has cleared.

The procedure may involve X-rays to help your doctor confirm your diagnosis. A radiographer (a health professional trained to perform imaging procedures) usually operates the X-ray machine and produce images on film or in digital format.

You must tell your doctor or radiographer about any medicines you are taking and if you have any allergies, glaucoma or heart disease. If you are a woman of childbearing age, you must tell your doctor or radiographer if you could be pregnant. X-rays are safe for adults, but may harm your developing baby. If you're pregnant, your doctor will discuss alternatives to the procedure.

Your doctor will usually ask you to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.
About the procedure

Urodynamic study usually takes 15 to 30 minutes.

You will need to remove your lower clothing and put on a hospital gown. You may need to lie back on a special X-ray table, which can be moved into different positions.

Fine tubes (catheters) with sensors attached to the tip are passed into your bladder through the urethra, and placed in your vagina or rectum. You doctor may apply a local anaesthetic gel around the entrance of your urethra beforehand to minimise any discomfort. You may feel the sensation of needing to pass urine as the catheters are put in.

With the catheters in place, the study may include the following tests.

* Filling cystometry - This test measures bladder capacity, bladder contractions and urinary leakage. Your bladder is slowly filled with sterile water. You will be asked to report any sensation you feel. You may be asked to cough, stand or bear down during the test.
* Voiding uroflometry - This test measures the strength of your urinary flow. You will be asked to urinate into a container linked to a computer that records your urine flow. The amount of urine left in your bladder after voiding is also measured.
* Urethral pressure study - This test measures the pressure and flow of urine out of your bladder. You will be asked to urinate while a sensor in the urethra measures the urethral pressure.
* Video cystourethrography - This test helps to identify structural problems in the bladder or urethra. The bladder is filled with contrast fluid (special dye that shows up in X-rays) and X-rays are taken as the fluid is voided.
* Electromyogram - This test helps measure muscle contractions that control urination. Electrode patches may be placed near the rectum or urethra to make the recording. You may be asked to try to tighten or relax your sphincter muscles.

What to expect afterwards

You will be able to go home when you feel ready. You can drive if you wish.
Results

Your results may be discussed with you immediately after the test or at a later date. Alternatively, a report may be sent to the doctor who recommended your test.
Recovering from urodynamic study

Drink plenty of clear fluids over 48 hours to help flush your bladder and reduce your risk of urinary infection.

Contact your GP if you develop any of the following symptoms, as you may have developed an infection:

* severe pain or pain that lasts for more than 48 hours
* high temperature
* burning sensation on passing urine or if your urine starts to smell
* heavy blood-stained urine

What are the risks?

Urodynamic study is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

If the test involves X-rays, you will be exposed to some X-ray radiation. The level of exposure is about the same as the background radiation that you would receive naturally from the environment over 12 to 14 months. X-rays can harm a developing baby. If you are, or think you may be pregnant, tell your doctor before your appointment.
Side-effects

These are the unwanted but mostly temporary effects of a successful procedure.

Side-effects of urodynamic study include:

* feeling some discomfort when passing urine
* feeling mild stinging when passing urine
* some blood in the urine for 24 hours

Complications

This is when problems occur during or after the procedure. Most people are not affected. Complications of urodynamic study are uncommon but can include:

* urinary tract or bladder infection (cystitis) - you may need antibiotics to treat this
* damage to the urethra - this may require treatment with medicines or surgery
* allergic reaction to contrast dye - medicines are available to treat this

The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your doctor to explain how these risks apply to you.

Autonomic Dysreflexia

2009-12-05T07:52:00.001-08:00

Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.

AD occurs primarily because of an imbalance in the body systems which control the blood pressure. The human body is an incredibly complicated and beautifully balanced machine. There are balances to each system of the body, including the blood pressure. One of the major ways the body controls blood pressure is by tightening or relaxing little muscles around the blood vessels.

When the muscles contract, the blood vessels get smaller and blood pressure increases. Imagine a garden hose with water streaming through it; when you put your thumb over the opening of the hose, reducing the opening for the water to flow through, the water shoots out at a higher pressure. Similarly, when the blood vessels are smaller, the blood rushes around your body at higher pressure.

When a noxious stimulus occurs, a reflex is initiated that causes the blood vessels to constrict and raises the blood pressure. In an intact spinal cord, this same stimulus also sets in motion another set of reflexes that moderates the constriction of blood vessels. However, in someone who has SCI at the T-6 level or above, the signal which tells the blood vessels to relax cannot get through the spinal cord because of the injury.

Some of the nerves at the T-6 level also control the blood flow to and from the gut, which is a large reservoir of blood. Uncontrolled activity of these nerves may cause the blood from the gut to flow into the rest of the blood system. The result is that blood pressure can increase to dangerous levels and the increase in blood pressure must be controlled by outside means.
What is "Autonomic Dysreflexia"?

Autonomic dysreflexia (AD), in the simplist terms, is the nervous system going crazy. Individuals that have a T-5, or higher, injury are the ones generally subject to suffering from AD. This is a condition that can be life-threatening and can be considered a medical emergency .
What are the indicators for the onset of AD?

* Hypertension (blood pressure greater than 200/100)
* Pounding headache
* Flushed (reddened) face
* Red blotches on the skin above level of spinal injury
* Sweating above level of spinal injury
* Nasal stuffiness
* Nausea (secondary to vagal parasympathetic stimulation)
* Bradycardia - slow pulse <60 beats per minute
* Piloerection ("goose bumps") below level of spinal injury
* Cold, clammy skin below level of spinal injury

What sort of things can precipitate this syndrome?

Irritants, things which would ordinarily cause pain, to areas of body below the level of spinal injury.

Things to consider include:

Bladder (most common) - from overstretch or irritation of bladder wall

* Urinary tract infection (UTI)
* Urinary retention
* Blocked catheter
* Overfilled collection bag
* Non-compliance with intermittent catheterization program

Bowel

* overdistention or irritation
* Constipation / impaction
* Distention during bowel program (digital stimulation)
* Hemorrhoids or anal infections
* Infection or irritation

Skin-related Disorders

* Any direct irritant below the level of injury
* Pressure by object in shoe or chair, cut, bruise, abrasion
* Pressure sores (decubitus ulcer)
* Ingrown toenails
* Burns (eg. - sunburn, burns from using hot water)
* Tight or restrictive clothing or pressure to skin from sitting

Sexual Activity

* Overstimulation during sexual activity
* [stimuli to the pelvic region which would ordinarily be painful if sensation were present]
* Menstrual cramps
* Labor and delivery

Other Causes

* Heterotopic ossification ("Myositis ossificans", "Heterotopic bone")
* Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
* Skeletal fractures

What can be done to manage an episode of autonomic dysreflexia?

The first thing to do is locate and remove the offending stimulus whenever possible. This will often prove successful enough to avoid pharmacological intervention. Once the source of irritation has been removed it will be a good idea to have the individual remain in a sitting up position and take frequent blood pressure checks until the episode has ended.
Typical Causes

Blocked Catheter
The most common cause of AD is a catheter that has become blocked. You will want to check the collection bag, irrigate the catheter and remove any kinks.

Bowel
If symptoms begin while digital stimulation is being performed, stop until symptoms quit. If the individual has impacted stool - begin disimpaction immediately. If digital stimulation continues to bring on the symptoms you may want to consider abdominal massage or commode-based bowel evacuation methods

Skin
Skin irritation, also a common cause of AD, is most often stopped by loosening the clothing. You will was to check for pressure sores and toenail problems.
How can autonomic dysreflexia be prevented?

* Frequent pressure relief in bed/chair
* Avoidance of sun burn/scalds (avoid overexposure, use of #15 sunscreen, watch water temperatures)
* Faithful adherence to bowel program
* Keep catheters clean and remain faithful to catheterization schedule
* Well balanced diet and adequate fluid intake Compliance with medications

CAUDA EQUINA

2009-12-02T20:11:00.000-08:00

http://www.emedicinehealth.com

Cauda Equina Syndrome Overview

The spinal cord extends from the brain down through the spinal canal inside the vertebral column. Nerves that branch off of the spinal cord (also called nerve roots) are an extension of the spinal cord and are responsible for sending signals to and from the muscles and other structures throughout the body. These signals allow the brain to interpret information from the body including pain, touch, and sense of position. Outgoing signals allow the brain to control actions of the organs and muscle movements.

The spinal cord ends near the first lumbar vertebra in the lower back, forming the conus medullaris. The fibrous extension of the spinal cord is the filum terminale. The bundle of nerve roots below the conus medullaris is named the cauda equina

Compression or inflammation of the nerve roots can cause symptoms of pain, altered reflexes, decreased strength, and decreased sensation. Although these symptoms can become severe, and in some cases disabling, most are self-limiting and respond to conservative care.

An extreme version of nerve compression or inflammation is cauda equina syndrome. Cauda equina syndrome is a serious condition caused by compression of the nerves in the lower portion of the spinal canal (see Multimedia File 2). Cauda equina syndrome is considered a surgical emergency because if left untreated it can lead to permanent loss of bowel and bladder control and paralysis of the legs.

Cauda Equina Syndrome Causes

Cauda equina syndrome is caused by significant narrowing of the spinal canal that compresses the nerve roots below the level of the spinal cord. Numerous causes of cauda equina syndrome have been reported, including traumatic injury, disk herniation, spinal stenosis, spinal tumors (neoplasms), such as metastatic tumors, meningiomas, schwannomas, and ependymomas, inflammatory conditions, infectious conditions, and accidental causes by medical intervention (iatrogenic causes).

Trauma

* Traumatic events leading to fracture or partial dislocation (subluxation) of the low back (lumbar spine) result in compression of the cauda equina.

* A collection of blood surrounding the nerves following trauma (epidural hematoma) in the low back area can lead to compression of the cauda equina.

* Penetrating trauma (gunshot or stab wounds) can cause damage or compression of the cauda equina.

* A rare complication of spinal manipulation is partial dislocation (subluxation) of the low back (lumbar spine) that can cause cauda equina syndrome.

Herniated Disk

* Most disk herniations will improve on their own (are self-limiting) and respond well to conservative treatment, including antiinflammatory medications, physical therapy, and short periods of rest (one to two days).

* Cauda equina syndrome results from a herniated lumbar disk in 1-15% of cases.

* Of lumbar disk herniations, 90% occur either at the vertebral levels L4-L5 or L5-S1.

* Seventy percent of cases of herniated disks leading to cauda equina syndrome occur in people with a history of chronic low back pain, and 30% develop cauda equina syndrome as the first symptom of lumbar disk herniation.

* Males in their 30s and 40s are most prone to cauda equina syndrome caused by disk herniation.

* Most cases of cauda equina syndrome caused by disk herniation involve large particles of disk material that have completely separated from the normal disk and compress the nerves (extruded disk herniations). In most cases, the disk material takes up at least one-third of the canal diameter.

Spinal Stenosis

* Spinal stenosis is any narrowing of the normal front to back distance (diameter) of the spinal canal.

* Narrowing of the spinal canal can be caused by a developmental abnormality or degenerative process.

* The abnormal forward slip of one vertebral body on another is called spondylolisthesis. Severe cases can cause a narrowing of the spinal canal and lead to cauda equina syndrome (see Multimedia File 3).

Tumors (Neoplasms)

* Cauda equina syndrome can be caused by isolated tumors (primary neoplasms) or from tumors that have spread to the spine from other parts of the body (metastatic spinal neoplasms). Metastatic spine tumors are most commonly from the prostate or lung in males and from the lung and breast in females.

* The most common initial symptom of people with cauda equina syndrome caused by a tumor (spinal neoplasm) is severe low back and leg pain.

* Later findings include lower extremity weakness.

* Loss of feeling in the legs (sensory loss) and loss of bowel or bladder control (sphincter dysfunction) are also common.

Inflammatory Conditions

* Long-lasting inflammatory conditions of the spine, including Paget disease and ankylosing spondylitis, can cause a narrowing of the spinal canal and lead to cauda equina syndrome.

Infectious Conditions

* Infections in the spinal canal (spinal epidural abscess) can cause deformity of the nerve roots and spinal column.

* Symptoms generally include severe back pain and rapidly worsening muscle weakness.

Accidental Medical Causes (Iatrogenic Causes)

* Poorly positioned screws placed in the spine can compress and injure nerves and cause cauda equina syndrome.

* Continuous spinal anesthesia has been linked to cases of cauda equina syndrome.

* Lumbar puncture (spinal tap) can cause a collection of blood in the spinal canal (spontaneous spinal epidural hematoma) in patients receiving medication to thin the blood (anticoagulation therapy). This collection of blood can compress the nerves and cause cauda equina syndrome.

Cauda Equina Syndrome Symptoms

Symptoms of cauda equina syndrome include the following:

* Low back pain

* Pain in one leg (unilateral) or both legs (bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)

* Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paresthesia)

* Bowel and bladder disturbances

* Lower extremity muscle weakness and loss of sensations

* Reduced or absent lower extremity reflexes

Low back pain can be divided into local and radicular pain.

* Local pain is generally a deep, aching pain resulting from soft tissue and vertebral body irritation.

* Leg pain (radicular pain) is generally a sharp, stabbing pain resulting from compression of the nerve roots. Radicular pain projects along the specific areas controlled by the compressed nerve (known as a dermatomal distribution).

Bladder disturbance (urinary manifestations) related to cauda equina syndrome include the following:

* Inability to urinate (urinary retention)

* Difficulty initiating urination (urinary hesitancy)

* Decreased sensation when urinating (decreased urethral sensation)

* Inability to stop or control urination (incontinence)

Bowel disturbances may include the following:

* Inability to stop or feel a bowel movement (incontinence)

* Constipation

* Loss of anal tone and sensation

When to Seek Medical Care

Cauda equina syndrome is a surgical emergency. Persons should seek immediate medical care or go to the emergency department if they believe they have symptoms of cauda equina syndrome. Some of the early symptoms related to cauda equina syndrome, including low back pain and muscle weakness, are more often caused by simple disk herniation, which does not require urgent attention. However, if you develop severe pain or loss of sensation or bowel or bladder disturbances, you should contact your physician immediately.

Your chances of regaining normal function and having a positive outcome are related to how long you have had symptoms of cauda equina syndrome. Most experts agree that people with cauda equina syndrome should undergo surgery to make more space for the nerves (lumbar decompression) within 48 hours in order to have the best chance for complete recovery.

Exams and Tests

The initial diagnosis of cauda equina syndrome is made based on findings from the individual's history, symptoms, and physical exam. The physical exam includes testing muscle strength of the lower extremities, evaluating sensation to touch and pain, especially around the groin (perineum), checking the lower extremity reflexes, and evaluating rectal tone, sensation, and reflex.

Imaging studies helpful in the diagnosis include plain x-ray films of the lower back to assess for evidence of trauma or severe arthritis (degenerative changes). MRI with and without contrast provides a detailed look at tumors, infection, intervertebral disks, and nerve roots. This study allows the doctor to determine if the nerves are being compressed, to what degree, and by what structures. Findings from these studies help the surgeon plan the appropriate treatment.

Not all people with back pain and/or leg pain and changes in bowel or bladder function have cauda equina syndrome. More common causes of bladder changes are urinary tract infections, which can be identified by a simple urine test, and diabetes, which can be identified with blood tests.

People with symptoms suggesting a possible infection or tumor should be further evaluated with blood and other tests to identify any abnormalities.

Cauda Equina Syndrome Treatment

Self-Care at Home

Cauda equina syndrome is a surgical emergency. Self-care at home is not appropriate for this condition.

Medical Treatment

Medical treatment options are useful in certain persons, depending on the underlying cause of the cauda equina syndrome. Antiinflammatory agents, such as ibuprofen (Advil, Motrin), and corticosteroids, such as methylprednisolone (Solu-Medrol, Depo-Medrol), can be effective in people with inflammatory processes, including ankylosing spondylitis.

People with cauda equina syndrome caused by an infection should receive appropriate antibiotic therapy. People with spinal tumors (neoplasms) should be evaluated for chemotherapy and radiation therapy.

Caution should be used in any medical management of cauda equina syndrome. Any person with cauda equina syndrome with symptoms of groin numbness (saddle anesthesia) and/or weakness or both legs or loss of bowel or bladder control should wait no more than 24 hours before seeking initial medical management. If no relief of symptoms is achieved during this period, immediate surgical decompression is often recommended to minimize the chances of permanent nerve injury.
Medications

People with infections or tumors (infectious or neoplastic causes) causing cauda equina syndrome should receive the appropriate antibiotics or chemotherapy for treatment of the underlying cause.

In most cases, treatment with medications alone is not indicated because of a need for emergent release of the nerve compression (surgical decompression) of the spinal canal.

Surgery

In many cases of cauda equina syndrome, emergency decompression of the spinal canal is the best treatment option. The goal is to relieve pressure on the nerves of the cauda equina by removing the compressing structures and increasing the space available for the nerves in the spinal canal. Traditionally, cauda equina syndrome has been considered a surgical emergency, with surgical decompression considered necessary within 48 hours of the onset of symptoms.

For people with a herniated disk as the cause of cauda equina syndrome, removal of a portion of the bone surrounding the nerves (laminectomy) is performed and the disk material compressing the nerves is removed (discectomy). Many clinical and experimental reports have presented data on the functional outcome based on the timing of surgical decompression. Some investigators have reported no significant differences in the degree of functional recovery as a function of the timing of surgical decompression. Even with these findings, however, most investigators recommend surgical decompression as soon as possible following onset of symptoms to offer the greatest chances of complete neurologic recovery.

Many clinical and experimental studies have investigated patient outcomes in relation to the timing of surgical decompression. Some investigators have reported no significant differences in the degree of functional recovery as a function of the timing of surgical decompression. Even with these findings, however, most investigators recommend surgical decompression as soon as possible following the onset of symptoms to offer the greatest chances of complete neurologic recovery.

Investigators have attempted to identify specific criteria that can aid in predicting the outcome of persons with cauda equina syndrome.

* People with pain in both legs (bilateral sciatica) have less chance or full recovery than persons with single leg pain (unilateral sciatica).

* People with complete groin numbness (perineal anesthesia) are more likely to have permanent paralysis of the bladder.

* The extent of groin numbness (perineal or saddle sensory deficit) is the most important predictor of recovery.

Follow-up

Persons with cauda equina syndrome should have close follow-up with their surgeon to monitor any changes in function. Early surgery gives the patient the best chance for complete recovery from cauda equina syndrome.

Prevention

Prevention of cauda equina syndrome is focused on early diagnosis by identifying the symptoms described above. While low back pain with leg pain and/or weakness is a common complaint that affects many people, cauda equina syndrome is a rare complication. Doctors should be vigilant in identifying these cases. People should be educated on signs and symptoms that could suggest possible cauda equina syndrome, including change in bowel or bladder function and loss of sensation in the groin.

WARFARIN

2009-11-27T22:30:00.000-08:00

GENERIC NAME: warfarin
BRAND NAME: Coumadin

DRUG CLASS AND MECHANISM: Coumadin is an oral anticoagulant that inhibits the synthesis of clotting factors, thus preventing blood clot formation. Blood clots can occur in the veins of the lower extremities, usually after periods of immobility. These clots can break off and become lodged in the blood vessels of the lung (pulmonary embolism), causing shortness of breath, chest pain, and even life-threatening shock. Blood clots can also occur in the atria of the heart during atrial fibrillation, and around artificial heart valves. One of these clots can also break off and obstruct a blood vessel in the brain, causing an embolic stroke with paralysis. Coumadin is important in preventing the formation of blood clots. It is also important to prevent extension of clots already formed, and to minimize the risk of blood clot embolization to other vital organs such as the lungs and brain.

PRESCRIBED FOR: Coumadin is used in treating patients with blood clots in the lower extremities to prevent extension of the clot, and to reduce the risk of pulmonary embolism. Patients with pulmonary embolism are treated with Coumadin to prevent further blood clot emboli. Coumadin is also used in patients with atrial fibrillation and artificial heart valves to reduce the risk of strokes. It is also helpful in preventing blood clot formation in certain orthopedic surgeries such as knee or hip replacements. Coumadin is also used in preventing blood clot closure of coronary artery stents.

DOSING: Coumadin may be taken with or without food. Since Coumadin is metabolized by the liver and excreted by the kidneys, dosages need to be lowered in patients with liver and kidney dysfunction. Frequent blood tests are performed to measure blood clotting time (protime) during Coumadin treatment. Protime results help doctors adjust medication dose to avoid excessive blood thinning and risk of bleeding.

DRUG INTERACTIONS: Many drugs, both prescription and nonprescription (OTC), can affect the anticoagulant action of Coumadin. Some medications can enhance the action of Coumadin and cause excessive blood thinning and life-threatening bleeding. A few examples of such medications include Aspirin, acetaminophen (Tylenol and others), alcohol, ibuprofen (Motrin), cimetidine (Tagamet), oxandrolone (Oxandrin), certain vitamins, and antibiotics. Patients on Coumadin should regularly consult their doctor before instituting any medications on their own. It is also advisable for patients on Coumadin to carry identifications to alert other health professionals.

PREGNANCY: Coumadin should be avoided by pregnant women or women who may become pregnant. Birth defects and fetal bleeding have been reported.

SIDE EFFECTS: The two most serious side effects are bleeding and necrosis (gangrene) of the skin. Bleeding can occur in any organ or tissue. Bleeding around the brain can cause severe headache and paralysis. Bleeding in the joints can cause joint pain and swelling. Bleeding in the stomach or intestines can cause weakness, fainting spells, black tarry stools, vomiting of blood, or coffee ground material. Bleeding in the kidneys can cause back pain and blood in urine. Other side effects include purple, painful toes, rash, hair loss, bloating, diarrhea, and jaundice (yellowing of eyes and skin). Signs of overdose include bleeding gums, bruising, nosebleeds, heavy menstrual bleeding, and prolonged bleeding from cuts.

PRECAUTIONS: Before taking warfarin, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: blood disorders (e.g., hemophilia), bleeding conditions (e.g., active ulcers), uncontrolled severe high blood pressure (malignant hypertension), recent or planned surgery, received certain procedures (e.g., spinal cord injections, major anesthesia). Before using this medication, tell your doctor or pharmacist your medical history, especially of: liver disease, kidney disease, alcohol abuse, tissue damage (e.g., gangrene, necrosis), trauma, high blood pressure, severe diabetes, congestive heart failure, cancer, collagen vascular disease (e.g., lupus, polyarteritis), radiation therapy, underactive or overactive thyroid, poor nutrition, intestinal absorption problems, low blood levels of vitamin K, swelling of the arms/legs (edema), high cholesterol/fat blood levels, catheters in your body (e.g., urinary or intravenous type), side effects with heparin treatment (heparin-induced thrombocytopenia), family members who did not respond to warfarin treatment, conditions that make it difficult to follow a warfarin treatment plan (e.g., dementia, psychosis). Avoid alcohol while taking this drug because it may increase the risk of stomach bleeding. Avoid getting injections into the muscles (intramuscular-IM). If they must be given, limit injections to the arms. The FDA has stated that generic warfarin products are interchangeable. However, consult your doctor and pharmacist before switching warfarin products. If you have an illness or infection that causes vomiting, diarrhea or fever for more than a few days, contact your doctor immediately because these conditions can affect how well this drug works. This medication can cause heavy bleeding. Be extra careful to avoid injuries (e.g., avoid contact sports). Use an electric razor when shaving and a soft toothbrush when brushing your teeth. It is important that all your doctors and dentists know you take warfarin. Caution is advised when using this drug in the elderly because they may be more sensitive to its effects. This medication must not be used during pregnancy because of possible fetal harm and birth defects. Discuss reliable forms of birth control with your doctor. If you become pregnant or think you may be pregnant, inform your doctor immediately. You will be switched over to another anticoagulant (e.g., heparin-type) during pregnancy. Consult your doctor for more information. This medication does not pass into breast milk. While there have been no reports of harm to nursing infants, consult your doctor before breast-feeding.
DRUG INTERACTIONS: This drug should not be used with the following medications because very serious interactions may occur: imatinib, mifepristone. If you are currently using any of these medications, tell your doctor or pharmacist before starting warfarin. Many drugs and herbal products interact with warfarin. Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: acetaminophen (repeated use or large doses), allopurinol, aminoglutethimide, amiodarone, anabolic steroids (e.g., danazol, stanozolol), certain injectable cephalosporin antibiotics (e.g., cefamandole, cefotetan), macrolide antibiotics (e.g., erythromycin, clarithromycin), certain oral and injectable penicillin-type antibiotics (e.g., dicloxacillin, piperacillin), quinolone antibiotics (e.g., ciprofloxacin, levofloxacin), certain other antibiotics (e.g., chloramphenicol, metronidazole), azole antifungals (e.g., voriconazole, vaginal miconazole), barbiturates (e.g., phenobarbital), birth control pills, certain drugs to treat cancer (e.g., capecitabine, fluorouracil), carbamazepine, drugs to lower cholesterol or triglycerides (e.g., cholestyramine, fenofibrate, gemfibrozil, lovastatin, simvastatin), cimetidine, corticosteroids (e.g., prednisone), disulfiram, glucagon, griseofulvin, herbal/dietary products (e.g., bromelains, co-enzyme Q, danshen, dong quai, garlic, ginkgo biloba, ginseng, St. John's wort), nonsteroidal anti-inflammatory drugs (NSAIDs such as celecoxib, ibuprofen, topical methylsalicylate), omeprazole, propafenone, propoxyphene, quinidine, quinine, rifamycins (e.g., rifampin, rifabutin), certain sedatives (e.g., chloral hydrate, ethchlorvynol, glutethimide), sulfa drugs, sulfinpyrazone, SSRI antidepressants (e.g., fluoxetine, fluvoxamine), tamoxifen, drugs to treat thyroid disease (e.g., levothyroxine, propylthiouracil), vitamin E, vitamin K, zafirlukast. Check all prescription and nonprescription medicine labels carefully since many contain pain relievers/fever reducers (NSAIDs such as ibuprofen, naproxen, or aspirin) which can increase the risk of bleeding/anti-platelet effect when used with warfarin. Low-dose aspirin, as prescribed by your doctor for specific medical reasons such as heart attack or stroke prevention or to prevent clotting of artificial heart valves (usually these dosages are 81-325 mg per day), should be continued. Consult your doctor or pharmacist for more details. Related drugs (anti-platelet drugs such as clopidogrel, dipyridamole, ticlopidine) prescribed for specific medical reasons should be continued, unless otherwise directed by your doctor. Consult your doctor or pharmacist for more details including the possible serious side effects associated with ticlopidine (e.g., immune system problem, liver disease when used with warfarin). While taking warfarin, it is important to eat a normal, balanced diet. The amount of vitamin K in your body affects the way that warfarin works. It is best to avoid sudden changes in your diet, especially unusual increases or decreases in the amount of foods high in vitamin K (e.g., liver, broccoli, cauliflower, cabbage, Brussels sprouts, kale, spinach and other green leafy vegetables, green tea, and certain vitamin supplements). It is best to avoid strictly vegetarian diets that consist of foods high in vitamin K. This product can affect the results of certain lab tests. Make sure laboratory personnel and your doctors know you use this drug.
OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include unusual or prolonged bleeding, dark urine or black stools.

NOTES: Do not share this medication with others. Laboratory and/or medical tests (e.g., blood tests such as PT/INR, complete blood count) should be performed periodically to monitor your progress or check for side effects. It is important to keep all lab and medical appointments. Consult your doctor or pharmacist for more details.

MISSED DOSE: If you miss a dose, use it as soon as you remember if it is on the same day. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up because this could increase your risk for bleeding. Keep a record of missed doses to give to your doctor or pharmacist. Call your doctor or pharmacist if you miss 2 or more doses in a row.

STORAGE: Store at room temperature between 59-86 degrees F (15-30 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For enrollment information call MedicAlert at 1-800-854-1166 (USA), or 1-800-668-1507 (Canada).

Colostomy care

2009-11-22T21:06:00.000-08:00

Definition

A colostomy is a surgically created opening in the abdominal wall through which digested food passes. It may be temporary or permanent. The opening is called a stoma from the Greek word meaning mouth. Stool passes through the stoma into a pouch attached to the stoma on the outside of the abdomen. The pouch, stoma, and skin surrounding the stoma require care and maintenance by the patient or caregiver.

Purpose

A pouch is worn over a colostomy to collect the stool passed through the stoma. There are a variety of pouches available for use with a colostomy. Over time the patient can determine which pouch type best suits his or her needs. A colostomy pouch is normally emptied one or more times daily. The pouch itself usually needs to be changed every four to six days. The stoma and surrounding skin need to be kept clean and sanitary.

Precautions

The nurse attending to a colostomy should wash his or her hands before and after the procedure, as well as wear latex gloves while performing care.

Description

A pouching system is normally worn over a colostomy stoma. Pouches can be obtained from several different manufacturers in both disposable and reusable varieties. The enterostomal therapy ET nurse can be an invaluable resource when helping patients select a pouch system.

Colostomy pouches may be either open ended or closed. Open-ended pouches require a clamp for closure. They can be drained simply and reused after they are emptied. Closed pouches are sealed at the bottom and are usually used by patients who irrigate their colostomies or who have a regular bowel elimination pattern. Two-piece pouch systems consist of a separate flange and pouch. The pouch has a closing ring that attaches to a matching piece on the flange. One-piece systems have a connected wafer and pouch that do not separate. The portion of the pouch that is applied to the abdomen is called a skin barrier wafer. Both two-piece and one-piece systems can be either closed or open ended.

Some patients with colostomies can irrigate their stomas using a procedure similar to an enema. This cleans the stool out of the colon through the stoma. A special irrigation system is used. Sometimes a special lubricant is used to prepare for the irrigation. Irrigating often leads to increased control over the timing of bowel movements.

Removing the colostomy appliance requires gently pushing away the skin surrounding the stoma and pulling the appliance downwards. Adhesive remover wipes are available to help in the removal of the wafer. The bag is then discarded in an appropriate waste container. The stoma should be cleaned with lukewarm water and dried with a soft towel. The stoma and surrounding skin should be assessed. The stoma should be pink or red and moist-looking, and may bleed slightly when cleansed. The stoma normally decreases in size slightly during the first weeks after surgery.

The opening in the wafer should fit snugly around the stoma. An opening that is too large will allow intestinal contents to leak onto the skin. Measuring guides come with the colostomy wafers so that the hole can be cut to the proper size. Skin barrier paste can be used to help create a better seal between the wafer and the patient's abdomen. Various skin preparation products are also available to help protect the skin under the wafer and around the stoma. They also aid in the adhesion of the wafer. Using the fingertips, gentle pressure should be applied to put the wafer in place.

After the application of the barrier, the bag should be applied (if it is a two-piece system). If it is an open system, apply a clamp to the bottom of the new pouch.

Preparation

The nurse should instruct the patient and caregiver(s) about the procedure before it is performed. Many people feel anxious and nervous when first dealing with an ostomy. Encourage the patient to ask questions, and explain all steps as they are performed.

Aftercare

The nurse should assess the patient's tolerance of the procedure and response to teaching or education about the appliance.

Health care team roles

Although most members of the health care team will come into contact with patients having ostomies, it is the nurse who has the responsibility for providing ostomy care and instructing the patient and/or caregiver how to provide care independently. An enterostomal therapy (ET) nurse is specially educated in all aspects of ostomy care.

Key Terms

StomaSurgically constructed mouth or passage between the intestine and the outside of the patient's body.

2009-11-09T05:29:00.000-08:00

MULTIPLE SCLEROSIS

Overview
Multiple sclerosis (MS) is an inflammatory, chronic, degenerative disorder that affects nerves in the brain and spinal cord. Myelin, the fatty substance that surrounds and insulates nerves and facilitates the conduction of nerve impulses is the initial target of inflammatory destruction in multiple sclerosis.
MS is characterized by intermittent damage to myelin , called demyelination. Demyelination causes scarring and hardening (sclerosis) of nerve tissue in the spinal cord, brain, and optic nerves. Demyelination slows conduction of nerve impulses, which results in weakness, numbness, pain, and vision loss. CLICK HERE FOR DETAILS

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CLICK HERE TO DOWNLOAD POWER POINT FILE. Power point file contains some videos. You must download the video to view power point file. Click here to download video1, video 2, video 3, video 4, video 5, video 6

Trombose en longembolie

2009-10-26T06:38:00.000-07:00

Wat is een longembolie?
Bij een longembolie (of pulmonaire embolie) valt een gedeelte van de long tijdelijk of soms blijvend uit doordat één of meerdere longslagaders verstopt zitten door bloedklonters die via de bloedstroom in de longen terecht komen. Dit is vaak het gevolg van een trombose elders in het lichaam waarbij een stolsel geheel of gedeeltelijk losraakt. Dit stolsel wordt vervolgens meegevoerd met het aderlijke bloed en komt via de rechterzijde van het hart in de longen terecht. Dit heeft negatieve gevolgen voor de zuurstofopname in de long, voor het aangedane deel van de long zelf (in ong. 10% van de gevallen treedt een longinfarct op met afsterving van longweefsel), en bij zeer grote afsluitingen heeft het grote gevolgen voor het hart.

De gevolgen van een longembolie zijn afhankelijk van de uitgebreidheid van de blokkage en de snelheid van behandeling.

• een minimale longembolie: volledige genezing met minimaal longweefselverlies. Sommige mensen blijven kortademig, vooral als ze zich inspannen.

• een middelmatige tot ernstige longembolie: evolutie naar een pulmonaire hypertensie ( = een verhoogde longdoorbloedingsweerstand) met chronisch rechter hartfalen en zware inspanningsinvaliditeit. Door een snelle behandeling en het voorkomen van een nieuwe embolie en een aangepaste behandeling, kan dit vaak met minimale gevolgen voor de toekomst aflopen.
• Een zware tot zeer zware longembolie kan leiden tot de dood, onmiddellijk of na enkele dagen.

Deze aandoening komt voor bij ongeveer 1 à 2 op 1.000 mensen.
zie ook artikel : Pulmonale hypertensie (PH)
zie ook artikel : Hartfalen

Oorzaak
De meest voorkomende oorzaak van een longembolie is diep veneuze trombose (DVT): bij een longembolie is in 70-90% van de gevallen ook een DVT aanwezig die niet altijd klachten geeft. Meestal gaat het om een DVT in de benen of (uitzonderlijk) de kuiten (‘trombosebeen’), soms in de armen.
Lange tijd heeft men gedacht dat een trombosebeen en een longembolie twee aparte ziektebeelden waren. Omdat oorzaken, behandeling en prognose vergelijkbaar zijn blijkt steeds meer dat het verschillende vormen zijn van een en dezelfde ziekte en worden daarom ook wel aangeduid met de overkoepelende term veneuze trombo-embolie (VTE). Hierdoor is ook de behandeling gelijksoortig.
Anders dan vaak wordt gedacht komen longembolieën vrijwel nooit uit aders onder het niveau van de knie, de plaats waar men meestal wel het duidelijkst de symptomen van een trombose waarneemt.
Voor de duidelijkheid: een bloedstolsel uit de benen kan niet naar het hoofd of het hart schieten.

Andere mogelijke oorzaken van een longembolie zijn:
- het aanprikken van een bloedvat waarbij per ongeluk lucht in het vat gespoten worden. De luchtbel kan net als een bloedstolsel de bloedstroom naar de longen verstoppen.
- vetbolletjes (vaak bij een breuk in een van de langere botten)
- vruchtwater bij een bevalling.

Risicofactoren

De risicofactoren voor het krijgen van longembolieën zijn dezelfde als die van trombose. Meestal gaat het om een combinatie van verschillende factoren: een trage bloedstroom door een ader, een verhoogde bloedstollingsneiging en een beschadiging van de aderwand.

• Een verminderde of vertraagde bloeddoorstroming in een ader. Dit kan optreden bij langdurige bedrust, door immobilisatie van het been (bv. gipsbehandeling) of door een periode weinig te bewegen, bijvoorbeeld tijdens een lange vlieg- of autoreis

zie ook artikel : Longembolie na vliegtuigreizen - 'economy class' syndroom

• Een beschadiging van de aderwand door een wonde, een infuus, een ontsteking...
• een recente operatie (vooral aan de onderste ledematen, heup, rug en zware algemene operaties).
• erfelijke aanleg
• Roken,
• overgewicht (BMI > 30 kg/m2)
• uitdroging
• anticonceptiepil, hormonale subsititutietherapie na menopauze (vooral in combinatie met roken) en andere hormonale behandelingen
• zwangerschap
• leeftijd (vanaf 40 jaar stijgt het risico)
• kanker: Diepe veneuze trombose en/of longembolie treden op bij 5-60% van de patiënten met kanker, afhankelijk van het soort kanker, van het stadium en van de behandeling. In ca. 10% van de gevallen kan dit een eerste uiting van de ziekte zijn die er soms maanden tot jaren aan vooraf kan gaan.
• aangeboren of verworven stollingsstoornissen, o.a. mutatie van factor II of van factor V (Factor VLeiden), antitrombine III-deficiëntie, proteïne S-deficiëntie, proteïne C-deficiëntie...
• chronische ziekten (nierinsufficiëntie, ziekte van Crohn...)
• een eerdere trombose, tromboflebitis of longembolie.

Symptomen
Heel vaak zijn er weinig of geen symptomen, vooral bij kleine embolieën. De symptomen van longembolie zijn bovendien vaak moeilijk te onderscheiden van andere hart- en longaandoeningen.

De meest voorkomende symptomen zijn
• Kortademigheid met ademhalingsmoeilijkheden (dyspnoe)
• pijn bij de ademhaling (met name bij diep inademen).
• Snelle en oppervlakkige ademhaling (tachypnoe)
• Prikkelhoest
• Pijn aan de zijkant van de borstkas
• Soms bloed ophoesten
• Hartritmestoornissen (snelle hartslag of tachycardie)
• soms lichte koorts
• soms daling van de bloeddruk en zelfs levensbedreigende shock (vooral bij een grote longembolie)

Diagnose
De diagnose van een longembolie is vaak lastig omdat de klachten kunnen variëren van griepklachten tot symptomen die aan een hartstoornis doen denken. Bij vermoeden van een longembolie zal de huisarts onmiddellijk doorverwijzen naar een ziekenhuis of naar de spoeddienst.
Afhankelijk van de klachten en het geschatte risico op longembolie, zullen verschillende onderzoeken worden uitgevoerd.

Bloedonderzoek om de bloedstolling (o.m. D-dimeertest) en de hoeveelheid zuurstof in het bloed te meten.

Elektrocardiogram (ECG) of trans-oesophageale echocardiogra?e (TEE) geeft, vooral bij grote longembolieën, vaak indirecte aanwijzingen door de overbelasting van de rechter harthelft. Het ECG toont bij 30% van de patiënten met een bewezen longembolie echter geen afwijkingen.

Duplex-scan van de benen : Bij een Duplexonderzoek zijn echografie en Doppleronderzoek verenigd in één toestel. De echografie brengt de bloedvaten in beeld. De Doppler meet de snelheid van de bloedstroom. De stroomsnelheid wordt zichtbaar op een beeldscherm als een golfbeweging. De golfbeweging geeft de toename en afname van de bloedstroomsnelheid onder invloed van de hartslag weer. Hiermee stelt uw arts de precieze plaats en de ernst van uw problemen vast.

Rontgenfoto van de borst (RX van de thorax) : Deze longfoto's laten vaak afwijkingen zien die typisch zijn voor een longembolie.

Ventilatie-perfusie longscan of longscintigrafie (VQ-scan) : Deze scan is bedoeld om te onderzoeken hoe de zuurstofvoorziening van de longen is en of bloed stroomt naar alle delen van de longen. In de arm wordt een dosis radioactieve stof gespoten die via de bloedbaan in de longen terecht komt. Met behulp van een gammacamera is de bloedstroom in de longen zichtbaar voor de onderzoeker. Op de plaats waar het bloedstolsel een bloedvat afsluit, zal de camera geen radioactiviteit waarnemen.
Na dit onderzoek volgt dan een ventilatie-onderzoek. Bij dit onderzoek ademt u radioactieve stof in. Dezelfde camera maakt daar weer foto’s van. Hierdoor kan de arts de gasuitwisseling in de longen meten. Gasuitwisseling is de opname van zuurstof en de afgifte van kooldioxide. Zonder doorbloeding van de longen is deze gasuitwisseling niet mogelijk.
De ventilatie-perfusiescan wordt tegenwoordig alleen gebruikt als CT-angiografie niet mogelijk of niet conclusief is.

Spiraal CT-scan (angioscan) . Dit is momenteel het meest gebruikte onderzoek voor een longembolie. Bij deze methode wordt er een injectie met contrastvloeistof toegediend. Vervolgens wordt het (eventuele) stolsel zichtbaar gemaakt met behulp van röntgenfoto's. Daarna maakt een computer een groot aantal foto's (dwarsdoorsneden). Hierbij kunnen karakteristieke afwijkingen in (takken van) de arteria pulmonalis gezien worden. Bovendien kunnen andere oorzaken van de klachten die de basis zijn voor de klinische verdenking op een longembolie, worden aangetoond.

Pulmonale angiografie: Een flexibele buis (catheter) wordt via de lies naar de bloedvaten in de long gevoerd. Vervolgens wordt een kleurstof ingespoten en worden de bloedvaten in de longen door middel van een röntgenfoto beoordeeld. Het nadeel hiervan is dat het een invasieve ingreep betreft met ca. 5% kans op complicaties (als gevolg van de katheterisatie of van contrasttoediening). Dit onderzoek is zelden meer nodig.

Behandeling
De behandeling van een longembolie vindt altijd plaats in een ziekenhuis en liefst zo snel mogelijk.
Het doel van de behandeling van een longembolie is tweeledig: ten eerste de groei van het stolsel remmen en de afbraak bevorderen, ten tweede wordt getracht een nieuwe trombusvorming te voorkomen. Indien een longembolie niet behandeld zou worden met antistolling, zal 30% een nieuwe niet fatale longembolie en 30% een nieuwe fatale longembolie doormaken binnen de 3 tot 6 maanden. Met een antistollingsbehandeling verloopt de ziekte veel minder ernstig en wordt de kans op een nieuwe longembolie veel kleiner. Van de patiënten die behandeld worden voor een longembolie maakt ongeveer 3% een nieuwe longembolie door die bij ongeveer 1 % fataal is. Na het stoppen van de behandeling neemt de kans op een nieuwe longembolie (recidief) weer toe. De kans op een nieuwe longembolie bedraagt 10% jaar in het eerste jaar na het stoppen van de behandeling, ongeacht of deze behandeling 6 maanden of langer werd gegeven.

1) Aanvangsbehandeling
Er worden 3 types van longembolie onderscheiden: een niet-massale longembolie, een massale longembolie en een intermediaire groep.

Niet - massale longembolie
Aangezien antistollingsmiddelen die via de mond worden ingenomen (orale anticoagulantia) pas werkzaam zijn na enkele dagen, wordt tijdens de eerste dagen een snel werkende behandeling toegepast met een intraveneuze inspuiting of infuus van heparine of laagmoleculaire heparine (LMWH).
Deze behandeling wordt gedurende minstens vijf dagen toegepast, tot bij controle van het bloed blijkt dat de werking van deze middelen op het gewenste niveau is: de bloedstolling (de zogenaamde protrombinetijd) uitgedrukt als INR-waarde (international normalised ratio ) moet op twee opeenvolgende dagen binnen de therapeutische grenzen (2 en 3) liggen. Meestal duurt dat ongeveer 8 tot 10 dagen.

Massale longembolie
Ingeval van een massale longembolie die levensbedreigend is, geniet een behandeling met bloedklonter oplossende medicatie (trombolytica) de voorkeur. Hierbij worden de stolsels met behulp van speciale catheters in de ader behandeld met lokale bloedklonter oplossende medicatie.
Indien deze behandeling niet mogelijk is (bv. omwille van bloedingsrisico), zullen snelwerkende antistollingsmiddelen (heparine) via een infuus of inspuiting toegediend worden.

Intermediaire groep
(patiënten met rechterkamerdysfunctie): toediening van heparine of van trombolytica.

2) Onderhoudsbehandeling
De onderhoudsbehandeling met orale stollingsremmers (anticoagulantia) is aangewezen om nieuwe emboliëen te voorkomen. De orale anticoagulatie wordt opgestart tussen dag 1 en dag 5 na het starten van de heparinebehandeling.
Meestal worden daarvoor cumarinederivaten gebruikt. In België zijn 3 cumarinederivaten beschikbaar: acenocoumarol (Sintrom®), fenprocoumon (Marcoumar®) en warfarine (Marevan®).

Meestal zal u de geneesmiddelen in de vooravond moeten innemen. Verander nooit de toedieningswijze of de dosis van de medicatie zonder het akkoord van uw arts. Bij inname van een te lage dosis zal de doeltreffendheid van de behandeling verminderen en bij een te hoge dosis loopt u kans op bloedingen. Als u het geneesmiddel minder dan 4 tot 6 uur geleden had moeten innemen, mag u de vergeten dosis innemen. Maar als het meer dan 6 uur geleden is, slaat u de dosis over en neemt u de volgende doses regelmatig in. Breng uw arts daarvan op de hoogte bij de volgende raadpleging.

Vanaf de 3de dag zal uw bloed regelmatig gecontroleerd worden. Zo kan de arts ervoor zorgen dat het effect van de medicijnen op de bloedstolling (en het risico op bloedingen) niet te groot en niet te klein is. Gestreefd wordt naar een INR-waarde tussen 2 en 3. Aan de hand van de bloeduitslagen stelt de arts de hoeveelheid medicijnen eventueel bij. In het begin van de behandeling worden frequente controles uitgevoerd (tweemaal per week). Zodra de INR tussen 2 en 3 ligt, wordt de frequentie van de controles verminderd tot eenmaal om de 3 tot 4 weken als de waarden stabiel blijven. Maar telkens als de dosis van het anticoagulans wordt veranderd, moet binnen de week na de wijziging een controle worden uitgevoerd. Uw behandelende arts zal met u bepalen hoe vaak uw bloed moet worden gecontroleerd, hoe de bloedafname gebeurt en hoe de behandeling dienovereenkomstig moet worden aangepast.

De behandeling met orale antistollingsmiddelen moet minstens drie tot zes maanden worden voortgezet, afhankelijk van de omstandigheden van de embolie en eventuele risicofactoren. Een trombose zonder duidelijke aanleiding zal men bijvoorbeeld vaak langer behandelen dan een embolie na een operatie of zwangerschap.
Bij een tweede embolie of een levensbedreigende eerste embolie kan een langere (soms zelfs levenslange) behandeling nodig zijn.

De nieuwere antistollingsgeneesmiddelen (zoals fondaparinux en ximelagatran) hebben een aantal voordelen in vergelijking met de coumarinederivaten (vereisen geen controle van de graad van anticoagulatie, geen regelmatige aanpassing van de dosis vereisen, snellere werking, minder interacties met andere geneesmiddelen) maar ook nadelen (vooral het optreden van bloedingen). Omwille van die nadelen en hun hoge kostprijs worden ze op dit ogenblik niet aangeraden, tenzij in uitzonderlijke omstandigheden.

Een langdurige behandeling met orale antistollingsmiddelen kan vervelende bijwerkingen hebben en vereist ook een aantal voorzorgsmaatregelen.

Chirurgie
Bij zeer levensbedreigende situaties kan een chirurgische ingreep worden verricht waarbij de hoofdlongslagader wordt geopend en de bloedklonter wordt weggehaald (trombectomie) of via een catheter wordt verwijderd (angioplastie).

Bij herhaalde embolieën is het mogelijk in de onderste holle ader een vangkorfje (onderste vena cava filter) te plaatsen dat losschietende emboli vangt voor deze het hart bereiken.

Hoe kan men een longembolie vermijden?

Bij medische behandelingen
Een antitrombotische behandeling kan zinvol zijn:
- bij zware orthopedische chirurgie (zoals een heup- of knie-operatie),
- bij operaties aan de buik
- bij operaties aan rug en schedel
- bij andere ingrepen die leiden tot langdurige immobilisatie bij patiënten met risicofactoren voor trombo-embolie (leeftijd boven 60 jaar, obesitas, hartfalen, respiratoire insufficiëntie, kanker, infectie, acute inflammatoire aandoening, vroegere trombose).

In dat geval worden meestal heparines met laag moleculair gewicht (LMWH) voorgeschreven. In België zijn ook fondaparinux en ximelagatran geregistreerd voor de preventie van diepe veneuze trombose na een orthopedische chirurgische ingreep zoals een heup- of knieprothese.
De preventieve behandeling wordt meestal opgestart enkele uren voor de operatie en gedurende een aantal dagen na de operatie voortgezet. Soms zal u ook na ontslag uit het ziekenhuis de medicatie nog gedurende enkele weken moeten gebruiken.

Andere voorzorgsmaatregelen:
- de patiënt na de operatie snel weer op de been helpen, of oefeningen om de benen te bewegen
- de benen hoog leggen
- het gebruik van steunkousen en/of een drukmanchet rond de voet en de kuit. De manchet wordt afwisselend opgeblazen en afgelaten.

Bedlegerigheid
Indien de bedlegerigheid het gevolg is van een (acute) ernstige ziekte, zoals CVA, hartfalen, COPD, trauma (bijvoorbeeld meerdere breuken), ernstige infecties of kanker, en als de patiënt ouder is dan 70 jaar, dan kan een preventieve behandeling met antistollingsmiddelen én steunkousen worden overwogen.

Sommige bewegingen verminderen de kans op veneuze trombose, zelfs als ze in bed worden uitgevoerd.
a) Zo vaak mogelijk de kuitspieren uitrekken door de voet te buigen en te strekken: dat stimuleert de veneuze bloedsomloop.
b) Positie van de benen: bij voorkeur in hoogstand met de voeten ongeveer ter hoogte van het hart.
c) Fietsbewegingen of de benen strekken naar het voetuiteinde van het bed en dan terug naar de borstkas trekken.

Zwangerschap en kraambed
In sommige omstandigheden kan het aangewezen zijn om tijdens de zwangerschap en na de bevalling preventieve maatregelen te nemen om longembolie te voorkomen.

Anticonceptie
De anticonceptiepil verhoogt licht de kans op een diep veneuse trombose, vooral in combinatie met roken. Voortzetting van het gebruik van de pil na een DVT of longembolie wordt meestal afgeraden.

Bij lange-afstandsreizen
Wat het risico van diepe veneuze trombose bij lange-afstandsreizen betreft, wijzen studies er op dat dit risico vooral hoog is bij aanwezigheid van andere risicofactoren zoals een vroegere diepe veneuze trombose, recente chirurgische ingreep, kanker. Het risico neemt toe naarmate de reis langer duurt (vanaf 6 uren). Voor reizigers zonder bekende risicofactoren zijn, onafhankelijk van de lengte van de vlucht, geen extra maatregelen nodig;

De aanbevolen preventieve maatregelen zijn de volgende:
- voldoende drinken,
- inname van alcohol en slaapmiddelen vermijden,
- de benen regelmatig bewegen
- eventueel steunkousen dragen (onder de knie, klasse 2).
- Bij hoogrisicopatiënten die geen antitrombotische behandeling nemen, kan ook een inspuiting van heparine met laag moleculair gewicht 2 à 4 uur vóór het vertrek worden aangeraden; acetylsalicylzuur wordt niet aanbevolen.

Verpleegkundige

2009-10-23T13:35:00.000-07:00

Als verpleegkundige help je mensen met een beperking, handicap of (dreigende) ziekte in hun thuissituatie of in een zorginstelling. Wat je precies doet, is afhankelijk van de afdeling of instelling waar je werkt en ook van de specialisatie die je tijdens je studierichting hebt gekozen. Je krijgt voornamelijk verzorgende en verpleegtechnische taken (mensen aankleden, een infuus aanleggen, enzovoort). Verder denk je mee over beleidszaken en werk je intensief samen met je collega’s, artsen en professionals uit andere disciplines.

Wat doet een verpleegkundige?

Verpleegkundigen komen bijvoorbeeld terecht in ziekenhuizen, verpleeghuizen, psychiatrische inrichtingen of bij de GGD. Binnen deze instellingen zijn er talrijke afdelingen waar zij werken. De onderstaande beschrijving is voornamelijk toegespitst op de werkzaamheden van een verpleegkundige in een ziekenhuis of verpleeghuis.
1. Helpt met de dagelijkse verzorging

Iedere dag verzorg je de patiënten die aan jou zijn toevertrouwd. Wat moet je je voorstellen bij het werk van een verpleegkundige?

* Je verschoont dagelijks het ondergoed en beddengoed van de patiënten.
* Je wast de patiënten, helpt hen met douchen en naar het toilet gaan. Sommige patiënten kunnen niet uit bed komen, waardoor de verzorging wordt beperkt tot het wassen met een washandje en het helpen met de po-stoel.
* Je helpt met aankleden, bijvoorbeeld door het aantrekken van steunkousen of een pyjama.
* Je ziet erop toe dat de patiënten eten en drinken krijgen. Meestal word je hierbij ondersteund door een voedingsassistent.
* Je controleert of patiënten wel de juiste medicijnen hebben gekregen en niet per ongeluk zijn overgeslagen.
* Tot slot heb je vaak nog kleine taken, zoals bestellingen opgeven aan de apotheek.

2. Verricht verpleegtechnische handelingen

Je hebt specifiek verpleegtechnische taken, die afhankelijk zijn van de afdeling of instelling waar je werkt. Op de chirurgische afdeling van een ziekenhuis verzorg je bijvoorbeeld wonden en operatieve ingrepen (een stoma bijvoorbeeld), breng je een katheter in (buisje voor het afvoeren van vloeistoffen zoals urine), leg je een infuus aan, enzovoort. Daarnaast bereid je medische onderzoeken en operaties voor door de benodigde instrumenten en apparatuur klaar te zetten. Een verpleegkundige bij de GGD zal zich bezighouden met de bestrijding van infectieziekten, inentingen en het geven van voorlichting.
3. Is verantwoordelijk voor de uitvoering van het behandelplan

Iedere patiënt in een ziekenhuis of zorginstelling heeft een eigen dossier, dat dagelijks door de verpleegkundige wordt gecontroleerd en aangevuld. In dit dossier staan de gegevens van deze persoon en het behandelplan. In het verslaggedeelte noteer je kort hoe een dag voor de patiënt is verlopen, bijvoorbeeld: "Ze deed alles zelf; geen bijzonderheden" of "Mevrouw is gevallen; wilde geen medicijnen innemen". Je bent ook verantwoordelijk voor de uitvoering van dit behandelplan, dat je in overleg met de arts of specialist hebt samengesteld. Je coördineert de zorg op jouw afdeling: je regelt allerlei zaken en geeft personeel en verpleegkundigen op lagere niveaus duidelijke instructies over wat wel en wat niet moet gebeuren.
4. Werkt samen met arts en andere professionals

Je overlegt geregeld met de artsen en specialisten en zij geven je ook instructies. Je ondersteunt hen intensief bij hun werk, bijvoorbeeld gedurende onderzoeken en behandelingen of het bezoeken van de patiënten, dat "visite lopen" heet.
5. Observeert en signaleert

Een belangrijke taak is het observeren van patiënten. Je hebt daarvoor een goed 'klinisch oog' nodig, waarmee je snel in de gaten hebt dat er iets aan de hand is. Wanneer iemand opeens bleek wordt of moeite krijgt met ademen, of bij andere ongewone veranderingen in het uiterlijk, gedrag of het ziektebeeld, grijp je meteen in. Je vraagt wat er aan de hand is en schat op basis van het verhaal van de zieke, je eigen inzicht en je ervaring, in welke (medische) behandelingen noodzakelijk zijn. Als je het niet alleen aankunt, waarschuw je collega’s. Je licht ook degene in die verantwoordelijk is voor de patiënt (meestal de arts of specialist).

Als je ziet dat er iets niet goed gaat op jouw afdeling of in de instelling, dan rapporteer je dat. Ten slotte denk je mee over het beleid tijdens vergaderingen met collega’s, artsen en andere zorgverleners.

Tineke van Dijk werkt als IC-verpleegkundige bij 't Lange Land Ziekenhuis in Zoetermeer: "Op de Intensive Care komen mensen terecht die in een levensbedreigende situatie zijn en die onder streng en continue toezicht moeten worden gesteld. Je hebt als IC-verpleegkundige daarom maar één of twee patiënten per dag onder je hoede. De patiënten liggen onder meer aan de hartbewaking of beademingsapparatuur. Via monitoren controleer je het hartritme en de bloeddruk en houd je scherp in de gaten of alle lichaamsfuncties naar behoren werken. Geeft een orgaan het plotseling op, een nier bijvoorbeeld, dan zul je direct niervervangende therapie moeten geven. Je bent voortdurend mensen aan het observeren en controleren."
6. Verstrekt inlichtingen aan patiënten en bezoekers

Je informeert de patiënt, diens familieleden en bekenden over het soort behandeling dat de persoon in kwestie moet ondergaan, of over welk soort onderzoek er wordt uitgevoerd. Ook geef je patiënten adviezen over het gebruik van medicijnen en bepaalde symptomen of klachten die bij het ziektebeeld horen. Na operaties of behandelingen licht je ze in over het verloop van de ingreep en wat de arts precies heeft gedaan. Je doet echter geen uitspraken over de resultaten van een onderzoek of de diagnose, dat is uitsluitend aan de arts voorbehouden.
7. Begeleidt mensen en vangt ze op

Je deelt lief en leed met je omgeving. Dat kan heel mooi, maar ook moeilijk zijn. Als iemand een slecht bericht krijgt, is de verpleegkundige vaak de eerste opvang. Vaak zijn er op zulke momenten geen familieleden of vrienden bij de patiënt. Denk aan mensen die veel pijn lijden en bij wie geen uitzicht op verbetering of genezing is. In een dergelijke situatie moet je toch kalm zien te blijven en de ander de mogelijkheid geven om te praten, mits hij zijn verhaal kwijt wil.
Rollen

* Zorgverlener. Je bent verantwoordelijk voor de dagelijkse verzorging van hulpbehoevende mensen.
* Regisseur. Vaak heb je meerdere coördinerende taken op een dag. Zo moet je er bijvoorbeeld op toezien dat in een kort tijdsbestek veel mensen worden gewassen, aangekleed en hun medicijnen toegediend krijgen.
* Steunpunt. Mensen kunnen bij jou hun verhaal kwijt als het moeilijk hebben, of wanneer ze gewoon een praatje willen maken. Daarnaast vang jij ze op bij klachten en problemen, of vragen over hun ziekte, de behandeling en dergelijke.
* Controleur. Je ziet niet alleen toe op de conditie van patiënten, maar ook op het werk van je collega's. Je werkt meestal in een team en bent daarom medeverantwoordelijk voor het functioneren en het gedrag van je collega’s. Immers, als een collega op jouw afdeling vergeet een patiënt zijn medicijnen te geven, kan dit ernstige gevolgen hebben. Door goed op elkaar te letten, ondersteun je elkaar.
* Professional. Of je nu algemeen of gespecialiseerd verpleegkundige bent: je bent ten alle tijde een professional die ontwikkelingen in het vakgebied nauwkeurig bijhoudt, deze toepast in de praktijk en overdraagt aan collega's.

Waar werk je als verpleegkundige?

Verpleegkundigen zijn in Nederland werkzaam in de volgende plekken:

* Ziekenhuizen (56 procent)
* Gehandicaptenzorg (12 procent)
* Thuiszorg (10 procent)
* Psychiatrie (9 procent)
* Verpleeghuizen (8 procent)
* GGD's (2 procent)
* Kraamzorg, schoolartsendienst en RIAGG's (1 procent) (Bron: Hogeschool van Amsterdam, 2005)

Trends en ontwikkelingen

Redelijk nieuw, maar al ontzettend populair bij zorginstellingen is de functie van nurse practitioner. Je neemt dan verpleegkundige taken en sommige medische handelingen over van de specialist of huisarts. Je doet bijvoorbeeld zelfstandig onderzoek bij een patiënt en beslist welke behandeling gegeven moet worden, ondanks dat normaal gesproken alleen de arts een diagnose mag stellen. Wel moet je altijd goed blijven overleggen met de verantwoordelijke arts en zijn er wel grenzen gesteld aan je handelen. Aangezien nurse practitioners het werk van de specialist of arts behoorlijk kunnen ontlasten, zijn ze – zeker met het oog op het tekort aan huisartsen en de overgrote zorgvraag – zeer welkom.
Wat is je plaats in de organisatie?
Collega’s of medewerkers

Met de volgende mensen werk je op hetzelfde niveau samen, of je geeft hen leiding. Dit is afhankelijk van de grootte en de inrichting van de organisatie.

* Verpleegkundigen. Dit zijn je directe collega’s.
* Verzorgenden. Zij werken in verpleeghuizen, de thuiszorg en bejaardenhuizen.
* Administratief personeel. De baliemedewerkers maken afspraken met patiënten, verstrekken algemene informatie, en ontvangen bezoekers.
* Professionals uit andere disciplines. Maatschappelijk werkers, fysiotherapeuten, psychiaters, enzovoort.
* Divers (medisch) personeel. Bijvoorbeeld operatieassistenten, voedingsassistenten, technici, de applicatiebeheerder, medewerkers van de keuken en transportdienst.

Wie is je baas?

Je directe leidinggevende is meestal je teamleider. Deze wordt op zijn beurt weer aangestuurd door de zogeheten Eerste verpleegkundige of Hoofdverpleegkundige. Er zijn echter ook 'zelfsturende teams', waarbij je elkaar coacht om op de juiste manier zorg te verlenen. Tenslotte krijg je ook instructies van artsen en andere professionals (psychologen, zorgmanagers).
Welke competenties moet je in huis hebben?

"Je moet hard kunnen werken. Als verpleegkundige werken is echt veel heen en weer rennen, veel dingen tegelijk onthouden en doen. Dus stressbestendig zijn. Tegen kritische situaties kunnen... En natuurlijk moet je goed met patiënten om kunnen gaan... Niet snel vies van iets zijn (want je komt echt vieze dingen tegen). Je moet je kunnen inleven in andere mensen."

- Persoonlijk verhaal van een propedeuse-studente Verpleegkunde in het opleidingenforum
1. Goede sociale vaardigheden

Geduld en begrip zijn onmisbaar in het contact met je omgeving. Als verpleegkundige wil je mensen graag helpen en verzorgen. Je luistert naar hun verhalen en vragen, stelt ze gerust wanneer dat nodig is, informeert ze en helpt ze met de dagelijkse verzorging. Je vangt ze op bij pijn en ander lijden. Je hebt hiervoor een sterke persoonlijkheid nodig; je bent niet bang om voor patiënten op te komen, maar anderzijds durf je ook duidelijk grenzen te stellen aan hun eisen.
2. Integriteit

Van patiënten zul je nogal eens vertrouwelijke informatie te horen krijgen. Je weet ook veel van hun situatie via het persoonlijk patiëntendossier. Ook verricht je handelingen die voor de patiënt belastend kunnen zijn, zoals het wassen van intieme delen, of een endoscopie, waarbij je een slang in de anus van de patiënt inbrengt om de darmen te onderzoeken. In dit soort gevallen is tact en een integere houding natuurlijk wenselijk. Ook inlevingsvermogen in de benarde situatie van een ander komt jou als verpleegkundige goed van pas.
3. Stressbestendig

In de verpleging werk je onder grote druk. Je krijgt bijvoorbeeld de opdracht om tien mensen te wassen, aan te kleden en aan tafel te zetten, en dat in een heel hoog tempo. Of iemand wordt plotseling onwel, en je moet hartmassage en mond-op-mondbeademing geven. Al met al heb je een zeer wisselend takenpakket, waardoor je snel moet kunnen schakelen. Bovendien krijg je met allerlei soorten mensen te maken, en niet altijd de gemakkelijkste... Je kunt te maken krijgen met agressie. Dit alles kan flink wat stress opleveren, maar een bekwaam verpleegkundige is daar tegen bestand.
4. Flexibiliteit

Je komt als verpleegkundige in zeer diverse en soms onverwachte situaties terecht. Daarvoor heb je een flexibele opstelling en doorzettingsvermogen nodig. Je past je snel aan een weet het overzicht te behouden tussen je verschillende bezigheden. Ook kun je op stressvolle momenten de juiste beslissingen nemen, bijvoorbeeld door goed in te schatten welke medische handelingen er verricht moeten worden. Verder draai je in de verpleging vaak onregelmatige diensten, hetgeen ook de nodige flexibiliteit vereist in het organiseren van je privé-leven.
5. Goede lichamelijke conditie

De verpleging is ook in lichamelijke zin een zwaar vak. Je moet veel lopen, tillen, bukken, noem maar op. Dat kan zeker bij een hoge werkdruk lichamelijke klachten opleveren. Een goede lichamelijke gesteldheid is dan ook onmisbaar. En het duurt nog tot je 55e voor je geen nachtdiensten meer hoeft te draaien…
6. Goede motoriek en verpleegtechnisch inzicht

Je moet zorgvuldig met je handen kunnen werken. Bij het verwisselen van een infuus, het inbrengen van een slangetje in iemands neus of wanneer je een injectie wilt geven, moet je bijvoorbeeld geen trillende handen hebben. Ook enig verpleegtechnisch inzicht komt van pas. Je begrijpt dan waarom je bepaalde dingen doet (wat er medisch gezien precies gebeurt) en wat de gevolgen van je handeling zijn voor geest en lichaam van de patiënt.
7. Empathie

Je moet ook een zekere mate van afstand kunnen bewaren. Als je je alles persoonlijk aantrekt, wordt het werk erg zwaar. De uitdaging is dus om empatisch te zijn en sociaal, zonder teveel bij je werk betrokken te raken.
Wat onderscheidt een top-verpleegkundige van een gewone verpleegkundige?

Als top-verpleegkundige bezit je een uitstekende vakkennis, die je ook goed op peil weet te houden. Je kunt vlot omgaan met mensen, bezit een behoorlijke dosis empathie en wordt niet snel uit het veld geslagen bij onverwachte situaties. Ook heb je je zaakjes goed op orde: je regelt de zorg voor anderen en bent in staat collega’s te coachen. Je beschikt bovendien over zelfinzicht, dus je durft te reflecteren op je eigen gedrag, en voor jezelf duidelijk te erkennen wat je wel en niet kunt.

Voorbeeld: stel, je houdt niet zo van injecteren. Op een gegeven moment moet je iemand een injectie in de arm geven, en het lukt je na een aantal pogingen niet om de ader te vinden. Wees niet te trots om toe te geven dat je dit niet aankunt, en haal er gewoon een collega bij die de klus van je overneemt.

Je hebt niettemin wel een goede klinische blik, waarmee je snel kunt afleiden uit het uiterlijk van patiënten hoe het met hen gaat. Een "lastige" patiënt ontwijk je niet, maar je gaat hem ook niet doorschuiven naar je collega. Je werkt gewetensvol en bent een betrouwbaar persoon voor je omgeving. Kortom, uit alles blijkt dat je sterk gemotiveerd bent voor dit vak, en dat straal je ook uit.
Hoe word je verpleegkundige?
Speciale opleiding als basis

De enige studie waarmee je je kunt kwalificeren als verpleegkundige, is de hbo-opleiding Verpleegkunde. Er zijn veel hogescholen die deze opleiding in het pakket hebben. De meeste van hen bieden bovendien hbo Verpleegkunde aan in zowel een voltijd-, deeltijd- en duale variant.
Mbo-vooropleiding

Met een afgeronde mbo Verpleegkunde (niveau 4) kun je al aan de slag in de verpleging, maar het is ook mogelijk te kiezen voor een speciaal doorstroomprogramma naar het hbo. Je mag dan een verkort traject volgen, waarmee je de bachelor Verpleegkunde in twee tot drie jaar kunt afronden. Samen met je studieloopbaanbegeleider schrijf je een Persoonlijk Opleidingsplan, waarin je studieplannen staan. Door het afleggen van assessments wordt duidelijk welke competenties je al beheerst en welke je nog moet ontwikkelen. Heb je een andere mbo-opleiding gedaan, dan doorloop je het volledige studieprogramma van vier jaar.
Wat ga je verdienen?

Als algemeen verpleegkundige in een ziekenhuis kun je rekenen op een aanvangssalaris van €1.640. Je kunt doorgroeien tot maximaal €2.507. Ben je gespecialiseerd verpleegkundige, dan verdien je vanzelfsprekend meer. Het maandsalaris van bijvoorbeeld een geriatrisch verpleegkundige (gespecialiseerd in de zorg voor ouderen) begint bij €1.925, en kan oplopen tot maximaal €3.165. Bovendien krijg je als verpleegkundige toeslagen voor eventueel overwerk en onregelmatige diensten (Bron: CAO Ziekenhuiswezen, 2004 – 2005).

Werk je met gehandicapten, psychiatrisch patiënten of in een ander werkveld, dan is je inkomen afhankelijk van de daar geldende CAO. Een wijkverpleegkundige die bijvoorbeeld in dienst is bij de Thuiszorg verdient minimaal €1.885, met een doorgroei tot ongeveer €2.625 (Bron: CAO Thuiszorg, 2004).
Medische tijgerWat zijn je carrièremogelijkheden?

Veel verpleegkundigen beginnen met een functie in een zorginstelling. Een aantal van hen kiest ervoor om zich – meteen na hun studie of later in de loopbaan – te specialiseren. Na de opleiding Verpleegkunde kun je terecht bij een groot aantal vervolgopleidingen, bijvoorbeeld de opleiding tot ambulanceverpleegkundige, Intensive Care-verpleegkundige, kinderverpleegkundige of arbo-verpleegkundige (bedrijfsverpleegkundige).

Wil je manager worden, dan zijn er twee mogelijkheden. Enerzijds de langzame route: je volgt naast je baan korte cursussen of een deeltijdopleiding (bijvoorbeeld de Kaderopleiding Verpleegkunde, waar echter wel een aantal jaar ervaring voor vereist is), waardoor je na verloop van tijd intern kunt solliciteren naar een leidinggevende functie als bijvoorbeeld Hoofdverpleegkundige, praktijkopleider of coördinator. Anderzijds is er de snelle route: je doet een universitaire masteropleiding als Beleid, Management en Gezondheidszorg (BMG) of Gezondheidswetenschappen. Deze studies leiden je op voor leidinggevende functies binnen de zorg, maar je kunt er bijvoorbeeld ook mee aan de slag in ministeries, het onderwijs (als docent Verpleegkunde) of op de afdeling Personeelszaken van een zorginstelling.

Een andere carrièremogelijkheid voor verpleegkundigen is kiezen voor het zelfstandig ondernemerschap. Je laat je dan inhuren door bijvoorbeeld particulieren, die afgestemde zorg nodig hebben in hun thuissituatie. Voordat je je als zelfstandige kunt vestigen, moet je wel eerst een aanvullend programma bij de Kamer van Koophandel volgen om je eigen onderneming te mogen starten.
Welke beroepen lijken erop?

* Anesthesiemedewerker
* Longfunctie-assistent
* Operatie-assistent
* Verloskundige
* Verzorgende

Aanbevolen websites

* Met de Verpleegkundige Loopbaandiagnose kun je kijken wat voor verpleegkundige je bent. Geef je graag leiding, zoek je vooral balans of werk je het liefst zelfstandig?
* Erg interessant is YouChooz.nl, een website met allerlei wetenswaardigheden over beroepen en opleidingen in de gezondheidszorg. Op deze pagina vind je ook uitgebreide informatie over alle vervolgopleidingen en carrièremogelijkheden in de zorgsector. Je kunt via de site eveneens in contact komen met studenten, docenten en verpleegkundigen.
* Op Nursing, de digitale versie van het landelijke vakblad, vind je het laatste nieuws, evenementen en dossiers (waaronder 'Agressie in de zorg') uit de gezondheidszorg. Je kunt je ook abonneren op de Nursing Nieuwsbrief.
* Verplegingenverzorging.nl biedt nieuws en themadossiers over onder andere opleidingen en beroepen in de zorg. Verder kun je onder meer een kennisdatabank raadplegen, waarin honderden scripties, onderzoeksresultaten, afstudeerprojecten, artikelen en andere documenten op het gebied van de gezondheidszorg te vinden zijn.
* Zorgportaal is een verzamelpunt voor vacatures, nieuws, een forum, agenda en andere interessante zorgonderwerpen.
* Op Verpleging Online vind je heel veel links, een vacaturebank en de CAO voor verpleegkundigen. Verder kun je via de discussiepagina in contact komen met collega's, reageren op vragen en meningen en zelf iets ter discussie stellen.
* Ook Ziekenhuis.nl biedt je links, een forum en een vacaturebank. Bovendien vind je er een medicijngids, medisch woordenboek, beschrijvingen van ziektebeelden en informatieve filmpjes.

Aanbevolen boeken

* Huilen mag (De Bruin, S., Gerrese, M. en Pollmann, J., Verpleegkunde Nieuws, 2003) bundelt achttien verhalen van verpleegkundigen over hun ervaringen met leven en dood in hun werk, aangevuld met het verhaal van een patiënte die te horen kreeg dat ze zou gaan sterven.
* In De verpleegkundige als patiënt (Odekerken, S., Bohn Stafleu van Loghum, 2004) lees je hoe een aantal verpleegkundigen 'het patiënt zijn' ervaart. Dit is een interessante invalshoek, want hoewel er in de opleiding volop aandacht wordt besteed aan empathie en patiëntgerichte competenties, krijg je pas echt inzicht als je het in de praktijk zelf meemaakt. De verhalen in dit boek zorgen ervoor dat je je als verpleegkundige in de situatie van de patiënt kunt verplaatsen. Bovendien stimuleren ze je om je werk door de ogen van de patiënt te bekijken.
* Het boek Onzichtbare zwaarte van zorg: verpleegkundigen en verzorgenden aan het woord (Bruntink, R. en Cremers, A., Elsevier Gezondheidszorg, 2005) laat twaalf verpleegkundigen en verzorgenden vertellen over hun vak. Ze zijn afkomstig uit verschillende werkvelden, en worden met situaties geconfronteerd waarvan de moeilijkheidsgraad door buitenstaanders vaak behoorlijk onderschat wordt.

Auteur: Vera van Dijk

Alzheimer's disease

2009-10-23T13:23:00.000-07:00

Definition

Alzheimer's disease is the most common cause of dementia — the loss of intellectual and social abilities severe enough to interfere with daily functioning. In Alzheimer's disease, healthy brain tissue degenerates, causing a steady decline in memory and mental abilities.

Alzheimer's disease is not a part of normal aging, but the risk of the disorder increases with age. About 5 percent of people between the ages of 65 and 74 have Alzheimer's disease, while nearly half the people over the age of 85 have Alzheimer's.

Although there's no cure, treatments may improve the quality of life for people with Alzheimer's disease. Those with Alzheimer's — as well as those who care for them — need support and affection from friends and family to cope.

Symptoms

Alzheimer's disease may start with slight memory loss and confusion, but it eventually leads to irreversible mental impairment that destroys a person's ability to remember, reason, learn and imagine.

Memory loss

Everyone has occasional lapses in memory. It's normal to forget where you put your car keys or to blank on the names of people whom you rarely see. But the memory problems associated with Alzheimer's disease persist and worsen. People with Alzheimer's may:

* Repeat things
* Often forget conversations or appointments
* Routinely misplace things, often putting them in illogical locations
* Eventually forget the names of family members and everyday objects

Problems with abstract thinking

People with Alzheimer's may initially have trouble balancing their checkbook, a problem that progresses to trouble recognizing and dealing with numbers.

Difficulty finding the right word

It may be a challenge for those with Alzheimer's to find the right words to express thoughts or even follow conversations. Eventually, reading and writing also are affected.

Disorientation

People with Alzheimer's disease often lose their sense of time and dates, and may find themselves lost in familiar surroundings.

Loss of judgment

Solving everyday problems, such as knowing what to do if food on the stove is burning, becomes increasingly difficult, eventually impossible. Alzheimer's is characterized by greater difficulty in doing things that require planning, decision making and judgment.

Difficulty performing familiar tasks
Once-routine tasks that require sequential steps, such as cooking, become a struggle as the disease progresses. Eventually, people with advanced Alzheimer's may forget how to do even the most basic things.

Personality changes

People with Alzheimer's may exhibit:

* Mood swings
* Distrust in others
* Increased stubbornness
* Social withdrawal
* Depression
* Anxiety
* Aggressiveness

Causes

No one factor appears to cause Alzheimer's disease. Instead, scientists believe that it may take a combination of genetic, lifestyle and environmental factors to trigger the onset of symptoms. While the causes of Alzheimer's are poorly understood, its effect on brain tissue is clear. Alzheimer's disease damages and kills brain cells.

Two types of brain cell (neuron) damage are common in people who have Alzheimer's:

* Plaques. Clumps of a normally harmless protein called beta-amyloid may interfere with communication between brain cells. Although the ultimate cause of neuron death in Alzheimer's isn't known, mounting evidence suggests that the abnormal processing of beta-amyloid protein may be the culprit.
* Tangles. The internal support structure for brain cells depends on the normal functioning of a protein called tau. In people with Alzheimer's, threads of tau protein undergo alterations that cause them to become twisted. Many researchers believe this may seriously damage neurons, causing them to die.

Risk factors

Age

Alzheimer's usually affects people older than 65, but can, rarely, affect those younger than 40. Less than 5 percent of people between 65 and 74 have Alzheimer's. For people 85 and older, that number jumps to nearly 50 percent.

Heredity

Your risk of developing Alzheimer's appears to be slightly higher if a first-degree relative — parent, sister or brother — has the disease. Although the genetic mechanisms of Alzheimer's among families remain largely unexplained, researchers have identified several genetic mutations that greatly increase risk in some families.

Sex

Women are more likely than men are to develop the disease, in part because they live longer.

Mild cognitive impairment

People who have mild cognitive impairment have memory problems that are worse than what might be expected for people of their age, yet not bad enough to be classified as dementia. Many of those who have this condition go on to develop Alzheimer's disease.

Lifestyle

The same factors that put you at risk of heart disease may also increase the likelihood that you'll develop Alzheimer's disease. Examples include:

* High blood pressure
* High cholesterol
* Poorly controlled diabetes

And keeping your body fit isn't your only concern — you've got to exercise your mind as well. Some studies have suggested that remaining mentally active throughout your life, especially in your later years, reduces the risk of Alzheimer's disease.

Education levels

Studies have found an association between less education and the risk of Alzheimer's. But the precise reason why this occurs is unknown. Some researchers theorize that the more you use your brain, the more synapses you create, which provides a greater reserve as you age. But it may simply be harder to detect Alzheimer's in people who exercise their minds frequently or who have more education.

Complications

In advanced Alzheimer's disease, people may lose all ability to care for themselves. This can make them more prone to additional health problems such as:

* Pneumonia. Difficulty swallowing food and liquids may cause people with Alzheimer's to inhale (aspirate) some of what they eat and drink into their airways and lungs, which can lead to pneumonia.
* Infections. Urinary incontinence may require the placement of a urinary catheter, which increases the risk of urinary tract infections. Untreated urinary tract infections can lead to more-serious, life-threatening infections.
* Injuries from falls. People with Alzheimer's may become disoriented, increasing their risk of falls. Falls can lead to fractures. In addition, falls are a common cause of serious head injuries, such as bleeding in the brain.

Tests and diagnosis

Doctors can accurately diagnose 90 percent of Alzheimer's cases. Alzheimer's disease can be diagnosed with complete accuracy only after death, when microscopic examination of the brain reveals plaques and tangles.

To help distinguish Alzheimer's disease from other causes of memory loss, doctors typically rely on the following types of tests.

Lab tests
Blood tests may be done to help doctors rule out other potential causes of the dementia, such as thyroid disorders or vitamin deficiencies.

Neuropsychological testing
Sometimes doctors undertake a more extensive assessment of thinking and memory skills. This type of testing, which can take several hours to complete, is especially helpful in trying to detect Alzheimer's and other dementias at an early stage.

Brain scans
By looking at images of the brain, doctors may be able to pinpoint any visible abnormalities — such as clots, bleeding or tumors — that may be causing signs and symptoms. Positron emission tomography (PET) can reveal areas of the brain that may be less active and the density of amyloid plaques.

* Magnetic resonance imaging (MRI). An MRI machine uses radio waves and a strong magnetic field to produce detailed images of your brain. You lie on a narrow table that slides into the tube-shaped MRI machine, which makes loud banging noises during scans. The entire procedure can take an hour or more. MRIs are painless, but some people feel claustrophobic in the machine.
* Computerized tomography (CT). For a CT scan, you lie on a narrow table that slides into a small chamber. X-rays pass through your body from various angles, and a computer uses this information to create cross-sectional images, or slices, of your brain. The test is painless and takes about 20 minutes.
* Positron emission tomography (PET). During a PET scan, you'll be injected with a low-level radioactive material, which binds to chemicals that travel to the brain. You lie on a table while an overhead scanner tracks the radioactive material. This helps show which parts of your brain aren't functioning properly. The test is painless and can be particularly useful in distinguishing between different types of dementia.

Treatments and drugs

Currently, there's no cure for Alzheimer's disease. Doctors sometimes prescribe drugs to improve signs and symptoms that often accompany Alzheimer's, including sleeplessness, wandering, anxiety, agitation and depression. But only two varieties of medications have been proved to slow the cognitive decline associated with Alzheimer's.

Cholinesterase inhibitors
This group of medications — which includes donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) — works by improving the levels of neurotransmitters in the brain. But cholinesterase inhibitors don't work for everyone. As many as half the people who take these drugs show no improvement. Other people may choose to stop taking the drugs because of the side effects, which include diarrhea, nausea and vomiting.

Memantine (Namenda)
The first drug approved to treat moderate to severe stages of Alzheimer's, memantine protects brain cells from damage caused by the chemical messenger glutamate. It sometimes is used in combination with a cholinesterase inhibitor. Memantine's most common side effect is dizziness, although it also appears to increase agitation and delusional behavior in some people.

Lifestyle and home remedies

A healthy lifestyle may help prevent or postpone the development of Alzheimer's disease. Because Alzheimer's is most common in people over the age of 80, delaying the onset of the disease would increase the probability that people will die of other causes before Alzheimer's has a chance to develop.

Eat your veggies
Maintaining a healthy weight and eating a healthy diet appears to reduce the risk of developing Alzheimer's disease. Your doctor may suggest:

* Lots of fruits and vegetables
* Fish or poultry, instead of red meat
* Whole-grain breads and cereals
* Alternate sources of proteins, such as beans, nuts and seeds
* More olive oil and less saturated fat

Exercise your body
Higher levels of physical activity have been associated with a lower incidence of Alzheimer's disease.

Exercise your brain, too
Maintaining mental fitness may delay onset of dementia. Some researchers believe that lifelong mental exercise and learning may promote the growth of additional synapses, the connections between neurons, and delay the onset of dementia.

Carry a reminder calendar.
Record not just upcoming events, but things that happen and activities you need to complete on a daily basis. And check off those activities when done. If you can make this process a habit before your memory problems worsen, you'll be more likely to retain this skill as the disease progresses. If you can't remember if you took your pills or who called that morning, you can check your journal.

Alternative medicine

Vitamin E
Some studies have shown that vitamin E can slow the progression of Alzheimer's disease, while other studies have shown no benefit. Doctors now warn people against taking large dosages of vitamin E, because it can increase your risk of cardiovascular death.

Ginkgo
Some people believe that extracts from the leaves of the ginkgo biloba tree may help slow the progression of memory problems associated with Alzheimer's disease. But a recent large-scale study showed no benefit. Be aware that these preparations can interact with blood-thinning medications and cause bleeding.

Huperzine A
Made from Chinese club moss, Huperzine A appears to work in ways similar to prescription cholinesterase inhibitors. Because of the increased risk of toxic side effects, you shouldn't take Huperzine A if you're also taking a drug like donepezil (Aricept).

Coping and support

People with Alzheimer's disease often experience a mixture of emotions — confusion, frustration, anger, fear, uncertainty, grief and depression.

You can help a person cope with the disease by being there to listen, reassuring the person that life can still be enjoyed, providing unconditional love, and doing your best to help the person retain dignity and self-respect.

A calm and stable home environment reduces behavior problems. New situations, noise, large groups of people, being rushed or pressed to remember, or being asked to do complicated tasks can cause anxiety. As a person with Alzheimer's becomes upset, the ability to think clearly declines even more.

Caring for the caregiver
Providing care for a person with Alzheimer's disease is physically and emotionally demanding. Feelings of anger and guilt, frustration and discouragement, worry and grief, and social isolation are common. If you're a caregiver for someone with Alzheimer's disease, you can help yourself by:

* Asking friends or other family members for help when you need it
* Taking care of your health
* Learning as much about the disease as you can
* Asking questions of doctors, social workers and others involved in the care of your loved one
* Joining a support group

Many people with Alzheimer's and their families benefit from counseling or local support groups. Contact your local Alzheimer's Association affiliate to get connected with support groups, doctors, resources and referrals, home care agencies, supervised living facilities, a telephone help line, and educational seminars.

Prevention

Right now, there's no proven way to prevent the onset of Alzheimer's disease. Human trials of a promising vaccine against Alzheimer's had to be stopped several years ago because some of the people who received the vaccine developed a serious inflammation of the brain.

However, you may be able to reduce your risk of Alzheimer's disease by reducing your risk of heart disease. Many of the same factors that increase your risk of heart disease can also increase your risk of dementia. The main players appear to be blood pressure, cholesterol and blood glucose levels.

Keeping active — physically, mentally and socially — also seems to reduce the risk of Alzheimer's disease.

Geriatrische fysiotherapie

2009-10-22T22:07:00.000-07:00

Waarom deze specialisatie?

Het aantal ouderen neemt toe. Uit cijfers van het CBS blijkt dat het aantal 65-plussers in 1990 bijna 2 miljoen bedroeg. Er wordt geschat dat dit aantal in 2020 ca. 4 miljoen zal bedragen. Het aantal ouderen neemt percentagegewijs het sterkste toe. De verwachting is dat het aantal ouderen tot voorbij 2050 zal stijgen. Daarbij blijkt dat de provincie Noord-Brabant tweemaal zo sterk vergrijst als de rest van Nederland.

Binnen de beroepsvereniging voor fysiotherapie zag men de noodzaak in om hiertoe een groep collega’s aanvullend te scholen. Deze post HBO-opleiding kwam tot stand in samenwerking met het Nederlands Paramedisch Instituut (NPi) en het Centrum voor Niet Aangeboren Hersenletsel (NAH). Vanuit onze groepspraktijk nemen we hieraan deel in de persoon van collega C.A. van Leent.

Wat is geriatrische fysiotherapie?

Veroudering is een normaal multi-dimensionaal ontwikkelingsproces (oa. fysiologisch, psychologisch en emotioneel). Het aantal beperkingen en stoornissen ten gevolge van leeftijdsgerelateerde veranderingen neemt met de jaren toe. Meer dan 20% van de mensen boven de 65 geeft aan problemen met mobiliteit en functionaliteit te hebben. De overige 80% verdient evenwel zeker zoveel aandacht en biedt een uitdaging aan de preventieve gezondheidszorg. De belangrijkste oorzaak van versnelde veranderingen in het bewegingsapparaat bij ouderen is voortdurend verminderde lichamelijke activiteit, een te rustige levensstijl. Dit leidt tot adaptatie: een complex aan veranderingsprocessen waardoor de functie zo optimaal mogelijk blijft.

Kennis van adaptatieprocessen van biologische regelsystemen is onontbeerlijk om in te kunnen schatten of door het toedienen van prikkels de regelsystemen tot optimalisering van de aanpassingen kunnen worden gestimuleerd. De ouder wordende mens zal, door gezondheidsvoorlichting en begeleiding van functieherstel en functiebehoud, ondersteuning moeten krijgen, zodat hij een betekenisvol zelfstandig leven zal kunnen leiden. Daarmee levert hij indirect een bijdrage aan de betaalbaarheid van het zorgsysteem.

De fysiotherapeut is de meest voor de hand liggende deskundige om het functiebehoud en het functieherstel van ouderen te begeleiden. Fysiotherapeuten houden mensen in beweging.

De blik van de fysiotherapeut moet echter verder reiken dan spieren, kapsels banden en gewrichten. Oorzaken van hypokinesie kunnen namelijk gelegen zijn in motorische, maar ook in psychologische en sociaal-maatschappelijke factoren. Slechts constateren dat de motorische uitvoering is gestoord geeft onvoldoende informatie over de oorzaken van de gestoorde activiteit Deze oorzaken kunnen gelegen zijn op bv. existentieniveau, cognitief niveau, planningsniveau, uitvoeringsniveau of energievoorzieningniveau. Het fysiotherapeutisch onderzoek zal daarop moeten worden aangepast met specifieke meetinstrumenten.

Ouderen zijn 55-plussers

De volgende indeling wordt gebruikt:
* 55 –65 jaar: de senior; staat nog volop in het leven.
* 65 –75 jaar: de jongere oudere; heeft een actief bestaan: de actieve recreant.
* 75 –85 jaar: de oude oudere.
* 85 –plusser: deze zeer oude oudere; de kans op verminderde activiteit en afhankelijkheid is vergroot.

Het mag duidelijk zijn dat de ouder wordende mens centraal staat met zijn functionele mogelijkheden en onmogelijkheden (op beperkings- en participatieniveau).

Het benutten van mogelijkheden staat voorop: Positief denken ! Preventie !

In het kader van de gewijzigde fysieke en psychische belastbaarheid van ouderen vereisen behandeling en begeleiding specifieke deskundigheid, vaardigheid en attitude van de fysiotherapeut. De taak van de fysiotherapeut in de geriatrie bestrijkt alle geledingen binnen de gezondheidszorg: ziekenhuis, verpleeghuis, verzorgingshuis en thuissituatie, aanleunwoning. Bij de thuiswonende oudere wordt niet alleen gedacht aan thuiszorg, maar aan alle fysiotherapeutische zorg rondom een oudere die thuis woont. Dit kan dus ook dagbehandeling in een verpleeghuis betreffen of MBVO (= meer bewegen voor ouderen).

Uitgangspunt voor deze specialisatie vormt een “holistische sociaal model of management” en niet zozeer het medisch behandelmodel waarbij de nadruk ligt op stoornisniveau. Binnen dit model zijn belangrijk:
* Community-based health promotion.
* Preventie.
* Revalidatie.
* Multi-disciplinaire samenwerking

Naast de technische zijde van werkzaamheden wordt de nadruk gelegd op educatieaspecten. De geriatrisch fysiotherapeut probeert het gedrag van de mensen te beïnvloeden.

Verder wordt er aandacht besteed aan effectonderzoek en beleidsontwikkeling binnen de zorg voor ouderen en de preventieve gezondheidszorg. De geriatrisch fysiotherapeut vervult een voorhoedefunctie binnen het wetenschappelijk onderzoek naar veroudering. Doel van dit onderzoek is het voorkomen dat mensen met het stijgen der jaren beperkingen ontwikkelen. Met behulp van goede meetinstrumenten dienen deze multifactoriële oorzaken van het verminderd aanpassingsvermogen in kaart te worden gebracht.

CANISIUS WILHELMINA ZIEKENHUIS

2009-10-22T21:51:00.000-07:00

653 bedden

Het CWZ is een modern, algemeen ziekenhuis voor de regio met 653 bedden en 28 medisch specialismen. Er werken bijna 4000 medewerkers en vele vrijwilligers die hun werk met hoofd en handen doen, met hart en ziel.

Topklinisch ziekenhuis

Het CWZ is ook één van de 26 topklinische opleidings-ziekenhuizen in Nederland. Dit betekent dat het ziekenhuis topklinische voorzieningen heeft: veelal dure medische technieken die niet elk ziekenhuis aanbiedt. Het CWZ heeft drie topklinische functies: neurochirurgie, PCI (dotteren met het plaatsen van een stent) en ICD (Implanteerbare Cardio Defribrillator). Daarnaast loopt het CWZ in Nederland voorop op het gebied van onder meer kinderdiabetes, grote vaatchirurgie, traanwegchirurgie en kijkbuischirurgie.

Opleidingsziekenhuis

Het hoge niveau van deze kennis en kunde is te danken aan de opleidingsstatus van het CWZ. De opleiding van vele professionals per jaar houdt het ziekenhuis alert. En maakt dat de medische en verpleegkundige zorg elke dag beter wordt.
Het CWZ is het vierde opleidingsziekenhuis van Nederland.

CEREBRAL PALSY

2009-10-22T21:17:00.000-07:00

Have you ever heard a family member talk about your first step or the first word you spoke? For kids with cerebral palsy, called CP for short, taking a first step or saying a first word is not as easy. That's because CP is a condition that can affect the things that kids do every day.

What's CP?

Some kids with CP use wheelchairs and others walk with the help of crutches or braces. In some cases, a kid's speech may be affected or the person might not be able to speak at all.

Cerebral palsy (say: seh-ree-brel pawl-zee) is a condition that affects thousands of babies and children each year. It is not contagious, which means you can't catch it from anyone who has it. The word cerebral means having to do with the brain. The word palsy means a weakness or problem in the way a person moves or positions his or her body.

A kid with CP has trouble controlling the muscles of the body. Normally, the brain tells the rest of the body exactly what to do and when to do it. But because CP affects the brain, depending on what part of the brain is affected, a kid might not be able to walk, talk, eat, or play the way most kids do.
Types of CP

There are three types of cerebral palsy: spastic (say: spass-tick), athetoid (say: ath-uh-toid), and ataxic (say: ay-tak-sick). The most common type of CP is spastic. A kid with spastic CP can't relax his or her muscles or the muscles may be stiff.

Athetoid CP affects a kid's ability to control the muscles of the body. This means that the arms or legs that are affected by athetoid CP may flutter and move suddenly. A kid with ataxic CP has problems with balance and coordination.

A kid with CP can have a mild case or a more severe case — it really depends on how much of the brain is affected and which parts of the body that section of the brain controls. If both arms and both legs are affected, a kid might need to use a wheelchair. If only the legs are affected, a kid might walk in an unsteady way or have to wear braces or use crutches. If the part of the brain that controls speech is affected, a kid with CP might have trouble talking clearly. Another kid with CP might not be able to speak at all.

For some babies, injuries to the brain during pregnancy or soon after birth may cause CP. Children most at risk of developing CP are small, premature babies (babies who are born many weeks before they were supposed to be born) and babies who need to be on a ventilator (a machine to help with breathing) for several weeks or longer. But for most kids with CP, the problem in the brain occurs before birth. Often, doctors don't know why.
What Do Doctors Do?

Doctors who specialize in treating kids with problems of the brain, nerves, or muscles are usually involved in diagnosing a kid with cerebral palsy. These specialists could include a pediatric neurologist (say: nyoo-ral-uh-jist), a doctor who deals with problems of the nervous system and brain in kids.

Three other kinds of doctors who can help kids with CP include a pediatric orthopedist (say: or-tho-pee-dist), who handles problems with bones or joints, a developmental pediatrician, who looks at how a kid is growing or developing compared with other kids the same age, and a pediatric physiatrist, who helps treat children with disabilities of many kinds.

There is no special test to figure out if a kid has cerebral palsy. Doctors may order X-rays and blood tests to find out if some other disease of the brain and nervous system may be causing the problem. To diagnose CP, doctors usually wait to see how a kid develops to be sure.

A case of cerebral palsy often can be diagnosed by the age of 18 months. For example, if a child does not sit up or walk by the time most kids should be doing these things, the kid might have CP or some other problem that is causing development to go more slowly. Doctors follow infant and child development closely and look for problems with muscle tone and strength, movement, and reflexes.
How Is CP Treated?

For a kid with CP, the problem with the brain will not get any worse as the kid gets older. For example, a kid who has CP that affects only the legs will not develop CP in the arms or problems with speech later on. The effect of CP on the arms or legs can get worse, however, and some kids may develop dislocated hips (when the bones that meet at the hips move out of their normal position) or scoliosis (curvature of the spine).

That is why therapy is so important. Kids with CP usually have physical, occupational, or speech therapy to help them develop skills like walking, sitting, swallowing, and using their hands. There are also medications to treat the seizures that some kids with CP have. Some medications can help relax the muscles in kids with spastic CP. And some kids with CP may have special surgeries to keep their arms or legs straighter and more flexible.
Living With CP

Cerebral palsy usually doesn't stop kids from going to school, making friends, or doing things they enjoy. But they may have to do these things a little differently or they may need some help. With computers to help them communicate and wheelchairs to help them get around, kids with CP often can do a lot of stuff that kids without CP can do.

Kids with cerebral palsy are just like other kids, but with some greater challenges that make it harder to do everyday things. More than anything else, they want to fit in and be liked.

Be patient if you know someone or meet someone with CP. If you can't understand what a person with CP is saying or if it takes a person with CP longer to do things, give him or her extra time to speak or move. Being understanding is what being a good friend is all about, and a kid with CP will really appreciate it.

Reviewed by: Steven J. Bachrach, MD

Multiple Sclerosis: Intrathecal Baclofen Pump

2009-09-22T20:03:00.000-07:00

http://www.medicinenet.com

Baclofen is a medication commonly used to decrease spasticity related to multiple sclerosis, spinal cord injuries, or other neurological diseases. Spasticity is a muscle problem characterized by tight or stiff muscles that may interfere with voluntary muscle movements.

How Does Baclofen Work?

Normally muscles receive electrical signals via nerves to contract and relax. Spasticity is caused by an imbalance of electrical signals coming from the spinal cord through the nerves to the muscle. This imbalance causes the muscle to become hyperactive, resulting in involuntary spasms. Baclofen works by restoring the normal balance and reducing muscle hyperactivity. In this way, it allows for more normal muscle movement

What Are the Side Effects of Baclofen Therapy?

Side effects may include:

* dizziness
* Drowsiness
* Headaches
* Nausea
* Weakness

What Is Intrathecal Baclofen?

Baclofen can be taken orally as a pill or delivered directly into an area of the spine called the intrathecal space. The intrathecal space contains the cerebrospinal fluid -- the fluid surrounding the spinal cord and nerve roots. Often MS patients receive intrathecal Baclofen because oral Baclofen causes unpleasant side effects, such as confusion, weakness, and sleepiness. But intrathecal Baclofen delivers the drug right to the target site in the spinal cord. Since the medication does not circulate throughout the body, only tiny doses are required to be effective. Therefore, side effects are minimal.

What Is the Intrathecal Baclofen Pump System?

The intrathecal Baclofen pump system is the way doctors give the drug directly into the spinal fluid. The system consists of a catheter (a small, flexible tube) and a pump. The pump -- a round metal disc, about one inch thick and three inches in diameter -- is surgically placed under the skin of the abdomen near the waistline.

The pump stores and releases prescribed amounts of medicine through the catheter. The pump is refilled by inserting a needle through the skin into a filling port in the center of the pump. With a programmable pump, a tiny motor moves the medication from the pump reservoir through the catheter. Using an external programmer, your treatment team can make adjustments in the dose, rate, and timing of the medication.

People with the pump must return to their doctor's office for pump refills and medication adjustments, typically every 2-3 months. The pump is taken out and replaced at the end of the battery's life span (which is usually 5 to 7 years).

Who Is a Candidate for the Intrathecal Baclofen Pump?

Anyone who has spasticity that is not responsive to oral treatment is a candidate.

If you are considering intrathecal Baclofen therapy, you will generally meet with a treatment team that may include a doctor specialized in rehabilitation (physiatrist), a physical therapist , an occupational therapist , a nurse, and a social worker. All of these professionals work as a team to provide a comprehensive evaluation of your spasticity symptoms and to establish a treatment plan adapted to your personal needs.

What Are the Advantages of the Baclofen Pump System?

The Baclofen pump system:

* Efficiently reduces spasticity and involuntary spasms, promoting a more active lifestyle, better sleep, and reduced need for oral medications.
* Continuously delivers Baclofen in small doses directly to the spinal fluid, increasing the therapeutic benefits and causing fewer and less severe side effects than the oral medication.
* Can be individually adjusted to allow infusion rates that vary over a 24-hour period.
* Can be turned off when it isn't needed.
* Reduces or eliminates pain and discomfort from spasms and spasticity.

What Are the Disadvantages of the Baclofen Pump System?

There are certain risks that must be considered with any surgery. Risks include:

* An adverse reaction to anesthesia
* Infection
* Bleeding
* Bladder control can be altered, causing loss of urine unexpectedly
* Pump malfunction: If the pump malfunctions, it may deliver too much medicine at once. In that instance, you will develop symptoms such as drowsiness, dizziness, weakness, insomnia (difficulty falling and/or staying asleep), lightheadedness, nausea, constipation, vomiting, loose muscles, trouble with vision, coma, respiratory depression, seizures, dry mouth, double vision, decreased concentration, diarrhea, or delayed responsiveness. Should this occur, go to the nearest Emergency Department immediately. A doctor can give you a drug called Physostigmine to counteract Baclofen.
* Kinked catheter: If the catheter becomes "kinked," surgery may be necessary to replace the catheter.

How Will My Doctor Know If the Baclofen Pump System Is Right for Me?

If your treatment team recommends the Baclofen pump system after your evaluation, you will have a trial of the therapy to test the potential effectiveness of the medication.

During the medication trial, Baclofen is injected into the spinal canal (using a small needle) and the treatment team assesses its effectiveness over 2-4 hours. If your muscles don't relax during the first trial, a larger dose may be given on a later date to determine its effectiveness.

If you experience positive results with the intrathecal medication you can decide with your doctor and family members if you should have a Baclofen pump system implanted during a surgical procedure.

What Happens After the Procedure?

After the implantation procedure, you will stay in the hospital a few days so your recovery can be closely monitored. While you are in the hospital, the dose of Baclofen will be adjusted.

Clexane (enoxaparin)

2009-09-22T19:56:00.000-07:00

Main use
Preventing blood clots

Active ingredient
Enoxaparin sodium

How does it work?

Clexane injection contains the active ingredient enoxaparin, which is a type of medicine called a low molecular weight heparin. It is used to stop blood clots forming within the blood vessels.

Blood clots normally only form to stop bleeding that has occurred as a result of injury to the tissues. The clotting process is complicated and begins when blood cells called platelets clump together and produce chemicals that activate the clotting process. The final part of this process involves a substance called thrombin being activated to produce a protein called fibrin. Fibrin binds the platelets together, forming a blood clot. This is the body’s natural way of repairing itself.

Sometimes, however, a blood clot can form abnormally within the blood vessels. This is known as a thrombus. It can be dangerous because the clot may detach and travel in the bloodstream, where it becomes known as an embolus. The embolus may eventually get lodged in a blood vessel, thereby blocking the blood supply to a vital organ such as the heart, brain or lungs. This is known as a thromboembolism.

Some people have an increased tendency for blood clots to form within the blood vessels. This is usually due to a disturbance in the blood flow within the blood vessels. For example, in coronary artery disease, fatty deposits (atherosclerosis) on the walls of the coronary arteries can disrupt the blood flow, giving a tendency for platelets to clump together and start off the clotting process. When a clot has formed in a coronary artery this reduces the flow of blood to the heart and causes chest pain (angina). It can also result in a heart attack.

Slow blood flow in the leg and pelvic veins can also result in clots forming in these veins (deep vein thrombosis). These clots can break off and travel to the lungs (pulmonary embolism). Being immobile for long periods of time, for example due to a severe medical condition or following surgery, can increase the risk of these types of blood clot.

Enoxaparin is used to prevent and treat these types of abnormal blood clots. It works by inactivating thrombin in the clotting process described above. This stops the formation of fibrin, the essential component of blood clots. The medicine is administered by injection under the skin (subcutaneous injection).

Enoxaparin can also be used to prevent blood clotting when it is filtered through a kidney dialysis machine.
What is it used for?

* Treatment of blood clots in the veins of the leg (deep vein thrombosis).
* Treatment of blood clots that travel to the lungs (pulmonary embolism).
* Preventing these types of blood clots (thromboembolic disorders), particularly following general surgery or surgery on the bones (orthopaedic surgery), or in people bedridden due to illness.
* Treating blood clots in the coronary arteries in unstable angina and heart attack (myocardial infarction).
* Preventing blood from clotting when it is filtered through an 'artificial kidney' (haemodialysis) machine as part of the management of kidney failure.

Warning!

* During treatment with this medicine you should have regular blood tests to monitor the numbers of blood cells called platelets in your blood.
* Your doctor may also want to monitor the level of potassium in your blood while you are having this medicine, particularly if treatment lasts for longer than 7 days.

Use with caution in

* People over 80 years of age.
* People who are underweight or overweight.
* Decreased kidney function.
* Chronic kidney failure.
* Decreased liver function.
* People who have previously developed a reduced platelet count in the blood due to treatment with heparin or low molecular weight heparin (heparin-associated thrombocytopenia).
* People with problems stopping bleeding.
* History of peptic ulcer.
* Recent stroke caused by a blood clot in the brain (ischaemic stroke).
* Severe uncontrolled high blood pressure (hypertension).
* Diabetes.
* Diabetes affecting the eyes (diabetic retinopathy).
* People who have recently had eye surgery.
* People who have recently had surgery on the brain or spinal cord (neurosurgery).
* People having spinal or epidural anaesthesia.
* High level of potassium in the blood (hyperkalaemia).
* Increase in the acidity of the blood (metabolic acidosis).

Not to be used in

* Allergy to heparin or other low molecular weight heparins.
* Bacterial infection of the heart valves and the lining surrounding the heart (bacterial endocarditis).
* Active major bleeding.
* Conditions with a high risk of uncontrolled bleeding, for example the blood clotting disorder haemophilia, or the conditions listed below.
* Active peptic ulcer.
* Recent stroke caused by bleeding in the brain (haemorrhagic stroke).
* Reduced platelet count in the blood (thrombocytopenia).
* This medicine is not recommended for use in children.

This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.
Pregnancy and breastfeeding

Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.

* The safety of this medicine for use during pregnancy has not been established. It is not recommended for use in pregnancy unless considered essential by your doctor. It is not recommended for preventing blood clots in pregnant women with artificial heart valves. Seek medical advice from your doctor.
* It is not known if this medicine passes into breast milk. Mothers who need treatment with this medicine should avoid breastfeeding their infants during the treatment. Seek further medical advice from your doctor.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

* Bleeding.
* Pain and irritation at the injection site.
* Blood clots which form a solid swelling at the injection site (haematoma).
* Decrease in the number of platelets in the blood (thrombocytopenia).
* Major bleeding (haemorrhage), for example in the abdomen or inside the skull.
* Alteration in results of liver function tests.
* High blood potassium level (hyperkalaemia).
* Death of skin cells (necrosis) at the site of injection.
* Blood clots in the spinal cord (intraspinal haematoma) in people also having spinal or epidural anaesthesia.
* Osteoporosis (a reduction in bone density leading to bones which may fracture easily) has occurred after long-term treatment with a similar medicine called heparin. It is possible that this could happen with Clexane.

The side effects listed above may not include all of the side effects reported by the drug's manufacturer.For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.
How can this medicine affect other medicines?

It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with this medicine. Similarly, check with your doctor or pharmacist before taking any new medicines while having treatment with this one, to ensure that the combination is safe.

There may be an increased risk of bleeding or increased time taken to stop bleeding, if this medicine is used in combination with medicines that affect blood clotting, such as the following:

* antiplatelet ('blood-thinning') medicines, such as aspirin, dipyridamole, clopidogrel
* clot-busting medicines (fibrinolytics) such as streptokinase, alteplase
* non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac, naproxen
* oral anticoagulants, such as warfarin, nicoumalone, phenindione.

There may be an increased risk of a rise in the amount of potassium in your blood if this medicine is used in combination with any of the following:

* ACE inhibitors, eg captopril, lisinopril
* ciclosporin
* potassium-sparing diuretics, eg spironolactone, triamterene, amiloride
* potassium supplements
* potassium-containing salt substitutes.

The amount of potassium in your blood should be regularly monitored if you are taking any of these during treatment with this medicine.

Erythropoietin (Eprex®, NeoRecormon®, Aranesp®)

2009-09-22T19:53:00.000-07:00

What is erythropoietin?

Erythropoietin is a type of protein that occurs naturally in the body. It can also be ade as a medicine. It stimulates the bone marrow to make red blood cells.

Erythropoietin can be given as a treatment for a low red blood cell count (anaemia), as an alternative to a blood transfusion|. Our red blood cells contain haemoglobin, which carries oxygen around the body. If your haemoglobin level falls too low after treatment with certain types of chemotherapy| or radiotherapy|, your doctor may recommend a course of erythropoietin.

There are two types of erythropoietin that work in similar ways. These are:

* epoetin (Binocrit®, Eprex®, NeoRecormon®, Dynepo® )
* darbepoetin (Aranesp®).

Why it is given

Towards the end of your treatment, particularly if you have had a lot of chemotherapy, your red blood cell count may fall. If you have too few red blood cells (anaemia), you will feel very tired| and may also be breathless|.

If you are anaemic, you will usually be treated with a blood transfusion. Erythropoietin is sometimes given as an alternative to a blood transfusion. It will help your red blood cell count to increase and can relieve the symptoms of anaemia. It takes about 2–3 weeks for the treatment to begin to raise your red blood cell level. You will have regular blood tests while you are having treatment with erythropoietin, to make sure that your red blood cell levels stay within a normal range.

What it looks like

Erythropoietin is a colourless fluid in a small glass bottle or a pre-filled syringe.

How it is given

Erythropoietin is normally given by an injection under the skin (subcutaneously), most often in the thigh or abdomen. It can be given from once a day, to one injection every three weeks, depending on the type of erythropoietin used and on advice from your doctor. You, or a person caring for you, can be taught how to give the injections so that you can continue the treatment at home, or it may be given by a district nurse or GP practice nurse.

Possible side effects

The amount of erythropoietin that occurs naturally in the body is very small. When erythropoietin injections are given, the amount in the body increases greatly. For this reason it causes side effects, even though it is a naturally occurring substance. The side effects are not usually severe however.

People react to drugs in different ways, so it is not possible to predict who is going to have side effects or which they will have. The most common side effects are listed below.

If you notice any effects which you think may be due to the drug, but which are not listed here, please discuss them with your doctor or nurse.

Flu-like symptoms Some people have flu-like symptoms, such as joint pains, weakness, dizziness and tiredness. These are more likely to occur at the start of your treatment. Your doctor may prescribe a painkiller, such as paracetamol, to help with these symptoms.

Headaches Some people may develop severe headaches, although this is rare. Let your nurse or doctor know if you develop this side effect.

High blood pressure can occur Your doctor will closely monitor your blood pressure while you are receiving erythropoietin. Let your doctor know if you take medication for high blood pressure.

Skin irritation may occur at the injection site This can be reduced by giving the injection in different places.

Skin rash You may develop a skin rash, which may be itchy.

Let your doctor or nurse know if you have any side effects.

Length of treatment

Erythropoietin can be given before anaemia develops to help prevent it occurring, or it can be started as soon as your anaemia has been diagnosed. The injections usually continue until one month after your chemotherapy course has finished, or until you are no longer anaemic.

Additional information

You may be given iron tablets or injections to help with production of new red blood cells.

Your erythropoietin should be stored in the fridge.

A number of trials| have looked at the benefits of using erythropoietin in the treatment of people with different types of cancer. The results from some of these trials have raised questions about its safety, and have suggested that sometimes erythropoietin may cause the cancer to grow in size. There is also concern that erythropoietin might increase the risk of developing a blood clot (thrombosis).

These results are being reviewed by the drug safety authorities. In the meantime there is no doubt that some people with cancer will definitely benefit from having erythropoietin, but the benefits and risks of its use should be carefully considered for each individual person.

Not all types of erythropoietin are suitable for Jehovah's Witnesses. Your doctor or pharmacist can give you further advice about this.
References Back To Top

This section has been compiled using information from a number of reliable sources including:

* Martindale: The Complete Drug Reference (35th edition). Sweetman et al. Pharmaceutical Press, 2006.
* British National Formulary (56th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2008.
* Erythropoetin (alpha and beta) and darbepoetin for the treatment of cancer-treatment induced anaemia - National Institute for Health and Clinical Excellence (NICE) 2008.

CIPROBAY

2009-09-22T19:47:00.000-07:00

Generic name: Ciprofloxacin
Product Brand Name: Ciprobay
Product Manufacturer: Bayer (Germany)

1. Description: Ciprobay is an antibiotic used to treat certain infections caused by bacteria, such as pneumonia; gonorrhea; infectious diarrhea; typhoid fever; inhalational anthrax (after exposure); and bone, joint, skin, and urinary tract infections. Antibiotics will not work for colds, flu, or other viral infections.
Cipro also is used to treat patients with cystic fibrosis who have lung infections. It also is used to treat some malignant ear infections and tuberculosis (TB). Cipro may be used with another medicine to treat disseminated Mycobacterium avium complex (MAC). Talk to your doctor about the possible risks of using this drug for your condition.
Cipro was approved by the U.S. Food and Drug Administration for use in patients who have been exposed to the inhaled form of anthrax.

2. Ciprobay is Prescribed for: Ciprois used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptible bacteria. Cipro is also frequently used to treat urinary infections caused by bacteria such as E. coli. Cipro is effective in treating infectious diarrheas caused by E. coli, campylobacter jejuni, and shigella bacteria.

3. Drug Mechanism: Cipro is an antibiotic used to treat bacterial infections. Many common infections in humans are caused by single cell organisms, called bacteria. Bacteria can grow and multiply, infecting different parts of the body. Medicines that control and eradicate these bacteria are called antibiotics. Cipro works by interfering with an enzyme that allows bacteria to reproduce. This enzyme interference halts the growth of bacteria and eventually leads to death of the bacteria.

4. Dosage Form: Cipro may be taken with or without food. Cipro is partially metabolized by the liver and excreted by the kidney. Dosages require adjustment in patients with severely abnormal liver or kidney function. Antacids block the absorption of ciprofloxacin and they should not be taken together.

5. Drug Interactions: Cipro administered together with theophylline can lead to elevated blood levels of theophylline. Theophylline is used to open airways in the treatment of asthma. Toxic levels of theophylline can lead to seizures, and disturbances in heart rhythm. If concurrent use of ciprofloxacin and theophylline cannot be avoided, frequent blood tests to monitor theophylline blood levels are performed. Cipro should be used with caution in patients with central nervous system diseases such as seizures, because rare seizures have been reported in patients receiving this medication. Cipro should be avoided in children and adolescents under 18 years old, as safe use in these patients have not been established.
Many antibiotics, including Cipro, can alter the normal bacteria in the colon and encourage overgrowth of a bacteria responsible for the development of inflammation of the colon (pseudomembranous colitis). Pseudomembranous colitis can cause fever, abdominal pain, diarrhea, and sometimes even shock. Patients taking ciprofloxacin can develop sensitivity of the skin to direct sunlight. Cipro can enhance the action of the anticoagulant warfarin (Coumadin), and increase the risk of bleeding.

6. Pregnancy: Cipro should be avoided in pregnancy, as safe use in these patients have not been established.

7. Nursing Mothers: Cipro should be avoided in nursing mothers, as safe use in these patients have not been established.

8. Dietary and Alcohol Considerations: Do not take Cipro with dairy products such as milk or yogurt alone. If you have dairy products as part of a meal, you may take Cipro with the meal. Drink at least eight full glasses of water or other liquid every day. Do not drink or eat a lot of caffeine-containing products such as coffee, tea, cola, or chocolate. Cipro increases nervousness, sleeplessness, heart pounding, and anxiety caused by caffeine.

9. Uses: This medication is used to treat a variety of bacterial infections. Ciprofloxacin belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for virus infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness.

10. How to use: Read the Patient Information Leaflet provided by your pharmacist before you start using ciprofloxacin and each time you get a refill. If you have any questions, consult your doctor or pharmacist. This medication may be taken with or without food, usually twice a day in the morning and evening or as directed by your doctor. The dosage and length of treatment is based on your medical condition and response to treatment. Drink plenty of fluids while taking this medication unless your doctor tells you otherwise.
Take this medication 2 hours before or 6 hours after taking any medications or antacids containing magnesium, aluminum, or calcium. Some examples include quinapril, certain forms of didanosine (chewable/dispersible buffered tablets or pediatric oral solution), vitamins/minerals, antacids, dairy products (e.g., milk, yogurt), calcium-enriched juice, and sucralfate. Other products include bismuth subsalicylate, iron, and zinc. These medications/products bind with ciprofloxacin and prevent its full absorption. However, this medication may be taken with dairy products or calcium-enriched juice as part of a meal because food helps prevent this effect.
Ask your doctor or pharmacist about safely using nutritional supplements/replacements with this medication.
Antibiotics work best when the amount of medicine in your body is kept at a constant level. It is important not to miss a dose. To help you remember and to keep the drug at a constant level, take it at the same times every day. Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may allow bacteria to continue to grow, which may result in a return of the infection. Tell your doctor if your condition persists or worsens.

11. Possible Side Effects: The most frequent side effects include nausea, vomiting, diarrhea, abdominal pain, rash, headache, and restlessness. Rare allergic reactions have been described, such as hives and anaphylaxis (shock).

12. Storage: Keep this medication in the container it came in, tightly closed, and out of reach of children. Ciprofloxacin should be stored at below 30°C (86°F) and away from excess heat and moisture (not in the bathroom). Keep away from light. Talk to your pharmacist about the proper disposal of your medication. Throw away any medication that is outdated or no longer needed.

13. Package Size and Type: Tablets: 250mg, 500mg. Tablets Ciprobay.

Before starting to take this medicine, it is vital that you should consult your doctor! Do not use it on your own initiative, without medical advice.

DEMENTIA

2009-09-22T19:41:00.000-07:00

Written by Christian Nordqvist

The word dementia comes from the Latin de meaning "apart" and mens from the genitive mentis meaning "mind". Dementia is the progressive deterioration in cognitive function - the ability to process thought (intelligence).

Progressive means the symptoms will gradually get worse. The deterioration is more than might be expected from normal aging and is due to damage or disease. Damage could be due to a stroke, while an example of a disease might be Alzheimer's.

Dementia is a set of signs and symptoms
Dementia is a non-specific syndrome in which affected areas of brain function may be affected, such as memory, language, problem solving and attention. Dementia, unlike Alzheimer's, is not a disease in itself. When dementia appears the higher mental functions of the patient are involved initially. Eventually, in the later stages, the person may not know what day of the week, month or year it is, he may not know where he is, and might not be able to identify the people around him.

Dementia is significantly more common among elderly people. However, it can affect adults of any age.
What are the symptoms of dementia?

* Memory loss - the patient may forget his way back home from the shops. He may forget names and places. He may find it hard to remember what happened earlier on during the day.

* Moodiness - the patient may become more and more moody as parts of the brain that control emotion become damaged. Moods may also be affected by fear and anxiety - the patient is frightened about what is happening to him.

* Communicative difficulties - the affected person finds it harder to talk read and/or write.

As the dementia progresses, the patient's ability to carry out everyday tasks diminishes and he may not be able to look after himself.

Diseases that cause dementia

# Alzheimer's disease - This is by far the most common cause of dementia. The chemistry and structure of the brain of a person with Alzheimer's disease changes and his brain cells die prematurely.

# Stroke (Vascular problems) - this means problems with blood vessels (veins and arteries). Our brain needs a good supply of oxygen-rich blood. If this supply is undermined in any way our brain cells could die - causing symptoms of vascular dementia. Symptoms may appear suddenly, or gradually. A major stroke will cause symptoms to appear suddenly while a series of mini strokes will not.

# Dementia with Lewy bodies - spherical structures develop inside nerve cells. Brain cells are nerve cells; they form part of our nervous system. These spherical structures in the brain damage brain tissue. The patient's memory, concentration and ability to speak are affected. Dementia with Lewy bodies is sometimes mistaken for Parkinson's disease because the symptoms are fairly similar.

# Fronto-temporal dementia - this includes Pick's disease. The front part of the brain is damaged. The patient's behavior and personality are affected first, later his memory changes.

# Other diseases - progressive supranuclear palsy, Korsakoff's syndrome, Binswanger's disease, HIV and AIDS, and Creutzfeldt-Jakob disease (CJD). Dementia is also more common among patients who suffer from Parkinson's disease, Huntington's disease, Motor Neurone disease and Multiple Sclerosis. People who suffer from AIDS sometimes go on to develop cognitive impairment.

There are two main categories of dementia

According to most experts, there are two main categories of dementia - cortical and subcortical dementias.

* Cortical Dementia - The cerebral cortex is affected. This is the outer layer of the brain. The cerebral cortex is vital for cognitive processes, such as language and memory. Alzheimer's disease is a form of cortical dementia, as is CJD (Creutzfeldt-Jakob disease).

* Subcortical Dementia - A part of the brain beneath the cortex (deeper inside) becomes affected or damaged. Language and memory are not usually affected. A patient with subcortical dementia will usually experience changes in his personality, his thinking may slow down, and his attention span may be shortened. Dementias which sometimes result from Parkinson's disease are subcortical dementias, as are those caused by AIDS and Huntington's disease.

A patient with multi-infarct dementia will have both the cortical and subcortical parts of the brain affected or damaged.
Diagnosis of dementia
Although there are some brief tests, a more reliable diagnosis needs to be carried out by a specialist, such as a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist.

The following tests are commonly used:

* AMTS (Abbreviated Mental Test Score) A score lower than six out of ten suggests a need for further evaluation.
* MMSE (Mini Mental State Examination) A score lower than twenty-four out of thirty suggests a need for further evaluation)
* 3MS (Modified Mini-Mental State Examination)
* CASI (Cognitive Abilities Screening Instrument)

It is important that the patient's score is interpreted in context with his socio-economic, educational and cultural background. The tester must also factor in the patient's present physical and mental state - does the patient suffer from depression, is he in great pain?

What is the treatment for dementia?
In the majority of cases dementia is incurable. Researchers are making inroads into treatments that may slow down dementia's progress. Cholinestaerase inhibitors are frequently administered during the early stages. Cognitive and behavioral therapies may also be useful. Several studies have found that music therapy helps patients with dementia. It is important to remember that the patient's caregiver also needs training and emotional support.

In the USA, Tacrine (Cognex), donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon) have been approved for the treatment of dementia caused by Alzheimer's disease - some physicians prescribe these drugs for vascular dementia as well. Selegiline, which is used for treating Parkinson's disease, has been found to slow down the progress of dementia.

In Canada, a country where two languages are spoken, English and French, researchers found that bilingual people who develop dementia do so four years later than monolingual people who develop dementia. The four year difference prevails even after factoring for such variables as cultural differences, education, employment, gender and immigration.
How common is dementia?

* United Kingdom - According to a report by the Alzheimer's Society (UK), approximately 700,000 people in the United Kingdom have dementia, out of a total population of about 61 million. Your chances of having dementia are 1 in 100 during your late 60s, this rises to 6 in 100 in your late 70s, and 20 in 100 in your late 80s. As people live longer experts predict dementia will rise significantly. According to predictions, there will be 940,000 people with dementia in the United Kingdom by 2021.

* Worldwide - According to a study published in The Lancet, approximately 24.3 million people had dementia worldwide in 2005, with 4.6 new cases every year. The number of people with dementia will double every two decades and reach 81.1 million by 2040. The rate of increase is expected to be faster in developing countries which have rapidly-growing life expectancies. (Lancet. 2005 Dec 17;366(9503):2112-7)

Sources - The Alzheimer's Society (UK), NIH, Wikipedia, The Lancet

Therapeutic Communication in the Nursing Profession

2009-09-22T19:31:00.000-07:00

Nursing is a caring profession. It is also a profession that is more and more evidenced based in practice. In as much as the scientific aspects of nursing is increasing due to the complex technological advancement of medicine and the machinery that is used at the patients bedside, the fact remains that the nurse is the first person that the client usually comes in contact with in any emergency or hospital setting

Having said this, the term, "caring" is an essential emotion that all nurses, for that matter, all individuals in the health profession must possess. With caring comes the trained ability of the nurse to facilitate therapeutic communication. One might ask, what is therapeutic communication? To better answer this question, the term communication should first be defined.

Communication can be defined as "The Process of transmitting messages and interpreting meaning." (Wilson and others, 1995) With therapeutic communication, the sender, or nurse seeks to illicit a response from the receiver, the patient that is beneficial to the patients mental and physical health. Just as stress has been proven to adversely affect the health of individuals, the therapeutic approach to communication can actually help. In any given situation everyone uses communication.

Everyone has seen the individual that looks like they are either angry, stressed, feeling ill or maybe sad. These emotions are communicated to others not always by words, but by gestures and facial expressions. A nurse must always be aware of these expressions in clients, for these expressions may be the only way that the nurse can tell if there is something else going on that needs their attention. The term given to this type of non-verbal communication is called, meta-communication. In meta-communication, the client may look at their amputated stump and say that it doesn't really look that bad, while at the same time tears are rolling down from their eyes.

In a case such as this the nurse should stay and further explore how the person actually feels. There are many factors associated with the healing and comforting aspects of therapeutic communication. Circumstances, surroundings, and timing all play a role in the effect of therapeutic communication. If a client is being rushed down for an emergency surgery there might not be time for a bedside conversation, but the holding of a hand could convey much more than words to the client at such a moment.

Ideally, for therapeutic communication to be effective the nurse must be aware of how they appear to the client. If a nurse appears rushed, for example, they are speaking quickly, their countenance looks harried, and they are breathing heavily, their eyes not on the client but perhaps on an intravenous bag on the client in the next bed. In a case like this, there is nothing that this nurse could say to the client in a therapeutic manner that the client would believe. The helping relationship has not been established and therefore therapeutic communication cannot be facilitated. Some of the emotions associated with therapeutic communication include but are not limited to the following: Professionalism, Confidentiality, Courtesy, Trust, Availability, Empathy, and Sympathy. (Potter, Patricia A., Perry, Anne G., Co. 2003, Basic Nursing Essentials for Practice, pg. 123, Mosby)

All of these emotions go into the client nurse relationship, which must be established by the nurse as soon as possible upon first meeting the client. To begin to establish this nurse client relationship, the nurse must assess the overall message that the client is communicating to the nurse, such as fear, pain, sadness, anxiety or apathy. The nurse should be trained in keying into the message that the client is sending. Only then can the nurse determine the best therapeutic approach. Anyone that has to be thrust in to a hospital or emergency room environment has level of anxiety.

This level can go up considerably when the client feels that they have been abandoned or that there is no one there that really cares about how they feel. When a client is the recipient of therapeutic communication from a caring individual, a level of trust is achieved and more than, that the clients entire countenance can change for the better. Their blood pressure, respirations and levels of stress can simultaneously decrease. When this takes place, the management of pain, if any is involved, can be resolved more quickly. The goal for a nurse is to become proficient in the medica