Unit C Outline
Adolescent & Young Adult
The Adolescent Growth & Development
- physical growth spurt: girls = 9.5-14.5 years,
boys = 10.5- 16 years
- can cause aches & pains
- girls tend to have more forethought, think
more long term
- boys tend to take more risks, pay less attention
to consequences
- Developing a sense of identity:
- Group Identity is extremely important
- pressure to belong to a group, based on similarities, should I conform or not?
- looking for differences between self & parents because parents suck
- adolescent culture is extremely self-centered
- conformity vs. nonconformity?
- this is tough for parents to deal with
- Individual Identity
- quest for “who am I?” part of developmental task
- body image (really effected by media, pop culture)
- societal influence
- #1 reason for adolescent suicide is homosexuality
- Sex-role identity
- influences: culture, geographic area, socioeconomic groups, peers, adults
-hetero/homo sexual relationships
- adolescent conflicts
- depression - not always textbook w/adolescents
-Sexuality: education: need to know what to expect,
school nurses need to be available/openminded
- education must be based on: biology
- social pressures
- health issues
- personal attitudes
- peers/pressures
- values, different value systems
- Adolescent Pregnancy, declining for last 20 years
- pay attention to special needs, education, resources
- risk should not be greater for teens w/adequate nutrition & prenatal care
- risk of pre-eclampsia is higher for teens, otherwise same as adults
- middle class is more likely to choose abortion
- variables: peer pressure, knowledge, emotional maturity, socioeconomic status
Nutrition;
females 2000 cal/day (44/46g protein), males 2500-3000 cal/day (45-59g protein)
- need increased Ca+, Fe, Zn - usually don’t get it
- need Zinc for bone growth (major physiological event for teens)
- food habits often suck, need education
- boys have increased metabolism & bone growth
- boys have more muscle than girls
- food habits: teens will do what they’ve grown up doing... they learn habits early
- Obesity: 11% of US children/adolescents
- Adipose Cell theory - some kids have bigger/more fat cells than stay larger
- Set point theory - programmed weight level, like thermostat, body wants to stay there
- Causes: high fat diet, not enough fruits
& veggies, food as a coping mechanism, parental obesity, sedentary lifestyle (25% of kids have no regular activity r/t
unsafe neighborhoods, apartment living, lack of leisure time with families)
- Anorexia Nervosa - self-imposed starvation, intense phobia of obesity
- distorted body image, most female, 1st occurrence in adolescence
- often about control, often really driven kids,
perfectionists, goal oriented, overachievers
- introverted, reserved, ritual personal hygiene, intensive work/study, excessive exercise
- often very rigid, OCD type tendencies
- may experience amenorrhea d/t decrease fat,
hormone imbalance, fatigue, dehydration, metabolic acidosis/alkalosis, electrolyte/mineral imbalances, hypotension, increased
HR, cardiac dysrhythmias can be life threatening, anemia d/t decreased Fe intake, hormone imbalance, hypothermia, vitamin/mineral/protein
deficiency
- starvation symptoms: lanugo/edema (late stage)
- albumin is a good indicator of overall health
- mortality rate = 5-10%
- treatment: regain weight to 90% of norm,
psych tx for whole family, nutrition therapy, antidepressant therapy, SSRI’s: Desyrel, Paxil, Zoloft, Celexa
- Bulemia Nervosa - can be harder to identify than anorexia because these kids eat
- uncontrollable binging & purging, happens often, mostly female 15-30 y/o
- mostly in late adolescence (18-19) is when it starts
- happens equally in all socioeconomic & ethnic groups
- very similar to anorexia nutritionally
- high cholesterol & fat stimulate insulin production & hunger
- feelings of abdominal discomfort, guilt, lack of control, anxiety
- happens many times a day
- treatment: similar to anorexia
- dentist may notice d/t tooth decay or discoloration
- may develop esophagitis
- behavior modification may be used
- psychotherapy is an option, individual, group, & family
- dietary counseling is necessary
Health Problems
of the Adolescent
- Infectious Mononucleosis (“the kissing disease”)
- usually younger than 25 y/o, caused by Epstein-Barr virus
- communicable via oral secretions? Not exactly certain of transmission
- sx: headache, fatigue, lowgrade fever, anorexia
- as progresses, fever increases, sore throat,
cervical lymph nodes enlarge (key sign)
- possible splenomegaly, petechiae, exudative pharyngitis/tonsilitis
- Monospot test - finger stick test to dx
- no specific tx because it’s viral, treat symptoms
- po PCN for sore throat if Strep B
- usually symptoms are gone in 7-10 days
- fatigue subsides in 2-4 weeks
- teaching: be alert for dyspnea, abdominal pain, sore throat, hydration is key
- enlargement of lymph nodes, tonsils, pharyngitis can cause dyspnea
- use APAP for symptoms instead of ASA d/t danger of Rye’s Syndrome
- if sx don’t get better in 7-10 days call Dr.
- Altered Growth & Maturation
- Gynecomastia - fairly common in boys, usually grow out of it
- Substance Abuse - fairly common to experiment
- Suicide
- traumatic injury = MVA #1 killer of teens
- AIDS - HIV is a retrovirus, infects CD4 T-lymphocytes
& turns them into HIV making machines & destroys them
- HIV in kids: lymphadenopathy, hepatosplenomegaly,
thrush, diarrhea, FTT, developmental delays, Parotitis
- AIDS in kids: PCP, LIP, bacterial infections,
wasting syndrome, HIV encephalopathy, candidal esophagitis, CMV disease, MAC (mycobacterium avium-intracellular complex infections),
severe herpes, pulmonary candidiasis, cryptosporidiosis
- can also lead to short stature, malnutrition,
cardiomyopathy, neurological defects, decreased motor ability, developmental delays
- Tx: antiretroviral drugs - suppress viral
replication for years & years
- Severe Combined Immunodeficiency Disease (SCID) (bubble boy)
- absence of humoral & cell-mediated immunity
- chronic infection, FTT, unusual illness
- hard to dx d/t delayed Ig in infants & maternal transfer for IgG
- poor prognosis
- Wiskott-Aldrich Syndrome - X linked recessive disorder
- 1. Thrombocytopenia 2. Eczema 3. Immunodeficiency
of selective function of B & T lymphocytes
- bloody diarrhead d/t thrombocytopenia, recurrent infection d/t eczema
- chronic herpes infection is problem - loss of vision d/t karatitis of eye
- chronic pulmonary disease, sinusitis, otitis media
- poor prognosis
- Sex Chromosome Abnormalities
- Turner Syndrome: females; absence of X - can be identified at birth
- webbed neck, low rear hairline, widely spaced
nipples, edema of hands/feet
- puberty - short stature, sexual infantilism, amenorrhea = infertile
- behavior problems, immature, socially inept, isolated
- tx w/hormone therapy, psychological counseling
(growth hormone when young, estrogen therapy at puberty)
- Triple X: “Super Female” - normal looking, tall, risk for impaired language
- learning difficulties, fertile, variable mental capacity & behaviors
- Klinefelter Syndrome: male; MOST COMMON, extra
X, seldom dx before puberty
- absence of sperm in semen (azoospermia), small
testes, defective development of secondary sex characteristics
- cognitive impairment, decreased gross motor
skills, developmental language delay, poor verbal skills, decreased auditory memory, shyness, passivity, behavior problems
- tall, long legs, gynecomastia possible
- XYY Male- tendency to be tall, long head, poor
coordination, aberrant behavior?
- normal sexual development
Young Adults
- Adulthood - 20-40 years, defined many ways
(age of alcohol consumption...), independence, maturity
- career establishment, building relationships,
start family
- independent thinking, idea of who we want
to be, more established values
- Erikson’s Intimacy vs Isolation - decrease in egocentrism, spiritual development
- focus on reality, religious teaching may
be accepted or redefined
- spirituality is broad - who/what I am in
the universe, not just religion
Thrombophlebitis - clot
irritating vein, foreign body causing inflammation
- also known as DVT
- can be superficial or deep
- Virchow’s triad - venous stasis, damage to the endothelium, hypercoagulability, sluggish circulation may be
even backup of blood
- signs/symptoms - may be asymptomatic, edema of affected extremity, most often in legs d/t their dependent position
- pain/tenderness - maybe redness d/t inflammation
- warm to touch
- elevated temperature
- may have + Homan’s sign - dorsiflexion to plantar flexion = pain in calf
- often obvious to see in superficial vein
- risk increases w/ disrupting bone marrow (& platelet creation) in hip, knee surgery (also prone to PE), bedrest,
& pregnancy
- dx: venous doppler - irregular, louder above phlebitis
- blood tests: D-dimer (fragment resulting from fibrin degradation,
increased w/fibrin clot lysis; Coagulation studies to show risk, to check appropriateness of heparin tx - helps determine
heparin dose
-venogram (visualize clot)
- Plethysmography - used when extremity is edematous to dx, not used
often, BP cuff attached proximal, medial, & distal areas of extremity; distal cuff records pulse volume, there’s
no increase in volume if DVT present
- Interventions: PREVENTION
- low dose heparin SQ, Lovenox SQ
- lose dose coumadin po (based on pt)
- early mobilization post-op (WALK!!!!!)
- TED’s
- SCD’s (for any surgery longer than 1 hour)
- exercise legs & feet - muscles pump blood back up legs
- If DVT already present: elevate affected extremity above heart level, warm moist compresses
- TED hose (MEASURE THEM!!!)
- strict bedrest initially, mild analgesics (NSAIDS for discomfort)
- anticoagulant therapy (coumadin & heparin work on different clotting proteins)
Heparin - 5000 Units is
a low dose, often comes in prefilled syringe
- IV usually given as continuous infusion after initial bolus dose
- inhibits conversion of fibrinogen to fibrin
- heparin dose regulated by PTT (or APTT), sliding scale based on PTT
- PTT will increase as heparin gets more effective, tx value 1.5-2.5 times the normal value, want result higher than
normal
- Can decrease platelet counts
- protamine sulfate is an antidote: overdose may also be treated by stopping heparin
- OD can cause bleeding anywhere
- calculation of infusions as weight/hour
- know how much med is in 1mL, know how much med/hour
- DO NOT PUT MEDS in w/HEPARIN!!!!
- some low molecular weight heparins (Lovenox) have been approved for tx of some cases of DVT, especially if PE is
not present
- administered SQ
- usually do not require daily labs
- given deep SQ (lateral abdomen - toward love handles)
Oral Anticoagulants - given
to maintain anticoagulation
- example: warfarin (Coumadin)
- usually started while on IV heparin
- takes 3-5 days for maximum effect
- regulated by Prothrombin time (PT) & INR
- aim for INR of 2-3 for tx effect
- vitamin K is antidote to Coumadin
- teach pt to take med same time every day, wear/carry ID showing what anticoagulant pt is taking, keep appointments
for blood tests, be aware of interactions w/other meds (aspirin), avoid marked changes in eating (consistant intake of vitamin
K), no using straight razors
- Control of peripheral edema - TED’s, SCD’s, elevation of legs
- Surgical intervention - thrombectomy, inferior vena cava interruption
- use soft toothbrush
- be careful of brusing/bleeding
- Greenfield filter (in superior vena cava)
- Vericose Veins - distended,
protruding veins
- vein wall weakens & dilates, venous pressure increases & valves become incompetent
- c/o pain & “fullness” in the legs
- dx test: trendelenberg test
- interventions: conservative meausres - TED’s, elevate legs
- sclerotherapy, laser therapy, surgery (vein ligation, vein stripping)
- nursing dx: knowledge deficient, pain, altered peripheral tissue perfusion, impaired skin integrity (or high risk)
- Respiratory System - Asthma
- usually begins in young adulthood - 1st sign of hypoxia - restlessness
- characterized by usually reversible airway obstruction
- intermittent airway narrowing caused by 3 processes:
-bronchospasm & bronchoconstriction
- excess production of mucus (part of inflammatory response)
- airway edema
- narrowing can be so bad as to make intubation difficult
- Triggers: allergens, resp infections, nose/sinus problems, exercise, cold/dry air, GERD, stress, air pollutants,
cigarette smoke
- classification: mild intermittent, mild persistent, moderate persistent (symptoms interrupt daily life), severe persistent
(pt needs medical attention now)
- Signs/Sx - cough (may be nonproductive initially & become productive as airways open)
- dyspnea (use of accessory muscles to breathe, gets progressively worse)
- wheezing (usually on exhalation, worse when both inhale & exhale; pt who stops wheezing has probably gotten worse
& doesn’t breathe forcefully enough to make a sound anymore...this pt is in trouble!!!)
- diminished/absent breath sounds (if airflow is restricted from obstruction)
- Dx studies - screening for severity - peak flow tests & ABG (asthmatics should have their own peak flow meter
at home to use regularly and monitor their own personal norms)
- ABG’s show change early because arterial blood is usually highly oxygenated
- asthma can induce respiratory acidosis
- Methacholine challenge test (looks at triggers, will try to induce attack)
- chest x-ray - probably will be normal
- Interventions: ask pt what they normally do!
- O2 therapy! Administer as ordered, especially if possibility of CO2 retention
- maintain airway patentcy - positioning (high fowler’s, leaning over a table, sitting on side of bed), ensuring
adequate fluid intake (to think mucus)
- space activities to allow for rest
- control anxiety
- chest physiotherapy (cupped hands, no bare skin) & postural drainage - more helpful when asthma complicated by
chronic bronchitis or other chronic resp condition
- health teaching - pursed lip breathing, controlled coughing, teaching about inhaler use
- drug therapy - includes maintenance meds & rescue meds
- Maintainence Medications:
- NSAIDS - most useful for prevention, not useful during attack
- cromolyn (Intal)
- nedocromil (Tilade)
- Corticosteroids - reduce inflammation in the throat & lungs - inhaled route is used for maintenance
- beclomethasone (Vanceril) (older but works)
- triamcinolone acetonide (Azmacort)
- Leukotriene inhibitors/receptor antagonists - have both antiinflammatory & bronchodilator effects - prevents inflammatory response/edema - oral meds - not used in acute attacks
- zafirlukast (Accolate)
- montelukast sodium (Singulair)
- zileuton (Zyflo)
- Theophylline derivatives - increase production of cAmp - oral bronchodilators - chronic lung disease, not usually
asthma maintenance, IV Aminophylline may be used IV in an acute asthma attack; side effects: increased HR, increased anxiety
- Aminophylline
- Theo-Dur
- Slo-bid (long acting)
- Anticholinergic medications - side effects lessened when inhaled
- ipratropium (Atrovent)
- Beta-2 agonists (sympathomimetics) - most useful for maintenance
- salmaterol (Serevent)
- Advair (combination of Serevent & corticosteroid)
- Rescue Medications:
- Corticosteroids - when used for rescue they are usually given orally or parenterally - many systemic side effects
- methylprednisolone (Solu-Medrol)
- prednisone
- Beta-2 agonists - (sympathomimetics)
- albuterol (Proventil)
- metaproterenol (Alupent)
- terbutaline
- epinephrine
- Nursing dx:impaired gas exchange, ineffective breathing pattern, ineffective airway clearance, altered nutrition:
less than body requirements, anxiety, activity intolerance, powerlessness, high risk for infection, risk for decreased immune
response (side effect of meds)
- Respiratory System
- Acute Bronchitis - inflammation of the bronchi & usually the trachea, usually viral, can be bacterial
- signs/sx: cough w/sputum (clear = no bacteria, cloudy = bacteria, usually), low-grade fever, malaise, abnormal breath
sounds
- tx: usually sumptomatic, ensure adequate fluid intake ( to thin sputum), analgesics, antipyretics, antibiotics only if appropriate
- Respiratory System
- Sinusitis - inflammation of the mucous membranes of one or more of the sinuses, acute or chronic
-signs/sx: headache, c/o pressure, drainage, ear aches, toothaches
- Nonsurgical interventions:
- antibiotics (cause often bacterial)
- decongestants (to break up mucous)
- expectorants (to help cough up/out mucous)
- nasal corticosteroid inhalers
- antihistamines
- adequate hydration
- saline nasal sprays, steam, humidifier, netti pot
- Surgical interventions:
- endoscopic sinus surgery
- Caldwell-Luc sinus surgery (only done as last resort)
- Ethmoidectomy
- Sphenoid sinus surgery
- Frontal sinus surgery
- Post-op care:
- assess for hemorrhage (often very bloody, look at how much swallowing pt is doing)
- ice compresses
- change drip pad as ordered
- frequent oral care
- keep mucosal lining moist after removal of packing
- avoid blowing nose for at least 48 hours after packing removal (hard for pt)
- Neuromuscular System
- Multiple Sclerosis - progressive degenerative disease that effects the myelin sheath - unknown etiology, suggested underlying
viral infection? - characterized by remission & exacerbations
- exacerbations triggered by:
- fatigue, stress, overexertion
- temperature extremes
- moist heat (hot showers, hot tubs, steam baths, saunas)
- pregnancy - remission may occur during gestation, but increased risk for exacerbation in postpartum
- assessment: thorough history is important!!!! (previous illness, surgeries, triggers)
- symptoms often vague/nonspecific
- symptoms classified as sensory, motor, cerebellar, spinal cord involvement, neurobehavioral
- sensory: numbness/tingling (where? duration?), blurred vision (triggers? duration?), paresthesias (burning, prickling
sensation), decreased sense of temperature, tinnitus, decreased hearting
- motor: weakness or feeling of heaviness in lower extremeties, paralysis, spasticity, diplopia
- cerebellar: incoordination, nystagmus (crazy eye movements periodically), dysphagia, slurred speech
- spinal cord involvement: abnormalities in bowel & bladder function (urinary or bowel incontinence, urinary retention,
constipation), sexual dysfunction
- neurobehavioral: emotional lability, depression, irritability, apathy, loss of short-term memory (also happens in
Alzheimer’s)
- Dx studies: no single reliable dx study
- based primarily on hx & clinical manifestations
- MRI, CT scan, visual/auditory evoked responses,
lumbar puncture w/CSF analysis
- Interventions: Medications: used to treat
acute attack, decrease the # & frequency of relapses, & for symptoms management
- basic goal is to decrease the inflammation & destruction of the myelin sheath therefore reducing the frequency
& severity of relapses.
- Medications:
- Corticosteroids - useful for exacerbations, antiinflammatory, many side effects, especially w/long term use - daily
maintenance
- ACH, SoluMedrol, Prednisone
- Immunosuppressants - may be helpful in decreasing exacerbations, side effects may outweigh the benefits - daily maintenance
- cyclosporine (Sandimmune)
- azithioprine (Imuran)
- cyclophosphamide (Cytoxan)
- Beta-interferons - help decrease relapses & seems to help to control the disease, not just relieve symptoms -
daily maintenance or as symptoms recur
- interferon beta-1b (Betaseron) - (SQ injection)
- Copaxone - unrelated to beta-interferons, but also decreases exacerbations & number of new lesions (given SQ)
- Medications given for symptom management:
- Spasticity - muscle relaxants, baclofen (Lioresal), dantrolene (Dantrium), diazepam (Valium)
- Spastic bladder & urge incontinence, oxybutynin (Ditropan), propantheline (Pro-Banthine), tolterodine (Detrol)
- urinary retnetion, bethanechol (Urecholine)
- antidepressants, amitriptyline (Elavil), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)
- Nursing Interventions:
- diplopia - eyepatch alternated from eye to eye every few hours
- if decreased sensation, protect from injury (teach to use a thermometer to check H2O tempature)
- encourage maintenance of indepence - adaptive equipment (occupational therapy consult!)
- encourage exercise - swimming, ambulation w/wide base of support, stationary bike
- manage discomfort, facial pain, paresthesias in feet
- prevent constipation
- prevent complications such as contractures, decubitus ulcers
- sexual/marital counseling
- goal of interventions is to maintain as much independence as possible, while keeping fatigue to a minimum
- Nursing dx: impaired physical mobility, self-care deficit, knowledge deficient, constipation, activity intolerance,
body image disturbance, high risk for injury, urinary incontinence or urinary retention
- GI/GU System - Peptic Ulcer
Disease - common in young adults, erosion of GI mucosa resulting from the digestive action of HCL & pepsin. The stomach
is protected by a gastric mucosal barrier - agents destroying that barrier include: H. pylori, aspirin, NSAIDS (prostaglandin
inhibitors), & corticosteroids (should be given w/food to prevent this problem); Pain is major symptom!
- Gastric Ulcer - normal/low secretion of gastric acid, normal stomach emptying rate, increased diffusion of gastric
acid back into the stomach (local mucosal inflammation from NSAIDS), pain in left upper/epigastric area, pain 1-2 hrs after
meals & rarely at night, pain NOT relieved by eating
- Duodenal Ulcer - increased gastric acid secretion, increased rate of gastric emptying, normal diffusion of gastric
acid back into the stomach, pain in right upper/epigastric area, pain 2-4 hrs after meals & often at night, pain relieved
by eating
- Contributing factors: NSAIDS (prostaglandin inhibitors),
alcohol abuse (irritating to stomach), smoking (nicotine increases HCL production), O blood type, diet? May contribute to development/may exacerbate
existing ulcers, Stress response (increased HR/BP, gastric emptying slows, resps increase,
parathormone release, epinepherine/norepinepherine release, corticosteroid release, blood flow shunted to extremities/flows
to vital organs, immune system depression, inflammatory response delayed)
- Symptoms - PAIN!!! usually described as gnawing, aching, burning, confined to small area of upper abdomen
- Dx studies: EGD, Endoscopy, GI series (upper GI), Testing for H. pylori (blood test, breath test, biopsy of mucosa
w/culture), gastric analysis (questionable value, involves insertion of NG tube & testing stomach contents in stimulated
& fasting state); pts are NPO before many tests
Medications:
- Antacids - (can disrupt pH balance) provide symptomatic relief, not healing, must give frequently, most effective
when given 1-3 hours after meals, wide variety available, Aluminum hydroxide can be constipating (Amphojel); Magnesium can
cause diarrhea; Calcium preparations (Tums, Rolaids) can be constipating; Systemic antacids (Sodium bicarb) may lead to systemic
alkalosis if used long term; these may be initial drug of choice in treatment of PUD
- Histamine (H2) receptor antagonists - block histamine stimulated gastric secretions, give 1 hour from antacids, few
side effects, often single dose HS; Tagamet, Zantac, Pepcid, Axid
- Proton Pump Inhibitors - suppresses the enzyme system of gastric acid production, mainly used for GERD, may be used
w/duodenal ulcers, may have antibacterial effect on H. pylori; Prevacid, Protonix, Prilosec
- Mucosal Protective Agents - Carafate: helps heal ulcer & decrease pain by coating ulcer, prevents irritation
from pepsin & gastric acid, increases prostaglandin synthesis, should be separated from antacids by at least 30 mins-1
hour, take on empty stomach; Cytotec: prostaglandin analog, replaces gastric prostaglandin & appears to have some antisecretory
effects, used in people who MUST take NSAIDS/helps prevent ulcers occurring w/use of NSAIDS
- H. pylori treatment: several recommendations, most combine Proton Pump Inhibitors or H2 Receptor Antagonists w/antiinfective
(often use Flagyl clarithromycin, or amoxicillin)
- Diet modifications: avoid foods that increase acid secretions/foods that cause discomfort, bland diet may be started
initially in 6 small feedings, no clear indication that this promotes healing, avoid alcohol & tobacco
- Complications: Pyloric obstruction (gastric outlet obstruction) caused by edema, spasm, or scar tissue, usually treated
conservatively, surgery usually vagotomy
- Hemorrhoids - swollen/distended
veins, can be internal/external, risk increases w/obesity, straining w/stools, occupations that require long standing/sitting,
heredity, pregnancy
- tx w/sitz bath, cold packs, witch hazel (Tucks pads), local anesthetic ointment, high fiber diet, stool softeners;
Invasive tx: sclerotherapy, elastic band ligation, cryosurgery, hemorrhoidectomy
- Urinary Tract Infection
- higher risk for females, pts w/structural abnormalities, obstruction, impaired bladder innervation, chronic disease, cystoscopy,
catheterization, pregnancy, sexual activity, delayed postcoital urination, wiping from back to front after urination
- Cystitis - lower UTI
- Pyleonephritis - upper UTI
- Dx: urinalysis, C&S (identifies bacteria & what kills it), IVP, CT
scan
- Ss/Sx - urinary frequency/urgency, dysuria, cloudy/foul smelling urine, fever/chills, lower back pain
- Tx: antibiotics: Bactrim, Macrodantin; increased fluids (3-4 liters/day), cranberry juice may help, teaching regarding
perineal hygiene
- Inflammatory Bowel Disease
- young adult nutrition: decreased Ca+ & Phosphorus needs (males 700mg/day, females 1000mg/day), caloric needs: males
2900kcal/day, females 2200kcal/day; protein needs: males 53gm/day, females 50gm/day
- Ulcerative Colitis & Crohn’s Disease: chronic acute inflammations & remissions, no specific cause,
may be autoimmune reaction, may be d/t infectious agents, may be food allergies or heredity
- Ulcerative Colitis - inflammed upper colon & rectum, peaks between age 15-40, both sexes but women more often,
may be cultural - more common in Jews & the upper middle class. Starts in the rectum & spreads up continuously; pt
develops abscesses which pop open, break into the sub-mucosa which causes bleeding/damage to mucosal epithelial tissue = diarrhea,
fluid/e-lyte imbalance; loss of absorption area/cell breakdown = protein loss in stool, granulation tissue develops causing
contracture of some surrounding tissue = usually tough tissue, not elastic - colon shortens & musculature gets thicker
- sx: pt can suffer from hypovalemia leading to tachycardia; 2-3 bloody diarrhea/day = mild case; 10-20 bloody mucousy
stools/day = severe case; during acute exacerbations pt will be NPO w/TPN & lipids, then move to high calorie high protein
low residue diet w/vitamin & iron supplementation
- Megacolon - d/t thick musculature, colon dilates
- Dx: can do biopsy w/a colonoscopy, barium enema (nurse must eyeball stool, should be gray/white)
- Management: REST BOWEL w/NPO status, HAL/TPN, antibiotics may be used
- Sulfasalazine - antibiotic w/antiinflammatory effects, po or retention enema in pt w/ left sided colitis = drug of
choice
- Steroids: prednisone (methylprednisone IV), cortisone (solumedrol IV), can be retention enema
- anticholinergics = decrease GI motolity - ProBanthine
- immunosuppressives = cyclosporine
- Surgeries: in 15-20% of all cases, last resort, if massive bleeding suggesting dysplasia (when cells become precancerous)
- Total Proctocolectomy w/Permanent Ileostomy - remove colon, rectum, anus, ileum = stoma RLQ below belt line
- Total Proctocolectomy w/Continent Ileostomy - Kock pouch - diminishes need for pouch/bag, pouch made in distal ileum
& one way valve created & sutured to abdomen, pouch holds contents & is drained regularly by inserting catheter;
Valve has HIGH failure rate - during recovery pouch must be irrigated w/NS regularly to flush mucous.
- Total Colectomy w/Rectal Mucosal Stripping w/Ileoanal Reservoir - 2 separate surgeries 8-12 weeks apart, high risk
for complications but most preferred surgery; 1st remove colon & create ileoanal anastamosis w/temporary stoma
created to heal sutures - temporary ileostomy & then closure of ileostomy which becomes a reservoir; 3-6 months for reservoir
to heal/mature & person’s Bms become more controlled - must be able to care for self w/no risk of CA or disease
Post-Op care: assess for hemorrhage, abdominal abscess, small bowel obstruction, teach regarding dehydration, monitor
ileostomy oupout - 1500-2000mL/day, keep surrounding skin clean/dry; JP drain - 100-150mL serosanguinous fluid, drain when
half full (should not be bloody drainage), Foley cath 2-5 days; Pt MUST walk!!
- Crohn’s Disease
- ages 15-30, high incidence in women, Jewish people & upper middle class; occurs slightly less than Ulcerative Colotis;
“mouth to anus disease” Inflammation of segments of the GI tract w/normal areas between diseased areas, ulcerations
are deep & long & widely penetrate mucosa, musculature thickens/narrows = strictures develop, abscesses burst &
fistulas develop, people develop bowel obstructions; can occur anywhere in GI tract, usually found in ileum, jejunum, &
colon
- Dx: same studies as ulcerative colotis
- Management: Drug therapy - Sulfasalazine (effective w/colon), corticosteroids, Flagyl
- Diet: elemental diet (pre-digested nutrients) during exacerbations, low fat/residue/roughage, high calories/protein,
lactose free, may have HAL through central line; Procalamine -peripherally infused TPN (not as irritating as HAL)
- Surgery only happens when people have fistulas/problems/symptoms & life threatening complications, surgery is
not curative for this disease (surgery can lead to “short gut syndrome” leading to lifetime TPN - these pts often
die of malnutrition)
- Woman’s Health
- Fibrocystic Breast Disorder - thickening of normal breast tissue & formation of cysts, appears to improve during
pregnancy & lactation & resolve w/menopause; probably caused by imbalance of progesterone & estrogen, can be very
painful; consists of one or more palpable lumps that are usually round, freely movable, usually bilateral, can be made worse
by caffeine & during PMS week; avoid caffeine, excess sodium, maybe take a mild diuretic - especially during PMS week
- Endometriosis - characterized by the presence of endometrial tissue outside the uterus, can be found in fallopian
tubes, ovaries, colon, bladder, or more distant sites; this tissue responds to hormone changes of the menstrual cycle; Sx:
dysmenorrhea, dyspareunia, backache, lower abdominal pain, pain is r/t site of implantation of the endometrial tissue, cause
is unknown, can cause infertility
- Ovarian Cysts - often asymptomatic, usually soft surrounded by a thin capsule & occur mainly during reproductive
years, Dr’s 1st clue may be irregular menses; Dx by ultrasound, CT, laparoscopy; may resolve spontaneously,
treated by oral contraceptives, surgery is cyst is large but surgery is not first choice
- PMS - symptoms associated w/Luteal phase of menstrual cycle, symptoms vary from person to person/month to month -
depends on physical health, coping mechanisms, personality; diary can be helpful to find triggers/patterns; Dx usually of
exclusion; no single treatment - AVOID CAFFEINE, ALCOHOL, REFINED SUGARS & SALT! Increase intake of complex carbs, vitamin
B complex & vitamin E & protein, exercise regularly, assess counseling/stress management needs; Medications: oral
contraceptives, prostaglandin inhibitors, antidepressants, diuretics
- Toxic Shock Syndrome - usually caused by Staph aureus, risk increases w/use of tampons - especially if tampons not
changed every 1-4 hours! Also caused by contraceptive sponges & diaphragms; Symptoms - fever, chills, sore throat, headache,
sunburn-like rash w/peeling of skin on palms/soles of feet, ulcerations of mucous membranes; fatalities occur from adult respiratory
distress syndrome, uncontrollable hypotension, disseminated intravascular coagulopathy
- Vaginal Candidiasis - yeast infection, thick white curd-like vaginal discharge, itching, dysuria, dyspareunia; treated
w/oral or intravaginal antifungals: Gyne-Lotrrimin, Mycelex, Monistat
- STD’s & STI’s - get a good sexual history - many people will not want to give specifics, both partners
must be treated
- TORCH infections - most commonly caused by toxoplasmosis, rubella, CMV - they can effect a growing embryo or fetus
& cause spontaneous abortion, abnormal fetal development, severe congenital abnormalities, mental retardation, & fetal
or neonatal death; mom may only have mild symptoms; 1st trimester is time of most risk; contracted by eating raw/partially
cooked meat of infected animals, contact w/feces of infected cats; pregnant women CANNOT touch litterboxes
- Abortion: Spontaneous: termination of pregnancy prior to viability
- Threatened: cervix closed, minimal bleeding, fetus/placenta retained, mild cramping, size of uterus appropriate,
tx w/bedrest, sedation, avoidance of stress
- Inevitable/Imminent: cervix opened, moderate/heavy bleeding, placenta/fetus not yet passed, moderate cramping, size
of uterus appropriate; will progress to incomplete or complete abortion
- Incomplete: cervix opened, heavy bleeding, fetus passed, placenta retained, severe cramping, uterus smaller than
expected, often need D&C
- Complete: cervix usually closed, minimal bleeding, fetus/placenta passed, mild cramping, uterus smaller than expected;
only tx to control bleeding if necessary
- Missed: fetus dies but is retained, cervix closed, slight/no bleeding, no uterine cramping, uterus is smaller than
expected; may need D&C or labor initiated
- Habitual/ Recurrent Pregnancy Loss: abortion occurs consecutively in 3 or more pregnancies, determine cause &
treat if possible
- Hydatidiform Mole - abnormal development of placenta resulting in fluid-filled grapelike clusters; possible complication
is choriocarcinoma (highly malignant cancer), vaginal bleeding almost universal w/molar preganancy, often brownish “like
prune juice,” HCG level markedly elevated, treatment is removal of mole, need close follow-up to be able to identify
if complication of choriocarcinoma is present; serum HCG weekly until normal level present 2 consecutive times; monitored
monthly for 1 year, it’s important that woman doesn’t get pregnant for 1 year
- Domestic Violence - myths: “only a small amount of violence exists” “battered women provoke the
men who hit them,” “alcohol/substance abuse causes violence” (this is an excuse); domestic violence happens
in all socioeconomic classes; it is a repeating cycle: tension building, acute battering incident, honeymoon period (men often
buy gifts during this phase)
