CHAPTER I CASE OVERVIEW

INTRODUCTION The group choose this title because the patients

condition really bothersome. It tickled the groups minds of how they will integrate the learned knowledge in connecting the series of events that lead to the complication the patient is facing skills now. to The patient had several medical diagnoses and received As first numerous treatment regimens that needs higher thinking order rationalize such intervention. timers at medical intensive care unit, the group did the best to dig out what was learned from previous lessons and applied such learnings in rendering wholistic quality paulinian care to the patient. Medical Intensive Care Units (MICUs) are designed to meet the special needs of acutely in myocardial and the critically MICU or ill patients. with or Patients commonly treated include those

respiratory

disease,

ischemia

infarction,

acute neurologic impairment. Patient L.L.U. 60 years old, female and a Filipino citizen residing in A. Mansueto Street, Bogo City, Cebu has experienced difficulty signs last and in breathing, vomiting and loss of consciousness and was during the course of her hemodialysis last February 9,2012. Her symptoms 10, persisted 2012 for for several hours therefore admitted to PSH- CHI, Medical Intensive Care Unit February further management. Her family history showed no bleeding disorders and renal diseases. Mrs. L.L.Us diet is usually high in sodium, sugar and fat. She is also having a sedentary lifestyle. Precipitating and predisposing factors identified were diabetes mellitus type 2 and hypertension during nursing health history. The arrest, patient end-stage was renal diagnosed disease of having cardiopulmonary to DM type 2, secondary

hypertensive emergency(February 11, 2012), healthcare related pneumonia and aspiration pneumonia, diabetes mellitus type 2, catheter related bacteremia and ventilator acquired pneumonia.
1

The group decided to choose the patients case because she was under the care and service of both group rotations in Cebu. Her diagnoses provided the group more opportunity of learning and of delivering quality ad critical Paulinian care. The span of time of caring for the patient was of great help as well in appreciating the disease condition and the nursing responsibilities asked of the primary nurse. The group has also realized that among all the patients, she is the one who is the most physiologically serious Lastly, unstable, requiring advanced and sophisticated judgment. The patient is as well most at risk in developing assessments. complications she was required requiring of thorough and intensive

complicated nursing support related to the use of intravenous (IV) polypharmacy and advanced biotechnology (e.g. mechanical ventilation).

CASE STUDY OBJECTIVES This clinical paper aims to: 1. Identify the condition of the patient. 2. Determine condition. 3. Improve skills in assessing and distinguishing normalcy from abnormality. 4. Recognize signs and symptoms manifested by the patient. 5. Familiarize the medications and integrate it to the patients condition. 6. Acknowledge all surgical management done to the patient. 7. Trace the pathophysiology of the diseases. 8. Correlate the pathophysiology to the clinical symptoms, nursing interventions, as well as the nursing, medical, and surgical management rendered. 9. Correlate results of diagnostic studies to the condition of the patient. 10. 11. 12. 13. 14. 15. 16. Utilize the nursing process in formulating appropriate Design appropriate the nursing care plans plans for the nursing care plans. patients identified clinical problems. Implement designed nursing care safely, effectively, and efficiently. Evaluate the effectiveness of the care implemented. Formulate conclusions based on the findings and data Give recommendations that will improve the quality of Empower Paulinian values such as client centeredness the etiology of the patients disease

gathered. care given to the patient. and professionalism.

SCOPE
This clinical paper contains information related to the care and condition of the patient. This paper also includes the review of systems, laboratory results with their corresponding interpretations, background of the normal anatomy and physiology of the affected part of the system affected, the pathophysiology of the disease, and the different surgical, medical, pharmacologic and nursing managements rendered to the patient and from the moment the patient is under the groups care in the Medical Intensive Care Unit of PSH-CHI. The data gathered depends on the cooperation of the patient, as well as the length of time they were able to interact with the patient and her family members. The group had three weeks exposure in Perpetual Succour Hospital per rotation, which includes more or less 15 days of clinical duty in the Operating Room and Medical Intensive Care Unit. The patient was under the care of ICU group in their 2pm-10pm shift. The OR group was able to handle the patient for 4 days in their prior rotation and the patients permanent catheter insertion last March 1,2012.

LIMITATIONS In the process of making this clinical paper, the group

encountered some limitations which are the following:

1. Difficulty in communicating with patient during the first week

(Feb. 20-24) since the patients speech was incomprehensible.

2. Achieving
patients caretaker

consistency
daughter knew and very

of
niece little

data

was

difficult
always the there

since
and

the
there

werent about

patients

personal

information.

CHAPTER II CASE DATA AND INFORMATION I. BIOGRAPHICAL DATA

Patients Name: Mrs. LLU Gender: Female Age: 60 y/o Birthdate: September 10, 1952 Birthplace: Bogo City,Cebu

Address: A. Mansueto St., Bogo City, Cebu Status: Married Religion: Roman Catholic Educational Attainment: College Graduate, Commerce Occupation: Businesswoman Nationality: Filipino Health care financing: Philhealth Source of information: Significant Others= 20% Patients chart = 20% Patient = 60% 100% Height: 5 feet and 4 inches Weight: 139 kilograms, present wt. Physician: Dr. Ma., Dr. Y., Dr. V., Dr. Mu., Dr. P. Contact person: Daughter M.C.U.

Case Number: 267897 II. REASON FOR SEEKING HEALTH CARE Mam, ang pasyente kay ga-dialysis unta siya atung panahuna kuyog ang iyang bana, nya dii dugay kay naglisud siya ug ginhawa, nisuka niece. III. HISTORY OF PRESENT ILLNESS Last January 17, 2012, patient was admitted due to pulmonary congestion diagnosed Nephropathy. and as pneumonia. Chronic Dr. Ma. She was treated to accordingly to undergo and was of Kidney advised Disease patient 5 secondary Hypertensive Creation ug nakuyapan man si Auntie didto. Gi-adto siya ug ER ug giingnan nga i-admit usa para mas matan-aw ug maau. As verbalized by

Atriovenous Fistula last January 18,2012. Fistula was found to develop hematoma and was not used for dialysis. Underwent right intrajugular catheter last January 28, 2012. Last February 6,2012, patient suddenly manifested dyspnea, vomited and lost consciousness while having her schedule of hemodialysis 2 times per week at the renal unit of PSHCHI. She got admitted in a regular private room but condition got worst and was admitted to MICU room #3 on February 10,2012 at 6:41pm for better monitoring and care. IJ Catheter was reinserted in left lateral side last February 27 and perm catheter last March 1, 2012.

IV.

PAST HEALTH HISTORY a. Childhood Illnesses: Patient positive for Measles, Chickenpox b. Hospitalizations: First Hospitalization was last January 2012 at Perpetual Succour Cebu Heart Institute due to pulmonary congestion and pneumonia c. Surgeries: Creation of Atriovenous fistula last January 18, 2012 on left antecubital area and right antecubital venous cutdown, Intrajugular catheter right lateral side of neck was installed January 28, 2012 since AV fistula was found to be of no use and with hematoma formation. Underwent Embolectomy of Right Intrajugular catheter last February 11, 2012. Left Intrajugular catheter insertion last February 27, 2012. Permanent Catheter insertion on left subclavian artery and vein last March 1, 2012. d. Serious Injuries: None e. Chronic Illnesses: Diabetes mellitus Type II and Hypertension since 40 years old. f. Immunizations: Up to date vaccines; Complete doses of OPV, Hep B, DPT, BCG & MMR g. Allergies: No known allergy. h. Medications: Telmisartan i. Recent Travel: None j. Military Service: None Insulin and antihypertensive drugs such as Mumps &

V.

FAMILY HISTORY HTN + 68 HTN + 71

DM & HTN + 80

HTN + 77

HTN + 66

HTN & DM + 61

HTN + 58

CKD DM + 49

HTN + 79

DM + 72

HTN + 66

DM CCa +52
DM HTN ESRD 60

HTN 57

HTN 55

DM HTN 52

HTN 49

DM 45

A&W 42

LEGEND: A&W Alive & Well CCa Colon Cancer CKD Chronic Kidney disease DM Diabetes Mellitus ESRD End-stage Renal Disease HTN- Hypertension Cardiovascular Problems RED Pulmonary Problems BLUE Endocrine Problems - BROWN Gastrointestinal Problems -ORANGE Renal Problems - PURPLE

-Client

-Female

-Male

Deceased

Interpretation: In the patients family history, it is presented that Diabetes Mellitus and Hypertension runs in the family. The genetic capability of these two diseases made the patient at risk of acquiring these progressive diseases. Her grandparents have hypertension and one among them has both diabetes mellitus and hypertension. In the generation of her parents, one or both of the diseases have been acquired by them. The individuals which are part of the first two generation died brought about by their disease condition. In the third generation which involved the patient, she has diabetes mellitus that lead to nephrosclerosis with End stage Hypertensive Neuropathy as well. Patients 6 current condition may be hereditary and gene encrypted which further more increases predisposition to cited chronic diseases. renal failure and

VI.

GORDONS FUNCTIONAL HEALTH PATTERNS ASSESSMENT TOOL

1. HEALTH PERCEPTION-HEALTH MANAGEMENT Past medical history: Able to experience the usual cough, colds and fever. Had chronic disorders which are Diabetes Mellitus type 2 and hypertension. Patient had arteriovenous immunization. fistula She creation smoke last January 18, 2012. She also She had is intrajugular catheter insertion last January 28, 1012. She has up to date doesnt cigarettes nor drinks alcohol. taking telmisartan, orally to manage her hypertension and Humulin to manage her type 2 diabetes mellitus. Patient has no known allergies, doesnt exercise on a regular basis and doesnt follow prescribed regimen.

2. NUTRITIONAL-METABOLIC Prior to admission, patient was on low salt diet and on diabetic diet with increased appetite. She is assisted by her husband during feeding and with chewing difficulties without her dentures (upper and lower partial dentures) and with no swallowing difficulties. While patient was admitted in the MICU, patient weighs 139 kg and has the height of 54 feet. Warm to touch, dry skin and poor skin turgor with non pitting edema on both upper and lower extremities. She has moist oral mucosa with visible lesion noted on the right lip due to long placement of the endotracheal tube. She is under D5 3%NaCL 1liter at 10cc/hr, patent and infusing well at right metacarpal vein. Nasogastric tube is also inserted on the right nostril. Bruises found on the right antecubital area with size 3cm and left antecubital of 2cm. 3. ELIMINATION Prior to admission, patient on moderate amount of usually defecates 3 to 4 times per week in color of soft semi-formed yellowish-brownish

stools at the comfort room and urinates at around 10-30 cc per hour voiding cloudy yellowish urine. While admitted, patient usually defecates 3 times per day on diaper with brownish moderate amount of soft semi-solid stool. Patient has distended abdomen upon inspection, soft upon palpation and hyperactive bowel sounds upon auscultation. Patient is also on Foley bag catheter attached to urobag and eliminated a total amount of 50cc for the entire 8hour shift.

4. ACTIVITY-EXERCISE Prior to admission, patient can attend to her self-care needs with assistance the radio. While admitted, patient still moves with assistance coming from from others in doing her activities of daily living. She doesnt exercise on daily basis and lies on bed most the time listening to

others. The respiratory rate of the patient ranges from 18-29cpm which are shallow and fast. She tends to become an abdominal breather when she is on distress. She has a productive cough. Patient was intubated with an endotracheal tube since admission to the medical intensive care unit and was extubated last March 5, 2012 at 10:00am. Upon auscultation rhonchi and diffused bibasal rales are usually present and louder in left lung than the right, while wheezing and crackles were heard once last February 17,2012. 5. SLEEP-REST Prior to admission, patient wakes up at 6:00am and sleeps at 8:00pm with morning and afternoon naps. She would feel rested after sleep and no awakening at night and doesnt have any rituals before sleeping. While admitted, patient is usually resting or sleeping in most hours but awakens in response to speech and doesnt follow any rituals or take in any medication prior to sleeping.

6. COGNITIVE-PERCEPTUAL Prior to admission patient is conscious with pleasant mood oriented to person, place, time and significant others. She has good recent and remote memory. Obeys to command with normal reflexes on all extremities. Patient is unable to see clearly due to her diabetic nephropathy but could still engage in conversations. When she lost her consciousness during her dialysis hence admission and when patient was still intubated, she was lethargic and calm in mood. She was still able to recognize significant others specifically her daughter. With a pupil size of 2mm with sluggish reaction to light. She grasps, pushes and pulls weakly on both right and left hand. Patient would respond to pain through facial grimace. When the patient was extubated, she had spontaneous eye opening, appeared confused, could communicate but with inappropriateness and obeys to command. Patient could hear with a normal to loud voice at a distance of 12inches.

7. SELF-PERCEPTION-SELF-CONCEPT Prior from loud to to admission, soft in patient quality. appeared She has calm, good properly eye dressed, but well kempt and has good personal hygiene. Voice volume changes depend on mood contact claims difficulty of seeing. She is undergoing her hemodialysis for the sake of her family and answers questions hesistantly. When patient was admitted, she appeared restless and makes several attempts to talk when she was intubated. Tries to make eye contact and tries to follow sounds heard. No unusual odor and with good hygiene. 8. ROLE-RELATIONSHIP Prior to admission, patient doesnt live alone, she is living with her husband and has two children. She is the second child of her parents and their first daughter. She managed her familys meatshop 6 years ago. She has her family as her support system. She underwent hemodialysis at her family members request. She then had limited social interaction and stays at home, in bed listening to the radio. When patient was admitted, her relationship with her family especially with her daughter became stronger. Her needs are attended well by her family and usually visited by her significant others at least thrice a week.

9. SEXUALITY-REPRODUCTIVE Patient is on menopausal stage at the age of 52 years old and has two children, no history of vaginal bleeding and sexually transmitted disease. Patient is not sexually active due to limited stamina. 10. COPING-STRESS TOLERANCE When patient is under stress, she should would cry and seek support from God and her family members. She would also indulge to eating to relieve herself from stress. She would also make use of the time to listen to the radio for relaxation. Upon admission, patient seems to manage stress and disease condition with the aid of her family members. She would often give motherly affection through hugging her children. 11. VALUE-BELIEF She is a Roman Catholic who hears masses during Sundays. She also goes to church during the days of obligation. She also follows the Churchs religious traditions such as fasting and abstinence during Lenten season and gift giving during Christmas. During course of admission in MICU, patient would always have a

rosary on one hand and also received the sacrament of the anointing of the sick from the hospital priests in the hope of regaining health and avoiding more complications brought about by disease.

10

Table No. 2.1: Physical assessment in three consecutive weeks.

System Assessed General Survey

February 24, 2012 (2:00pm10:00pm) Awake, stuporous in Semi Fowlers position, with GCS of 10(E4V1M5);we akness on right leg; pupil 2mm in size,isocoric and reactive to light;

February 27, 2012 (2:00am10:00pm) Asleep on bed on left side lying position, with GCS of 10 (E4V1M5);weak ness on both lower extremities; pupil 2mm in size, isocoric and reactive to light; -same

March 1, 2012 (2:00 am10:00 pm) Awake, stuporous in Semi Fowlers position, with GCS of 10 (E4V1M5); weakness on both extremities; pupil 2mm in size, isocoric and reactive to light; -same

March 6, 2012 (2:00 am10:00 pm) Awake, stuporous in Semi Fowlers position, with GCS of 13(E4V3M6); pupil 3mm in size, isocoric and reactive to light;

positive gag and corneal reflexes. Well kempt with slight unusual odors noted. Appearance is older than stated age; well kempt; has big body built; Lightbrown complexioned female. With NGT attached on the right nostril and feeding on ENSURE 5 scoops in 200 ml water, 50 cc for 10 minutes per feeding, four times a day. Electrodes in place attached to cardiac monitor and

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

11

pulse oximeter with sinus tachycardia on ECG Tracing. ET Tube in place with Mechanical Ventilator weaning Tpiece at 2 liters/minute with O2 saturation of 99%. With IVF of D50 3% NaCl 1L @10gtts/min infusing well on right metacarpal vein; at 600 cc level; Right Arm Cutdown and AV fistula on left arm; FBC in place draining to urobag 3055cc per shift yellow urine and Bowel movement per diaper. Body malaise and difficulty upon changing position noted. With the following baseline Vital Signs: -T=36.8C, afebrile. -HR=125 -patient extubated last March 5 at 10 am. -O2 saturation of 97% -IVF of D50 3% NaCl 1L @10gtts/min infusing well on right metacarpal vein received at 820 cc level -O2 saturation of 100% -IVF of D50 3% NaCl 1L @10gtts/min infusing well on right metacarpal vein received at 750 cc level -O2 saturation of 100% -IVF of D50 3% NaCl 1L @10gtts/min infusing well on right metacarpal vein received at 300 cc level

-same

-same

-same

-same

-same

-Normal power in all extremities.

-With the following baseline Vital Signs: -T=39.2C, febrile. -HR= 129 bpm, tacycardia with irregular rythm
12

-With the following baseline Vital Signs: -T=37C, afebrile -HR= 90 bpm, regular rythm (+2).

-With the following baseline Vital Signs: -T=36.7C, afebrile -HR= 89 bpm,regular rythm (+2)

bpm,tachycardi a with irregular rythm and bounding pulses. -RR=29cpm, tachypneic with shallow abdominal breathing, attatched to Mechanical Ventilator at AC mode and O2 therapy @ 2 LPM alternately through ET Tube. -BP= 130/90 mmHg, normotensive on left arm -Weight=139 kg -Height=54 -Abdominal Girth= 100cm Integument ary System SKIN - Uniform skin color with slightly darker on exposed areas. - Mucous membranes and conjunctiva pale. - Skin not intact with old wound incision in the right and left subclavian part and on both antecubital

and bounding pulses.

-RR= 26 cpm tachypneic with shallow abdominal breathing attatched to Mechanical Ventilator at AC mode and O2 therapy @2LPM alternately through ET Tube. -BP= 220/110 mmHg, hypertensive on left arm. -same -same -same

-RR= 22 cpm eupneic attached to Mechanical Ventilator and O2 therapy @ 2 LPM alternately through ET Tube.

-RR= 19 cpm eupneic, ongoing O2 therapy @ @LPM

-BP= 120/80 mmHg, normotensive on left arm. -same -same -same

-BP= 110/80 mmHg, normotensive on left arm. -same -same -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

13

area; flat moles 1 mm in height & 0.5 cm in diameter noted all over body - Warm and rough to touch in both upper and lower extremities - Dry, thin, wrinkled skin noted - Poor skin turgor, skin returns to its previous state 4 seconds after being pinched - Watery Stool noted in the Diaper Lines/rashes noted on both thighs with minimal pain noted - First Degree Pressure Ulcer with 5 cm in length and 3.5 cm in width noted in the sacral part. HAIR -dry and thin grey patchy hair noted on scalp - Scalp intact & Nontender - Hair not evident on upper and -same -same -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same
14

-same

-same

lower extremities NAILS - Light-pink colored nail beds noted on upper extremities and on lower extremities - Nails thick, rough in texture with Convex curvature and 160 degrees angle attachment - Intact epidermis surrounding nails noted - Poor capillary refill of 4 seconds in upper extremities and in lower extremities. - Head Circumference = 57cm; contour round with symmetrical facial features - No tenderness, masses, lesions and depressions upon palpation - TMJ symmetrical with no pain, crepitus or clicking; - Limited

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

Head and Face

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same
15

-same

-Able to open

Eyes

ability to fully open mouth due to the ET Tube. Eye sight unclear; parallel in alignment with both eyes slightly drooping Eyelashes slightly curled outward with no crusting or infestation Hair in eyebrows and eyelashes sparsely distributed Eyeballs soft and nontender upon palpation Lacrimal and nasolacrimal ducts nontender with clear, serous discharges Palpebral and Bulbar Conjunctiva Intact,pinki sh in color Iris round and brown in color Pupils isocoric, round, reactive to light; Sluggish accommodatio n with 2-3 mm diameter in dilated size; consensual & briskly constricts

mouth spontaneously -same -same -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same -same

-same -same

-same -same

16

to about 1 mm in diameter

Ears

- Ears consistent with skin color; intact with no lesions & swelling noted - Symmetrical ears of 4cm in height with helix aligned with outer eye canthus; attached 10 angle - Mobile and firm; Pinna recoils within 2-3 seconds - cerumen noted upon inspection - Able to hear through clear, loud voice tone - Nose consistent with skin color, located midline and symmetrical - Mobile and patent with nasal flaring, slight clear serous drainage and no masses noted - Nasal septum intact and located midline - Internal Nasal Mucosa pale-pink

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same -same

-same -same

-same -same

Nose and Sinuses

-same

-same

-same

-same -same

-same -same

-same -same

-same

-same

-same

17

with scant mucus noted; intact with no lesions - With NGT inserted at right nostril -Facial sinuses nontender with no discoloration - Frontal & Ethmoidal Sinuses Resonant tone upon percussion Neck - Neck erect, located midline, with no lumps, bulges, or masses and in upright sitting position - Easily palpable jugular veins and carotid arteries - Cervical Nodes nonpalpable and nontender - Unequal muscle strength; uncoordinate d head movement noted with discomforts and limited stamina - Thyroid located midline not visible upon swallowing; slightly

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

18

Mouth, Oropharynx & Throat

palpable, movable, nontender with no nodularity & enlargement - No adventitious sounds noted upon auscultation - Lips dry, pale in color and symmetrical in shape; Soft and nontender with chancre noted in the right area. - With ET tube inserted.

-same

-same

-same

-same

-same

-same

-same

-same

-patient extubated March 5, 2012 10 am - same -Eupneic with RR= 19 cpm. -same

Thorax and Lungs

- Positive gag reflex - Labored breathing with RR= 29 cpm. - Productive cough noted with thick clear yellow phlegm secretions - Anteroposter ior to transverse diameter is 1:2; Chest circumferenc e= 93 cm - Uniform skin temperature upon palpation; temperature noted to be slightly cold in exposed areas - Chest wall intact; absence of

-same -Labored breathing with RR= 26 cpm. -same

-same -Labored breathing with RR= 22 cpm. -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

19

tenderness, lesions and masses - Slight dullness heard upon percussion over both left and right lung fields anteriorly and posteriorly until coastal margin near the liver - with rales noted upon inspiration at both anterior and posterior left and right lung fields -trachea located midline,nonten der and has no deformity

-same

-same

-same

-same

-same

-same

-same

-same

-same

Cardiovasc ular

- Easily distinguisha ble and palpable carotid arteries and jugular veins on sternocleido mastoid muscle - Carotid artery firm with unequal pulse rates of 90 bpm on the left and on the right; rhythm regularly, strong and

- same

-same

-same

- Carotid artery firm with unequal pulse rates of 88 bpm on the left and on the right; rhythm regularly, strong and bounding pulsations noted

- Carotid artery firm with unequal pulse rates of 91 bpm on the left and on the right; rhythm regularly,st rong and bounding pulsations noted

- Carotid artery firm with unequal pulse rates of 92 bpm on the left and on the right; rhythm regularly, strong and bounding pulsations noted

20

bounding pulsations noted - Positive Thrills and palpable on five cardiac sites; bounding thrills most prominent on Apex of the Heart - Dullness noted on 3rd to 5th ICS to left sterna border extending to midaxillary lines upon percussion; Cardiomegaly noted based on laboratory result - Apical heart rate: 111 beats per minute, irregular rhythm - With sinus tachycardia with premature atrial contractions noted based in Electrocardi ogram. - Arterial pulsations not visible - Abdominal veins not visible and nonpalpable - Positive 1 non-pitting edema noted

-same

-same

-same

-same

-same

-same

- Apical heart rate: 120 beats per minute on, irregular rhythm -same

- Apical heart rate: 90 beats per minute on Apex regular rhythm -same

- Apical heart rate: 89 beats per minute on, regular rhythm -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

21

on both upper and lower extremities with minimal to no traces of hair distribution - Leg Circumferenc e: L= 31cm R= 32 cm - BP= 110/80 mmHg-200 /90 mmHg

- Leg Circumference : L= 31cm R= 32 cm - BP= 120/80 mmHg-160 /80 mmHg

- Leg - Leg Circumferen Circumferenc ce: e: L=31cm L= 31cm R=32cm R= 32 cm - BP= 100/60 - BP= 100/60 mmHg-120 mmHg-120 /80 mmHg /80 mmHg -same -same

Abdomen

- Uniform skin color with slightly lighter on abdomen than on other exposed areas - Abdominal contour round, distended with girth of 100 cm. - Umbilicus inverted and midline - Abdominal movement symmetrical during respiration with labored breathing noted - Abdominal Distension noted. - Senile kyphosis noted; knees midline - Equal size on both sides of the

-same

- Abdominal contour round, distended with girth of 100 cm. -same

- Abdominal contour round, distended with girth of 98 cm. -same

- Abdominal contour round, distended with girth of 98 cm. -same

-same -same -same

-same -same -same

-same -same -same

Musculoskeletal

-same

-same

-same

22

Genitourin ary

body. - Left and right extremities has 5 of muscle strength. - Absence of bone deformities. - Leg Length: Left= 62cm; Right= 63cm - Leg Circumferenc e on both legs 30cm - Arm Length: Left= 65cm; Right= 66.5cm - Arms sagging with Arm Circumferenc e: 32cm on both arms - Scant grey hair on genitalia with no infestation - Vaginal skin intact absence of masses, lesions and abscence of any unusual discharges - Intact skin, surrounding anus - With FBC in place attached draining to urobag - Urinary output of 30-55cc per shift of yellow urine per shift - Flatulence noted during shift - Defecated brown and

-same

-same

-same -same -same

-same -same -same

- Left and right extremities has 6 of muscle strength. -same -same -same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same -same

-same -same

-same -same

-same

-same

-same

-same - same
23

-same - same

-same - Defecated brown and

watery stool once on diaper.

watery stool twice on diaper.

Neurologic

Asleep but arousable to speech With the Glasgow coma scale of 10 (E4, V1, M5). Eye opens spontaneousl y; no response due to endotracheal tube inserted; identifies localized pain. No seizure attack

-same -same

-same -same

Asleep but arousable to speech With the Glasgow coma scale of 13 (E4, V3, M6). Eye opens spontaneous ly; uses inappropria te words; reacts to verbal command.

- myoclonic jerk, right uooer extremity with midline gazing -same

Focal jerky movement, back of upper extremity

-no seizure attack

Cranial Nerves

CN I- Patient is with nasogastric tube on the right nostril. CN II III, IV, VIPatient is able to see approximately at only a distance of two feet on both eyes. - Eyes opens spontaneousl y; PERRLA direct and consensual, EOM intact. CN V Patient is on ET Tube with leukoplast tape to keep

same

-same

-same

-same

-same

-same

-same

-Patient extubated already last March 5 at 10

24

tube in place. - Patient perceives light touch and superficial pain bilaterally. - Corneal reflex intact. - Sluggish accommodatio n with 2-3 mm in diameter. CN V Facial nerve intact; able to make faces. CN VII Patient is able to hear at only a distance of approximately 2 feet on both ears. CN IX & X Swallow and cough reflex intact. - Speech not intact due to presence of secretions. CN XI Bilateral weakness - Poor ROM of neck with +2/5 strength CN XII Patient cannot protrude tongue due to ET Tube. Light Touch Light

-same

-same

am. -same

-same -same

-same -same

-same -same

-same

-same

-same

-same

-same

-same

-same -same

-same -same

-same -same

-same

-same

-same

-same

-same

-same

Sensory Function

-same

-same

-same

25

sensation intact bilaterally in upper and lower extremities. -same Pain Pain sensation intact bilaterally in upper and lower extremities. -same Vibration Vibration sensation intact bilaterally in upper and lower extremities. -same Kinesthetics Position sensation intact bilaterally in upper and lower extremities -same Stereognosis Stereognosis intact bilaterally. -same Graphesthesia intact bilaterally. -same Two- point discrimination Discriminates between two points on fingertips no more than 0.5 cm apart and on hands no more than 2 cm apart. -same Point localization Point localization
26

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

intact. Reflexes Deep tendon reflexes -same Sensory extinction Extinction intact. -same Biceps reflex Contraction of biceps with flexion of forearm, +2 -same Triceps reflex Contraction of triceps with extension of elbow, +2 -same Brachioradiali s Flexion at elbow and fingers, +2 -same Patellar Contraction of quadriceps with extension of knee, +2 -same Achilles Plantar flexion of foot, +2 -same Abdominal Umbilical moves towards stimulus -same Anal Anus puckers when anus was gently stroked with gloved hand -same Plantar Flexion of all toes when sole of patients foot was stroked in an arc from lateral heel to medial ball.
27

-same

-same

-same

-same

-same

-same

-same

-same

-same

-same

Superfi cial reflexe s

-same

-same

-same

same

-same

-same

-same

-same

Laboratory Results Legend: Red Increased Blue- Decreased

Routine Laboratory Results I. Hematologic studies (I)

DEFINITION: A complete blood count (CBC) is a series of tests used to evaluate the composition and concentration of the cellular components of blood. It consists of a series of tests that determine the number, variety, percentage, concentrations and quality of blood cells. RATIONALE: The CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is used for the following purposes as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis, to identify persons who may have an infection, to diagnose anemia, to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia, to monitor treatment for anemia and other blood diseases and to determine the effects of chemotherapy and radiation therapy on blood cell production.

CBC RESULTS
300 250 200 150 100 50 0 Platelet (140-440) Mean Platelet volume (0-100)

Figure 2.1 Complete Blood Count Results

28

CBC RESULTS
100 90 80 70 60 50 40 30 20 10 0 1-Mar 24-Feb 24-Feb 22-Feb 17-Feb 15-Feb 12-Feb 11-Feb 10-Feb WBC (4.1-10.9) RBC (4.5-5.9) MCV (80-100) MCH (26-34) MCH con (31-36) RCDist width (11.6-14.8)

Figure 2.2 Complete Blood Count Results

CBC RESULTS
110 100 90 80 70 60 50 40 30 20 10 0 1-Mar 24-Feb 24-Feb 22-Feb 17-Feb 15-Feb 12-Feb 11-Feb 10-Feb Basophils eosinophils monophils lymphocytes neutrophils

Figure 2.3 Complete Blood Count Results

INTERPRETATION: Hematologic studies shows that patient is having severe infection because WBC results are increased, RBC results (hemoglobin, platelet, hematocrit) are decreased which indicates decrease O2 carrying capacity and risk for bleeding.

29

II.

Hematologic studies (II)

DEFINITION: These are series of tests that measure the clotting mechanisms of the body and identify the type & extent of suspected coagulation studies. RATIONALE: Clotting time and bleeding time are assessed in the case of our patient because upon assessment of surgical incision, presence of palpable hematoma or blood clot was noted and needs to be lyzed & excreted out of the body. These tests are important to determine if anti-platelets and anti-coagulants can be safely given to our patient or not, especially in patients with hemophilic cases that bleed easily, Anti-coagulants, Thrombolytics, anti-platelet medications are strictly contraindicated. (March 1, 2012) Prothrombin time Control Protime % activity INR INTERPRETATION: Hematologic studies (II) show that patients results are normal. This indicates that patients body is using up its clotting factors so quickly that the blood can bleed and clot at its normal span of time. Normal values 11.5-15.5 70-100 - <1.2 Results 13.0 13.2 94 1.04

Table 2.2 Prothrombin Time Results

III. Blood Chemistry DEFINITION:

Blood chemistry testing is defined simply as identifying the numerous chemical substances found in the blood. The serum chemistry profile is

one of the most important initial tests that is commonly performed. These measurements aid in assessing the function of various organs and body systems. The analysis of these substances will provide clues to the functioning of the major body systems. RATIONALE: Most nurses are concerned with the fact that many blood chemistry tests are performed on the serum derived from whole blood. Serum, of course, is the liquid remaining after whole blood has clotted in the sample tube. Some blood chemistry tests are performed on other parts of blood as well.

30

February 24, February 2012 27, 2012 SODIUM 133-146 (CU) 133-146 (SI) POTASSIUM 3.4-5.2 (CU) 3.4-5.2 (SI) SGPT/AU 5.0-50 (CU) 5.0-50 (SI) CREATININE 0.60-1.50 (CU) 53.04132.60(SI) CALCIUM 8.4-10.3 (CU) 2.10-2.58 (SI) PHOSPORUS 2.5-4.7 (CU) 0.81-1.52 (SI) MAGNESIUM 1.4-2.4(CU) 0.56-0.96 (SI) CHLORIDE 98.0-107 (CU) 98.0-107 (SI) INTERPRETATION: 129.00mmol/L 129.00mmol/L -

February 2012 142.00 mmol/L 142.00 mmol/L

10, March 2012

4,

139.00mmol /L

5.04mmol/L 5.04mmol/L -

54.00 u/L 54.00 u/L 5.19mg/dl 458.80umol /L -

4.54mmol/L 4.54mmol/L -

5.09mmol/L

7.28mg/dl 1.82 mmol/L

4.80 mg/dl 1.55 mmol/L 2.10 mg/dl 0.84 mmol/L 104.00 mmol/L 104.00 mmol/L

Table 2.3 Serum Electrolytes Results

Blood chemistry results shows that sodium level is decreased which indicates dilutional hyponatremia since patient is experiencing generalized edema. Increased SGPT and creatinine also indicates increased nitrogenous waste products circulating in the serum. Decreased calcium in the serum indicates hypocalcemia which was supported in the CT scan result that calcium is deposited in the gallbladder and in the left kidney.

IV.

Capillary Blood Sugar

DEFINITION:
Blood glucose monitoring is a way of testing the concentration of glucose in the blood (glycemia). Particularly important in the care of diabetes mellitus, a blood glucose test is performed by piercing the skin (typically, on the finger) to draw blood, then applying the blood to a chemically active disposable 'teststrip'.

31

RATIONALE: This is routinely done to the patient to monitor her blood glucose level since the patient had a diabetes mellitus type 2 which reveals individual patterns of blood glucose changes, and helps in the planning of meals, activities, and at what time of day to take medications. Also, testing allows for quick response to high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia). This might include diet adjustments, exercise, and insulin (as instructed by the health care provider).

CBS MONITORING RESULTS

370 350 330 310 290 270 250 230 210 190 170 150 130 110 90 70 50

Normal level: 70-100mg/dl

result at 6:30 am result at 8 :30 pm

26-Feb

10-Feb

12-Feb

14-Feb

16-Feb

18-Feb

20-Feb

22-Feb

24-Feb

28-Feb

1-Mar

3-Mar

Figure 2.4 Capillary Blood Sugar Results

Interpretation: The result shows that patient had fluctuating blood glucose level since February 10 until March 5, 2012. Almost all results from the first day were above 100mg/dl. There were no result showing decrease in blood glucose level of the patient. V. Urinalysis (urinary catheter)

DEFINITION: Urinalysis is a test that determines the content of the urine. Urinalysis can be used to detect some types of disease, particularly in the case of metabolic disorders and kidney disease. It can also be used to uncover evidence of drug abuse. RATIONALE: This was ordered to the patient to identify if the patient is having a urinary tract or kidney infection since patient is experiencing END Stage Renal Disease. This also used to evaluate patients causes of kidney failure, to screen for progression of her chronic conditions such as diabetes mellitus and high blood pressure (hypertension)

32

5-Mar

Date: February 22, 2012 Components Macroscopic Examination Color Appearance Glucose CHON Ph Spgr Bilirubin Urobilinogen Ketone Nitrite Leukocytes Blood +++ Microscopic examination RBC WBC Epithelial cells mucus threads Amorphous materials Bacteria INTERPRETATION: The result shows positive for glucose which indicates that the filtered load of glucose exceeds the maximal tubular reabsorvative capacity for glucose, positive for blood which indicates presence of large number of RBCs and WBCs in the urine sediment which establishes the diagnosis of hematuria and presence of rare amount of mucus threads, amorphous materials and bacteria which indicates infection. Normal values Amber yellow Clear Negative 5.0-9.0 1.003-1.030 negative Negative Negative Negative Negative negative Results Yellow Cloudy (++) 150mg/dl (+++) 300mg/dl 8.0 1.005 Negative Negative Trace mg/dl Negative 25 WBCs/ ul 0.03 mg/dl

Less than 5/hpf Less than 5/hpf Negative or rare Negative Negative negative

30-40/hpf 10-20/hpf Rare Rare Rare Rare

Table 2.4 Urinalysis Results

VI.

Fecalysis

DEFINITION: Fecalysis is also known as stool analysis. It refers to a series of laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer. RATIONALE: This is done to the patient for diagnostic purposes such as to examine the general condition of the digestive tract of the patient if there are any changes on the levels of any substances such as RBC and WBC which may be signs of infection and if the patient is having signs of poor absorption.
33

Components Macroscopic Examination Color Consistency

Normal Values brown soft and bulky, small and dry, depending on the diet 0-3 hpf 6-8 hpf None None

Results Light yellow Mucoid watery

Microscopic Examination RBC/hpf WBC/hpf Ova and Parasites Bacteria INTERPRETATION:

0-2 hpf 0-1 hpf No ova and parasites seen Many

Table 2.5 Fecalysis Results

The results of fecalysis shows decrease in WBC and many bacteria present in the stool which may indicate infection. The results also shows light yellow color and mucoid watery consistency of the stool which is an abnormal finding. SPECIFIC LABORATORY RESULTS I. Arterial Blood Gases

DEFINITION: Arterial blood gases (ABGs) are diagnostic tests performed on blood taken from an artery which contains oxygen and carbon dioxide. RATIONALE: Arterial Blood Gases or ABGs are done to evaluate oxygenation and acid-base-balance. Numerous factors can be evaluated to determine whether tissue oxygenation is adequate and the excretion of waste products (CO2- carbon dioxide) is occurring properly from the lungs. Temp PH Date 3/5/12 PC O2 PO2 HCO3 TCO2 BEecf BE(b) SO2 C 96% PaO2

36.9 7.39 35 mm Hg

84 mm Hg

21.2 mmol/ L

22.3 mmol/ L

-3.8 mmol/ L

-3.2 mmol/ L

0.39 \mmHg

Table 2.6 Arterial Blood Gas Results Normal values: PH-7.35-7.45 PCO2- 35-45mmhg PO2- 80-100mmhg HCO3-22-26mEq/L 34

PaO2-30-40mmhg

INTERPRETATION: Patients ABG result shows that there is a decrease in the PO2 ,HCO3 and PaO2 thereby indicates that the patients lungs are unable to release the rising systemic carbon dioxide. Causing the bodys acidbase balance to become unstable.

II.

Cardiac Troponin I

DEFINITION: Troponin tests are primarily ordered to evaluate people who have chest pain to see if they have had a heart attack or other damage to their heart. However, troponins are the preferred tests for a suspected heart attack because they are more specific for heart injury than other tests (which may become positive in skeletal muscle injury) and remain elevated for a longer period of time. RATIONALE: The troponin test is used to help diagnose a heart attack, to detect and evaluate mild to severe heart injury, and to distinguish chest pain that may be due to other causes. In those who experience heart-related chest pain, discomfort, or other symptoms and do not seek medical attention for a day or more, the troponin test will still be positive if the symptoms are due to heart damage. Troponin I INTERPRETATION: (February 10, 2012) Troponin concentration Below 0.1 ug/L >=0-1-< 0.8 ug/L >= 0.8 ug/L Interpretation Trop= negative Possible myoarchial AMI cut-off 0.09ug/dl

Table 2.7 Cardiac Troponin Results

III. Blood Culture DEFINITION: A blood culture is a test to find an infection in the blood. The blood does not normally have any bacteria or fungi in it. A blood culture can show what bacteria or fungi are in the blood.

35

RATIONALE: A blood culture is done to find if the patient is experiencing bacterial infection that has spread into the different systems of the body since the patient is at risk for developing infection due to her intrajugular Catheter and endotracheal tube, venous cutdown and AV Fistula. A culture can also show what type of bacteria is causing the infection such as fungal infection. This finds the best antibiotics for the patient to kill the bacteria or a fungus which is called sensitivity testing and as well as finds the cause of an unexplained fever or shock or a person becoming extremely ill. DATE February 27, 2012 February 28, 2012 February 29, 2012 February 25, 2012 February 26, 2012 February 26,2012 SPECIMEN Blood IJ Cath Blood IJ Cath Blood IJ Cath Blood Left Hand Blood Right Arm Endotracheal Tip FINAL RESULT Gram- Bacilli Burkholderia Capacia with Sensi Candida Tropicalis Result on March 25, 2012 Result on March 26, 2012 February 29,2012: 1.)Candida Tropicalis 2.) Burkholderia Cepacia

Table 2.8 Blood Culture Results

INTERPRETATION: Blood culture shows that patient is positive for Candida Tropicalis and Burkholderia Cepacia both on IJ Cath and ET Tube Tip. Once B. cepacia enters the body, there are three possible effects and it is not possible to predict which will happen. Sometimes B. cepacia colonizes in the lungs, causes no symptoms, and has no long term effect. Other times B. cepacia colonizes in the lungs and causes damaging lung infections and inflammation that lead to a slow deterioration of lung function. Candida tropicalis is a species of fungus that belongs to the Candida family. Like the more common Candida albicans, it is a yeast-type fungus that proliferates in the skin and digestive tract and is a normal fungus that grows in most animals and humans. However, Candida tropicalis often proliferates to the point it can cause septicemia (a type of poisoning or infection) in the body, especially in those with diabetes, lymphoma and leukemia.

IV.

Urine Culture

DEFINITION: A urine culture is a test to find and identify germs (usually bacteria) that may be causing a urinary tract infection (UTI). RATIONALE:

36

This test was done to the patient to know if the patient is experiencing urinary tract infection and to know the growth rate of the microorganism present in the urine of the patient.

DATE February 26, 2012 February 27, 2012

RESULT Gram + Cells: no microorganisms seen; no growth after 24 hours of incubation Final report: no growth after 48 hours of incubation

Table 2.9 Urine Culture Results

INTERPRETATION: The results of urine culture shows negative for microorganism growth after 24 and 48 hours of incubation.

V.

Antimicrobial Susceptibility Testing

DEFINITION: AST is a laboratory method for determining the susceptibility of organisms to therapy with antibiotics. RATIONALE: This was done to the patient to determine what kind of antibiotics is susceptible or resistant to the bacteria or fungi causing the infection in the patient. This helps the patient identify the best antibiotic therapy for the patients condition. DISK USAGE (ug) MICU (ug/mL) Penicillins Cephalosporins Ceftazidine (a,b) Aminoglycosides Flourquinolones Others: Meropenem Trisulfamethoxazole Date: March 02, 2012 DISK USAGE (ug) MICU (ug/mL) Penicillin 10 Ampicillin(Acdef) (Sub/(ace) Amociclav(a,c,e) Ticarliclav(a,b) Piperacillin/ tazobactam 10/10 20/10 75/10 110
37

/ INTERPRETATION

30

Susceptible

10 1.25/1.23

Susceptible Susceptible

/ INTERPRETATION Resistant Intermediate Resistant susceptible susceptable

Cephalosporin Cefazolin Cephalotin Cefoxitin Cefuroxime Cefotaxime Ceftazidime Cefepime Aminoglycoside Amikacin Gentamicin Tobramycin Flourquinolones Lipofloxacin Others Azetreonam Chlorphenicol Imepenem Tetracychline Meropenem Tri sulfamethoxazol Levofloxacin INTERPRETATION:

30 30 30 30 30 30 30 30 10 10 5 30 30 10 30 10 1.25/23 5

Resistant Resistant Resistant Intermediate Susceptible Susceptible Susceptabe Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible Susceptible

Table 2.10 Antimicrobial Susceptibility Test Results

The results shows that drugs who are susceptible to the fungi seen on blood culture are likely, but not guaranteed to inhibit the pathogenic microorganism; may be an appropriate choice for treatment, drugs which are intermediate are may be effective at a higher dosage, or more frequent dosage, or effective only in specific body sites where the antibiotic penetrates to provide adequate concentrations and drugs which are resistant are not effective at inhibiting the growth of the organism and may not be an appropriate choice for treatment.

DIAGNOSTIC RESULTS I. Medical Imaging Center (CT scan section)

DEFINITION: Computed Tomography (CT) is a powerful nondestructive evaluation (NDE) technique for producing 2-D and 3-D cross-sectional images of an object from flat X-ray images. RATIONALE: CT is used for spine and head imaging, gastrointestinal imaging, vascular imaging (e.g., detection of blood clots), cancer staging and radiotherapy treatment planning, screening for cancers and heart disease, rapid imaging of trauma, imaging of musculoskeletal disorders, detection of signs of
38

infectious disease, and guidance of certain interventional procedures (e.g., biopsies). CT is the most commonly performed procedure for imaging the chest. CT is also used to perform noninvasive angiographic imaging to assess the large blood vessels.

Date February 26, 2012 (Brain Plain)

Interpretation

defined hypodensities with volume loss are noted in the right occipital lbe and Hx: 1 day prior noted to have right cerebellar hemisphere episode of seizure, afternoon prior to scan noted recurrence -small hypodensities are noted of focal seizure episodes, (+) in the thalami dimension non-contrast axial CT images of the head reveal the -patchy hypodensities are noted following findings: in both frontal, parietal and occipital white matter. -the rest of the parenchymal density is normal with no focal lesions evident. The rest of the gray white matter interface is maintained. -no acute intracranial hemorrhage nor abnormal extra axial fluid accumulation is seen -the peripheral sulci, lateral fissures, cisterus and ventricles are prominent -the midline undisplaced structures are

-well

-the internal carotid arteries and left vertebral artery are segmentally classified -the sella turica and gland are not unusual pineal

-soft tissue densities are seen in the left sphenoid and posterior ethmoid sinuses -the rest of the included paranasal sinuses, petro mastoid, orbits, and bony
39

cadvaria are unremarkable IMPRESSION: 1. Chronic infarcts, right occipital lobe and right cerebellar hemisphere. 2. Lacunar thalami infarcts, beta

3. Chronic small vessel ischemic changes, beta frontoparietooccipital white matter 4. Brain atrophy 5. Atherosclerotic disease. 6. Left sphenoid posterior sinusitis vessel

and ethnoid

February 23, 2012 (Adrenal Plain) Hx: T/C adrenal mass Non contrast axial CT images of the adrenals revealing the following: Both adrenals are normal in size and configuration. No definite evidence of adrenal mass noted. The visualized gallbladder shows multiple calcific densities (157 to 178 HU) within, the largest measuring o.5x0.6cm The visualized liver, pancreas and spleen are unremarkable The visualized left kidney shows punctuate calcific densities (107-127HU) within
40

its calycer. No hydronephrosis is seen in both kidneys. The right kidney shows no radiopaque literiasis. No parenchymal lesions are detected. The visualized unusual. bowels are not

Table 2.11 CT Scan Results

II.

Electroencephalogram

DEFINITION: An electroencephalogram (EEG) is a test that measures and records the electrical activity of your brain. Certain conditions, such as seizures, can be seen by the changes in the normal pattern of the brain's electrical activity. RATIONALE: An electroencephalogram (EEG) was done to the patient to check the patients electrical activity of the brain and to diagnose epilepsy and see what types of seizures are occurring in her. EEG is useful and important test in confirming a diagnosis of epilepsy. This checks the patients problems with loss of consciousness or dementia and help find out a patient's chance of recovery after a change in consciousness. Date: February 13, 2012 Clinical History: Patient had history of cardiopulmonary arrest for approximately 12-15 minutes post-resuscitation she was noted to have referential gaze and decrease sensorium Technical Reading: This is a 16 electrode EEG recording done in wakefulness and drowsiness. No sleep recording was performed. The background activity in wakefulness predominantly consists of low amplitude. Theta waves 5-7 Hz. There is good reactivity to manual eye closure and opening. Photic stimulation was remarkable. Hyperventilation was not performed. No epileptiform discharges and clinical events were noted during the recording. Conclusion: This is an abnormal EEG recording due to the presence generalized slowing of background activity in wakefulness. This may be found in cases like hypoxic encephalopathy. No epileptiform activity was noted during the recording.

41

III. Electrocardiogram DEFINITION: An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical activity of your heart. An EKG translates the heart's electrical activity into line tracings on paper. The spikes and dips in the line tracings are called waves. RATIONALE: An electrocardiogram (EKG or ECG) is done to the patient to check her heart's electrical activity and find the cause of her unexplained chest pain, which could be caused by a heart attack, inflammation of the sac surrounding the heart (pericarditis), or angina. This also finds the cause of symptoms of the patients heart disease, such as shortness of breath,dizziness, fainting, or rapid, irregular heartbeats (palpitations) and to find out if the walls of the heart chambers are too thick (hypertrophied). This checks the health of the heart because high blood pressure, high cholesterol, diabetes, or a relative who had early heart disease are present to the patient.

DATE TIME Atrial Rate Ventricular Rate Rhythm P-Wave Axis PR Interval QRS duration QT QRS Complex ST Segment T-wave Transitional Zone Conclusion

February 03, February 10, February 10, February 10, February 11, 2012 2012 2012 2012 2012 4: 52 PM 5:19 PM 5:25 PM 6:37 PM 107/min 160/min 150/min 125/min 136/min 107/min Sinus Upright 40 0.12 0.08 sec 0.36 sec Normal Isoelectric 160/min Sinus Upright 56 0.16 0.14 sec 0.24 sec Wide Isoelectric 150/min Sinus Upright - 0.16 0.08 sec 0.32 sec Normal Isoelectric 125/min Sinus Upright 40 0.16 0.08 sec 0.32 sec Normal Isoelectric; depressed at III,IV AVF,V4,V5,V3 Upright V4 Sinus tachycardia; left atrial abnormality; nonspecific 136/min Sinus Upright 63 0.16 0.08 sec 0.30 sec Normal Isoelectric, depressed at VS, Vb Upright V4-V5 Sinus tachycardia; left atrial abnormality Poor P wave

Upright V3-V4 Sinus tachycardia; left atrial abnormality; non-

Upright V6 Sinus tachycardia with occasional premature

Upright Sinus tachycardia with frequent premature

42

speciific atrial ventricular ST-T wave contractions contractions changes left atrial of two forms abnormality; complete right bundle branch block; persisted posterobasal forces; nonspecific STT wave changes
Table 2.12 ECG Results

ST-T wave progression changes from V1-V3; Nonspecific ST-T waves changes

IV.

Chest X-ray

DEFINITION: A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. X rays are a form of radiation that can penetrate the body and produce an image on an x-ray film. Another name for x ray is radiograph. RATIONALE: Chest X-RAY was ordered to my patient for diagnostic purposes to detect if there any abnormalities in her lungs since she commonly was experiencing dyspnea as well detect abnormalities in her heart, aorta, and the bnes of the thoracic area. This was also done to the patient to compare previous studies and check for the placement of her endotracheal tube since she have ET tube upon admission. DATE February 08,2012 IMPRESSION 1.) Cardiomegaly 2.) Minimal left pleural effusion and/or thickening 3.) Artherosclertic aorta 1.) Progressing pulmonary congestion 2.) Right basal pneumonia congestion 3.) Minimal left pleural effusion and/or t thickening 4.) Left basal bronchoiectiatic changes with complications 5.) Atherosclerotic aorta 6.) Suggest ETT Repositioning 1.) Hyperaerated right lung 2.) Resolving pulmonary congestion 3.) Intercurrent pneumonia still not ruled out 4.) Minimal left pleural effusion and on thickening 5.) Left basal bronchiectatic changes with complications 6.) Atherosclerotic aorta 7.) ETT repositioning still suggested 1.) Left basal bronchiectatic changes
43

February 12, 2012

February 14, 2012

February 15, 2012

February 26, 2012

2.) Intercurrent pneumonia not ruled out 3.) Minimal left pleural effusion or thickening 4.) Pulmonary congestion- status quo 5.) Atherosclerotic aorta 6.) ETT repositioning suggested 1.) Resolving left basal pneumonia with bronchiectatic changes 2.) Minimal left pleural effusion and/or thickening 3.) Pulmonary congestion 4.) ETT in place 5.) Atherosclerotic aorta
Table 2.13 Chest X-Ray Results

44

CHAPTER III Literature Review ANATOMY AND PHYSIOLOGY

ENDOCRINE SYSTEM

Fig.A.1 ENDOCRINE SYSTEM Homeostasis depends on the precise regulation of the organs and organ systems of the body. The nervous ad endocrine systems are the two major systems responsible for that regulation. Together they regulate ad coordinate the activity of nearly all other body structures. When these systems fail to function can result in diseases such as diabetes mellitus or Addisons disease. The regulatory functions of the nervous and endocrine systems are similar in some respects, but they differ in other important ways. The nervous system controls the activity of tissues by sending action potentials along axons, which release chemical signals at their ends, near the cells they control. The endocrine system release chemical signals into the circulatory system, which carries them to all parts of the body. The cells that can detect those chemical signals produce responses. The nervous system usually acts more quickly and has short-term effects, whereas the endocrine system usually responds more slowly and has longer-lasting effects. In general, each nervous stimulus controls a specific tissue or organ, whereas each endocrine stimulus controls several tissues or organs. Functions of endocrine system The main regulatory functions of the endocrine system include: 1. Water balance. The endocrine system regulates controlling the solute concentration of the blood. 45 water balance by

2. Uterine concentration and milk release. Regulates uterine contractions during delivery of the newborn and stimulates milk release from the breasts in lactating females. 3. Growth, metabolism, and tissue maturation. Regulates the growth of many tissues, such as bone and muscle, and the rate of metabolism of many tissues, which helps maintain a normal body temperature and normal mental functions. Maturation of tissues, which results in the development of adult features and adult behavior, are also influenced by the endocrine system. 4. Ion regulation. Regulates Na+, K+, and Ca2+ concentrations in the blood. 5. Heart rate and blood pressure regulation. The endocrine system helps regulate the heart rate and blood pressure and helps prepare the body for physical activity. 6. Blood glucose control. The endocrine system regulates blood glucose levels and other nutrients level in the blood. 7. Immune system regulation. Helps control the production and functions of immune cells. 8. Reproductive functions control. Controls the development and the functions of the reproductive system in males and females. Endocrine glands: Endocrine organs, called glands, secrete hormones into the bloodstream. Hormones affect the activity of target sites that are often located far from the site of release. Exocrine organs direct the function of their target sites by releasing their active. Human endocrine system: The major endocrine organs include the hypothalamus and the hypophysis, or pituitary gland. Other endocrine glands within the body include: thyroid, parathyroids, adrenals, pancreas, ovaries, and testes.

The hypothalamus: The hypothalamus is located in the forebrain, directly above the pituitary gland. The hypothalamus receives input from other parts of the brain and from peripheral nerves. This input affects neurosecretory cells within the hypothalamus. The pituitary gland: The anterior pituitary synthesizes its own hormones. Capillaries within the anterior pituitary receive signals from the hypothalamus that tell the anterior pituitary whether or not to release certain hormones. The thyroid gland: The thyroid gland is a bilobed structure found at the trachea. It synthesizes and secretes three hormones: 1. thyroxine (T4), 2. triiodothyronine (T3), and 3. calcitonin. The parathyroids are four small glands embedded in the thyroid. They produce and secrete parathyroid hormone (PTH).

The adrenal gland: The adrenal glands are located on top of the kidneys. Each gland is subdivided into an outer adrenal cortex and an inner adrenal medulla. The pancreas: The pancreas is both an endocrine organ and an exocrine organ. The exocrine portion of the pancreas secretes digestive enzymes into the pancreatic duct. The endocrine portion of the pancreas secretes hormones, including insulin and glucagon. The ovaries: The ovaries produce and secrete steroid hormones known as estrogens and progesterone.

46

TYPES OF HORMONES In order to regulate the myriad functions required for normal bodily function, the glands and organs that comprise the endocrine system create many types of hormones, each with a specific function. Included in the different types of hormones your endocrine system produces are the following: Vasopressin -- Created by the hypothalamus, vasopressin prompts the pituitary gland to release a hormone that helps maintain blood pressure and water and electrolyte balance. Growth Hormone -- Growth hormone, or GH, is one of the types of hormones produced by the pituitary gland (one of the most important glands in the endocrine system); GH stimulates growth during childhood and also stimulates cell reproduction, which helps adults maintain muscle and bone mass. Calcitonin -- Calcitonin, produced by the thyroid gland, aids in bone construction. Insulin -- Insulin regulates glucose, or sugar intake, by helping it move from the blood into cells. Insulin is a hormone produced by the pancreas which is central regulating carbohydrate and fat metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle. Insulin stops the use of fat as an energy source by inhibiting the release of glucagon. With the exception of the metabolic disorder diabetes mellitus and Metabolic syndrome, insulin is provided within the body in a constant proportion to remove excess glucose from the blood, which otherwise would be toxic. When blood glucose levels fall below a certain level, the body begins to use stored sugar as an energy source through glycogenolysis, which breaks down the glycogen stored in the liver and muscles into glucose, which can then be utilized as an energy source. As its level is a central metabolic control mechanism, its status is also used as a control signal to other body systems. In addition, it has several other anabolic effects throughout the body. When control of insulin levels fails, diabetes mellitus will result. As a consequence, insulin is used medically to treat some forms of diabetes mellitus. Patients with type 1 diabetes depend on external insulin for their survival because the hormone is no longer produced internally. Patients with type 2 diabetes are often insulin resistant and, because of such resistance, may suffer from a "relative" insulin deficiency. Some patients with type 2 diabetes may eventually require insulin if other medications fail to control blood glucose levels adequately. Over 40% of those with Type 2 diabetes require insulin as part of their diabetes management plan. Insulin also influences other body functions, such as vascular compliance and cognition. Once insulin enters the human brain, it enhances learning and memory and benefits verbal memory in particular. Enhancing brain insulin signaling by means of intranasal insulin administration also enhances the acute thermoregulatory and glucoregulatory response to food intake, suggesting that central nervous insulin contributes to the control of whole-body energy homeostasis in humans. Human insulin is a peptide hormone composed of 51 amino acids and has a molecular weight of 5808 Da. It is produced in the islets of Langerhans in the pancreas.

Adrenaline -- Produced within the adrenal glands (small glands located at the top of each kidney), adrenaline works with noradrenaline to produce the "fight or flight" response by increasing the supply of oxygen to the brain and muscles, dilating the pupils, and suppressing bodily functions not useful in an emergency situation (such as digestion). Noradrenaline -- Noradrenaline works with adrenaline to help the endocrine system produce the "flight or flight" response; in an 47

emergency situation, it boosts the oxygen supply to the brain and the supply of glucose to the muscles. CARDIOVASCULAR SYSTEM

Fig. A. 2. CARDIOVASCULAR SYSTEM

The heart is a muscular organ that is essential for life because it pumps blood through the body. Fluids flow through the entire body only if they are forced to do so. The force is commonly produced by a pump, which increases the pressure of the liquid at the pump above the pressure in the pipe. Thus, the liquid flows from the pump through the pipe from an area of higher pressure to an area of lower pressure. If the pressure produced by the pump decreases, flow the liquid through the pipe decreases. Like a pump that forces water to flow through a pipe, the heart contracts forcefully to pump blood through the blood vessels of the body. The heart of a healthy adult, at Functions of the heart 1. Generating blood pressure. Contractions of the heart generate blood pressure, which is required for blood flow through the blood vessels. 2. Routing blood. The heart separates the pulmonary and systemic circulations, which ensures the flow of oxygenated blood to tissues. 3. Ensuring one-way blood flow. The valves of the heart ensure rest, pumps approximately 5 liters of blood per minute. For most people, the heart continues to pump at approximately that rate for more than 75 years; and, during short periods of vigorous exercise, the amount of blood pumped per minute increases several fold. If the heart loses its pumping ability foe even a few minutes, however, blood flow through the blood vessels stops and the life of the individual is in danger.The heart is actually two pumps in one. The right side of the heart pumps blood to the lungs and back to the left side of the heart through vessels of the pulmonary circulation. The left side of the heart pumps blood to all other tissues of the body ad back to the right side of the heart through vessels of the systemic circulation a one-way flow of blood through the heart and blood vessels.

48

4. Regulating blood supply. Changes in the rate and force of heart contraction match blood flow to the changing metabolic needs of the tissues during rest, exercise, and changes in body position. The Circulatory System: The circulatory system delivers oxygen and nutrients to tissues and removes carbon dioxide and waste from tissues. Blood circulation: Pulmonary Circuit - circulation between lung and heart releases carbon dioxide. Systemic Circuit - circulation between the heart and body delivers oxygen and nutrients and also picks up waste. The Heart: Anatomy and Conduction: The main pump in the cardiovascular system which generates the pressure required to move blood through the system. SA node: The heart has a unique, automatic electrical conducting system. The central nervous system (CNS) modulates the rate of contraction of the heart, but the heart can generate and maintain its own rhythm independent of the CNS. Sinoatrial node contains pacemaker cells, which create action potentials at a frequency that results in a normal heart rate of 70-80 beats/minute. Electrocardiography: The electrocardiogram detects the electrical activity of each heartbeat as it develops over time. The P wave represents the depolarization as it spreads over the atria. The QRS complex corresponds to the current that spreads over the ventricles. The T wave represents the repolarization of the ventricles, during which time they become ready for the next contraction. Oxygen Delivery Blood pressure is generated nutrients to the body. to heart the facilitates Tissues delivery of

by

the

and

Capillaries are the smallest blood vessels, where exchange takes place. Passive diffusion lets oxygen/ nutrients out of the blood into the tissue, and lets carbon dioxide/ waste out of the tissue into the blood. Hydrostatic pressure is caused by the blood pressure generated by the heart beating. Na+ and other electrolytes cause osmotic pressure. Blood & Blood Vessels

Smooth muscle around arterioles modulates blood pressure by changing peripheral resistance. If systemic blood pressure is decreased, neuromodulation of the arterioles causes vasoconstriction, which, in turn, causes an increase in blood pressure.Blood is made up of the following components: plasma contains water and proteins, red blood cells, white blood cells and platelets. Coagulation is an important process in which soluble proteins form an insoluble clot.Oxygen is delivered to the tissues bound to hemoglobin. Hemoglobin is a metalloprotein, made up of 4 globin polypeptide chains with 4 imbedded oxygen-binding heme molecules.

49

URINARY SYSTEM

Fig. A. 3 URINARY SYSTEM The urinary system consists of two kidneys, two ureters, the urinary bladder, and the urethra. A large volume of blood flows through the kidneys, which removes substances consumed with food. The urine produced by the kidneys flows through the ureters to the urinary bladder, where it is stored until it is eliminated through the urethra. The kidneys can suffer extensive damage and still maintain their extremely important role in the maintenance of homeostasis. As long as about one-third of one kidney remains functional, survival is possible. If the functional ability of the kidneys fail completely, however, death will result without special medical treatment. Functions of the urinary system 1. Excretion Remove waste products, many of which toxic, from the blood. Most waste products are metabolic by products of cells and substances absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some of these waste products, but they cannot compensate if the kidneys fail to function. 2. Regulation of blood volume and pressure. The kidneys play a major role in controlling the extracellular fluid volume in the body by producing either a large volume of dilute urine or a small volume of concentrated urine. Consequently, blood volume and blood pressure are regulated by the kidneys. 3. Regulation of the concentration of solutes in the blood. The kidneys help regulate the concentration of the major molecules and ions such as glucose, Na+, Cl-, K+, Ca2+, HCO3-, and HPO4 2-. 4. Regulation of red blood cells synthesis. The kidneys secrete a hormone, erythropoietin, which regulates the synthesis of red blood cells in bone, marrow. 5. Vitamin D synthesis. The kidneys play an important role in controlling blood levels of Ca2+ by regulating the synthesis of vitamin D.

Kidneys The kidneys are located in the back of the upper abdomen and are protected 50

by the lower ribs and rib cartilage of the back. The kidneys are involved with a number of bodily functions which include:

The filtering and excretion of unwanted waste products such as urea from the body. The maintenance of water balance. the regulation of the acid-base balance of body fluids. the production of renin, which is important in the regulation of blood pressure. The production of the hormone erythropoieten, which stimulates the production of red blood cells.

Ureters The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder. Bladder The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder. Urethra The urethra is a tube that extends from the bladder to the outside world. It is through this tube that urine is eliminated from the body.

HEMATOLOGIC SYSTEM

Fig. A. 4. HEMATOLOGIC SYSTEM The structures of the hematologic or hematopoietic system include the blood, blood vessels, and blood-forming organs (bone marrow, spleen, liver, lymph nodes, and thymus gland). The major function of blood is to carry necessary materials (oxygen, nutrients) to cells and to remove carbon dioxide and metabolic waste products. The hematologic system also plays an important role in hormone transport, the inflammatory and immune responses, temperature regulation, fluid-electrolyte balance, and acid-base balance. Bone Marrow Contained inside all bones, occupies interior of spongy bones and center of long bones; Primary function is hematopoiesis (the formation of blood cells) 51

Two kinds of bone marrow, red and yellow Red (functioning) marrow Carries out hematopoiesis; production site of erythroid, myeloid, and thrombocytic components of blood; one source of lymphocytes and macrophages Yellow marrow: red marrow that has changed to fat; found in long bones; does not contribute to hematopoiesis All blood cells start as stem cells in the bone marrow; these mature into the different, specific types of cells, collectively referred to as formed elements of blood or blood components: erythrocytes, leukocytes, and thrombocytes.

Blood Composed of plasma (55%) and cellular components (45%) Hematocrit Reflects portion of blood composed of red blood cells Distribution 1300 ml in pulmonary circulation 400 ml arterial 60 ml capillary 840 ml venous 3000 ml in systemic circulation 550 ml arterial 300 ml capillary 2150 ml venous

Plasma Liquid part of blood; yellow in color because of pigments Consists of serum (liquid portion of plasma) and fibrinogen Contains plasma proteins such as albumin, serum globulins, fibrinogen, prothrombin, plasminogen Albumin: largest of plasma proteins, involved in regulation of intravascular plasma volume and maintenance of osmotic pressure Serum globulins: alpha, beta, gamma Alpha: role in transport of steroids, lipids, bilirubin Beta: role in transport of iron and copper Gamma: role in immune response, function of antibodies Fibrinogen, prothrombin, plasminogen (see Coagulation) Cellular Components Cellular components or formed elements of blood are erythrocytes which are responsible for oxygen transport; leukocytes which play a major role in defense against microorganisms; and thrombocytes which function in hemostasis. Erythrocytes [Red Blood Cells (RBC)] Bioconcave disc shape, no nucleus, chiefly sacs of hemoglobin RBCs are responsible for oxygen transport via hemoglobin (Hgb) Two portions: iron carried on heme portion; second portion is protein Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in men than in women (12-14 g) 52

Production Start in bone marrow as stem cells, released as reticulocytes (immature cells), mature into erythrocytes Erythropoietin stimulates differentiation; produced by kidneys and stimulated by hypoxia Iron, vitamin B12, folic acid, pyridoxine (vitamin B6), and other factors required for erythropoiesis Hemolysis (destruction) Average life span 120 days Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood, connective tissue, spleen, liver, lungs, and lymph nodes) Mature cells removed chiefly by liver and spleen Bilirubin: byproduct of Hgb released when RBCs destroyed, excreted in bile Iron: freed from Hgb during bilirubin formation; transported to bone marrow via transferrin and reclaimed for new Hgb production Premature destruction: may be caused by RBC membrane abnormalities, Hgb abnormalities, extrinsic physical factors Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen, liver, bone marrow) Leukocytes: granulocytes and mononuclear cells [White Blood Cells (WBC)]: involved in protection from bacteria and other foreign substances Granulocytes: eosinophils, basophils, and neutrophils Eosinophils: involved in phagocytosis and allergic reactions Basophils: involved in prevention of clotting in microcirculation and allergic reactions Eosinophils and basophils are reservoirs of histamine, serotonin, and heparin Neutrophils: involved in short-term phagocytosis mature neutrophils: polymorphonuclear leukocytes immature neutrophils: band cells (bacterial infection usually produces increased numbers of band cells) Mononuclear cells: monocytes and lymphocytes: large nucleated cells Monocytes: involved in long-term phagocytosis; play a role in immune response largest leukocyte produced by bone marrow: give rise to histiocytes (Kupffer cells of liver), macrophages, and other components of reticuloendothelial system Lymphocytes: immune cells; produce substances against foreign cells; produced primarily in lymph tissue (B cells) and thymus (T cells) (see also Immune Response) Thrombocytes (Platelets) Fragments of megakaryocytes formed in bone marrow 53

Production regulated by thrombopoietin Essential factor in coagulation via adhesion, aggregation, and plug formation Release substances involved in coagulation Systems that initiate clotting Intrinsic system: initiated by contact activation following endothelial injury ("intrinsic" to vessel itself) Factor XII initiates as contact made between damaged vessel and plasma protein Factors VIII, IX, and XI activated Extrinsic system Initiated by tissue thromboplastins, released from injured vessels ("extrinsic" to vessel) Factor VII activated Common pathway: activated by either intrinsic or extrinsic pathways Platelet factor 3 (PF3) and calcium react with factors X and V. Prothrombin converted to thrombin via thromboplastin. Thrombin acts on fibrinogen, forming soluble fibrin. Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot. Clot resolution: takes place via fibrinolytic system by plasmin and proteolytic enzymes; clot dissolves as tissue repairs. GENITOURINARY SYSTEM

Structures and functions: Ovaries Are paired organs that produce secondary oocytes (cells that develop into mature ova, or eggs, following fertilization) and hormones, such as progesterone and estrogens (the female sex hormones), inhibin, and relaxin. Uterine Tubes Females have two uterine (fallopian tube) tubes that extend laterally from the uterus and transport the secondary oocytes from the ovaries to the uterus and are normally are the sites where fertilization occurs. Uterus The uterus serves as a part of the pathway for sperm deposited in the vagina to reach the uterine tubes. This is the site for the implantation of a fertilized ovum, development of the fetus during pregnancy and labor. Vagina The vagina is a tubular canal that extends from the exterior of the body to the uterine cervix. It receives the penis during sexual intercourse and is a passageway for childbirth. Perineum and Vulva The perineum is the diamond- shaped area between the thighs and buttocks of both males and females that contains the external genital s and anus. 54

The term vulva refers to the external genitals of the female. The mons pubis is an elevation of adipose tissue covered by coarse pubic hair, which cushions the public symphysis. From the mons pubis, two longitudinal folds of skin, the labia majora, extend down and back. Medial to the labia majora are two folds of skin called the labia minora. The labia minora do not contain pubic hair or fat and have fe sudoferous (sweat) glands, they do, hoever contain numerous sebaceous (oil) glands. The clitoris is a small, cylindrical mass of erectile tissue and nerves. It is located at the anterior junction of the labia minora. Mammary Glands The mammary glands located in the breasts, are modified sudoferous (sweat) glands that produce milk. The breasts lie over the pectoralis major ad serratus anterior muscles and are attached to them by a layer of connective tssuee. These synthesize, secrete and eject milk for nourishment of the newborn through a series of closely spaced opening of ducts, which we called as nipples, one pigment projection in each breast. NEUROLOGICAL SYSTEM FIGURE 3.1 The Nervous System The nervous system is broken down into two major part: the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system, which includes all nerves, which carry impulses to and from the brain and spinal cord. These include our sense organs, the eyes, the ears, our sense of taste, smell and touch, as well as our ability to feel pain. Fig. A.5 NERVOUS SYSTEM A.)Central Nervous System

Spinal Cord The spinal cord is a long bundle of neural tissue continuous with the brain that occupies the interior canal of the spinal column and functions as the primary communication link between the brain and the rest of the body. The spinal cord receives signals from the peripheral senses and relays them to the brain. Ascending and Descending Spinal Tracts Ascending tracts within the spinal cord carry sensory information from the body, upwards to the brain, such as touch, skin temperature, pain and joint position. Descending tracts within the spinal cord carry information from the brain downwards to initiate movement and control body functions. Spinal Nerves Nerves called the spinal nerves or nerve roots, branch off the spinal cord and pass out through a hole in each of the vertebrae called the Foramen. These nerves carry information from the spinal cord to the rest of the body, and from the body back up to the brain. There are four main groups of spinal nerves, which exit different levels of the spinal cord. These are in descending order down the vertebral column: 55

Cervical Nerves "C": (nerves in the neck) supply movement and feeling to the arms, neck and upper trunk. Also control breathing. Thoracic Nerves "T": (nerves in the upper back) supply the trunk and abdomen. Lumbar Nerves "L" and Sacral Nerves "S" : (nerves in the lower back) supply the legs, the bladder, bowel and sexual organs. Brain

Brain Stem The brain stem is the part of the brain that connects the cerebrum and diencephalons with the spinal cord. Medulla Oblongata The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic centers including:

The respiratory center, which regulates breathing. The cardiac center that regulates the rate and force of the heartbeat. The vasomotor center, which regulates the contraction of smooth muscle in the blood vessel, thus controlling blood pressure. reflex actions including vomiting,

The medulla also controls other sneezing, coughing and swallowing. Pons

Continuing up the brain stem, one reaches the Pons. The pons lies just above the medulla and act as a link between various parts of the brain. The pons connects the two halves of the cerebellum with the brainstem, as well as the cerebrum with the spinal cord. The pons, likes the medulla oblongata, contain certain reflex actions, such as some of the respiratory responses. Midbrain The midbrain extends from the pons to the diecephalon. The midbrain acts as a relay center for certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay center for auditory information. Diencephalon The diencephalons are located between the cerebrum and the mid brain. The diencephalons houses important structures including the thalamus, the hypothalamus and the pineal gland. Thalamus The thalamus is responsible for "sorting out" sensory impulses and directing them to a particular area of the brain. Nearly all sensory impulses travel through the thalamus. 56

 Hypothalamus The hypothalamus is the great controller of body regulation and plays an important role in the connection between mind and body, where it serves as the primary link between the nervous and endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior, and some emotions, including fear, pleasure and pain. Cerebellum The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly. Cerebrum The largest and most prominent part of the brain, the cerebrum governs higher mental processes including intellect, reason, memory and language skills. The cerebrum can be divided into 3 major functions:

Sensory Functions - the cerebrum receives information from a sense organ; i.e., eyes, ears, taste, smell, feelings, and translates this information into a form that can be understood. Motor Functions - all voluntary movement and some involuntary movement. Intellectual Functions - responsible for learning, memory and recall.

Meninges The meninges are made up of three layers of connective tissue that surround and protect both the brain and spinal cord. The layers include the dura mater, the arachnoid and the pia matter. Cerebrospinal Fluid The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and remove waste products from these tissues. Fig. A. 6 NEURONS B.) Peripheral Nervous System Nerves Nerves are made up of specialized cells, which act as little wires, transmitting information to and from the central nervous system and brain. Nerves form the network of connections that receive signals (known as sensory input) from the environment and within the body, and 57

transmit the body's responses, or instructions for action, to the muscles, organs, and glands. Nerve cells are located outside the central nervous system or spinal cord. Neuron Structure The brain is made of approximately 100 billion nerve Figure 3.2 neuron cells, called neurons.Neurons have the amazing ability to gather and transmit electrochemical signals. Neurons share the same characteristics and have the same makeup as other cells, but the electrochemical aspect lets them transmit signals over long distances (up to several feet or a few meters) and send messages to each other. Neurons have three basic parts: Cell body or soma. This main part has all of the necessary components of the cell, such as the nucleus (which contains DNA), endoplasmic reticulum and ribosomes (for building proteins) and mitochondria (for making energy). If the cell body dies, the neuron dies. Axon . This long, cablelike projection of the cell carries the electrochemical message (nerve impulse or action potential) along the length of the cell. Depending upon the type of neuron, axons can be covered with a thin layer of myelin sheath, like an insulated electrical wire. Myelin is made offat and protein, and it helps to speed transmission of a nerve impulse down a long axon. Myelinated neurons are typically found in the peripheral nerves (sensory and motor neurons), while non-myelinated neurons are found in the brain and spinal cord. Dendrites or nerve endings. These small, branchlike projections of the cell make connections to other cells and allow the neuron to talk with other cells or perceive the environment. Dendrites can be located on one or both ends of a cell. Basic Types of Neurons These fundamental members of the nervous system also vary with respect to their functions. Sensory neurons carry signals from the outer parts of your body (periphery) into the central nervous system. Motor neurons (motoneurons) carry signals from the central nervous system to the outer parts (muscles, skin, glands) of your body. Interneurons connect various neurons within the brain and spinal cord. The Peripheral Nervous System is responsible for the remainder of the body. It includes cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal cord) and all the major sense organs. The PNS includes:

The

Somatic

Nervous

System Fig. A. 7 AUTONOMIC NERVOUS SYSTEM 58

(SNS) Responsible for all muscular activities voluntary or that are within our conscious control.

that

we

consider

The Autonomic Nervous System (ANS) Responsible for all activities that occur automatically and involuntarily, such as breathing, muscle contractions within the digestive system, and heartbeat. The components of the ANS work together to create a balanced response to outside stimuli1. The ANS includes:

The Sympathetic System Stimulates cell and organ function. The sympathetic system is activated by a perceived danger or threat, very strong emotions such as fear, anger or excitement, by intense exercise, or when under large amounts of stress. Basically, anything the body perceives as an emergency will trigger a protective response. Once initiated, it speeds up heart rate, increases the activity of the sweat and adrenal glands, slows down the digestive system and sends blood to the skin and muscles; all of which prepare the body for a fight or flight response. The Parasympathetic System Inhibits cell and organ function. The parasympathetic system slows down heart rate, resumes digestion, and increases relaxation throughout the body. This rest and digest response counteracts the fight or flight response and helps the body recuperate after a crisis is over. A person's normal resting heart rate is determined by the parasympathetic system. If blood pressure is too high or blood carbon dioxide levels are too low, this system slows the heart down and lowers its output.

Cranial Nerves: The cranial nerves are so called because they are attached to the brain inside the skull (cranium). Some are sensory, some are motor and others mixed. They leave the skull through various openings in the skull Fig. A. 8 CRANIAL NERVE foramina. Cranial Nerves Summary Nerves in Order Olfactory Optic Oculomotor Modality Special Sensory Special Sensory Somatic Motor Smell Vision Levator palpebrae, superioris, superior, medial & inferior recti muscles Parasympathetic to ciliary & pupillary constrictor Function

Visceral Motor

59

muscles Trochlear Somatic Motor Branchial Motor Trigeminal General Sensory Superior oblique muscle Muscles of mastication Sensory for head/neck, sinuses, meninges, & external surface of tympanic membrane Lateral rectus muscle Muscles of facial expression Parasympathetic to all glands of head except the parotid Sensory for ear and tympanic membrane Taste anterior two-thirds of tongue Vestibulocochlear Special Sensory Branchial Motor Visceral Motor Visceral Sensory Glossopharyngeal General Sensory Hearing and Balance Stylopharyngeus muscle Parotid Gland Carotid Body Sensation posterior onethird tongue & internal surface of tympanic membrane.

Abducens Facial

Somatic Motor Branchial Motor Visceral Motor General Sensory Special Sensory

Special Sensory

Taste posterior one-third tongue Branchial Motor Visceral Motor Vagus Visceral Sensory Special Sensory Sensory from pharynx, larynx & viscera Sensory from external ear Branchial Motor Spinal Accessory Trapezius & sternocleidomastoid muscles Tongue muscles except palatoglossal Muscles pharynx & larynx Parasympathetic to neck, thorax, & abdomen

Hypoglossal

Somatic Motor

60

RESPIRATORY SYSTEM The entire process of gas exchange in the body, called respiration, occurs in three basic steps: 1. Pulmonary ventilation, or breathing, is the flow of air into and out of the lungs 2. External respiration is the exchange of gases between the air spaces ( alveoli) of the lungs and the blood in pulmonary capillaries 3. Internal respiration is the exchange of gases between blood in systemic capillaries and tissue cells Two parts: Two Upper respiratory system -includes the nose, pharynx, and associated structures Lower respiratory system -consists of the larynx, trachea, bronchi, and lungs parts based on function: Conducting zone -consists of a series of interconnecting cavities and tubes- nose, pharynx, larynx, trachea, bronchi, bronchioles, and terminal bronchioles- that conduct air into the lungs Respiratory zone - consists of tissues within the lungs where gas exchange occurs- the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli

Nose External nose -consists of bone and cartilage covered with skin and lined with mucous membrane. It has to openings called the external nares or nostrils Internal nose-connects to the throat through the two openings called the internal nares -four paranasal sinuses ( frontal, sphenoidal, maxillary, ethmoidal) and the nasolacrimal ducts also connect to the internal nose Pharynx -funnel- shaped tube that that starts in internal nares and extends partway down the neck -lies just posterior to nasal and oral cavities and just anterior to the cervical neck -functions as a passageway for air and food -it has three portions: nasopharynx, oropharynx, laryngopharynx Larynx -or voice box, is a short tube of cartilage lined by mucous membrane -connects the pharynx with the trachea -thyroid cartilage: consists of hyaline cartilage, forms the anterior wall of the larynx -epiglottis: routes food in to the esophagus -cricoid cartilage: a ring of hyaline cartilage that forms the inferior wall of the larynx and is attached to the first tracheal cartilage Trachea -or wind pipe, is a tubular passageway for air that is located anterior to the esophagus

61

-extends from the larynx to the upper part of the fifth thoracic vertebra, where it divides to right and left primary bronchi -walls are lined with mucous membrane and is supported by a cartilage -mucous membrane is composed of pseudostratified cilated columnar epithelium, consisting of ciliated columnar cells, goblet cells, and basal cells -cilia in the lower respiratory tract move mucus and trapped particles up toward the pharnx -cartilage layer consists of 16 to 20 C-shaped rings of hyaline cartilage tacked one on top of another - solid parts of the C-shaped cartilage rings provide rid support so the tracheal wall does not collapse inward and obstruct the air passageway Bronchi and Bronchioles -contain incomplete rings of cartilage and are lined by pseudostratified ciliated columnar epithelium -pulmonary blood vessels, lymphatic vessels, and nerves enter and exit the lungs with the two bronchi -branching of the bronchial tree: Trachea

Primary bronchi

Secondary bronchi

Tertiary bronchi

Bronchioles

Terminal Bronchioles Lungs -two spongy, cone- shaped organs in the thoracic cavity -separated from each other by the heart and other structures in the mediastenum -pleural membrane: double- layered serous membrane that encloses and protects each lung -parietal pleura: outer layer is attached to the wall of the thoracic cavity and diaphragm -visceral pleura: inner layer and is attached to the lungs -pleural cavity: contains the lubricating fluid secreted by the membranes -each lung lobe is divided into smaller segments that are supplied by a tertiary bronchus -the segments in turn, are subdivided into many small compartments called lobules -terminal bronchioles subdivide into microscopic branches called respiratory bronchioles 62

-respiratory bronchioles, in turn, subdivide into several alveolar ducts - the two or more alveoli that share a common opening to the alveolar duct are called alveolar sacs Alveoli cup- shaped out pouching of the alveolar sac walls consist mainly of thin alveolar cells, which area simple squamous epithelium main sites for gas exchange lungs contain roughly 300 million alveoli, providing huge surface area for gas exchange scattered among them are surfactant- secreting cells that secrete alveolar fluid, which keps the surface betwwen cells and air moist included in the alveolar fluid is surfactant that reduces the tendency of alveoli to collapse around the alveoli, the pulmonary arteriole and venule form lush networks of blood capillaries exchange of oxygen and carbon dioxide between the air spaces in the lungs and the blood takes place by diffusion across the alveolar and capillary walls respiratory membrane consists of the following layers: The alveolar cells which form the wall of an alveolus The epithelial basement membrane underlying the alveolar cells A capillary basement membrane that is often fused to the epithelial basement membrane The endothelial cells of a capillary respiratory membrane is as thin as of tissue paper which permits oxygen and carbon dioxide to diffuse efficiently between the blood and alveolar air spaces PULMONARY VENTILATION flow of air between the atmosphere and the lungs occurs due to differences in air pre contraction and relaxation of skeletal muscles pressure changes that power breathing External Respiration: Pulmonary Gas Exchange

create

the

air

is the diffusion of oxygen from air into the alveoli of the lungs to blood in pulmonary capillaries and the diffusion oxygen diffuses from alveolar air where its partial pressure is 105mm Hg, into the blood in pulmonary capillaries, where partial pressure of oxygen is about 40mm Hg in a resting person Internal Respiration: Systemic Gas Exchange left ventricle pumps oxygenated blood into the aorta and through the systemic arteries to systemic capillaries as oxygen leaves the blood stream, oxygenated blood is converted into deoxygenated blood occurs in tissues throughout the body due to pressure differences, oxygen diffuses out of the capillaries into tissue cells, and blood partial pressure of oxygen decreases deoxygenated blood then returns to the heart for another process of external respiration Transport of Oxygen

63

heme part of hemoglobin contains four atoms of iron, each capable of binding to a molecule of oxygen in systemic capillaries, where partial pressure of oxygen is lower, hemoglobin releases oxygen which then can diffuse from blood plasma into interstitial fluid and into tissue cells Carbon Dioxide Transport Transported in three main forms: Dissolved carbon dioxide- dissolved in blood plasma. Upon reaching the lungs, it diffuses into alveolar air and is exhaled Bound to amino acids- most prevalent protein in the blood is the hemoglobin, most carbon dioxide transported to this manner is bound to hemoglobin( carbaminohemoglobin ) Bicarbonate ions- as carbon dioxide diffuses into tissue capillaries and enters the red blood cells, it combines with water to form carbonic acid

Integumentary System

Epidermis

Fig. A. 9 INTEGUMENTARY SYSTEM

outer layer of skin.

Four principal types of cells:

keratinocytes (90%)- produces the protein keratin that helps protect skin and underlying tissues from heat, microbes, and chemicals melanocytes (8%)- produce the pigment melanin that contributes to skin color and absorbs damaging ultraviolet lights Langerhan cells- participates in immune responses Merkel cells- detect different aspects of touch sensations

Dermis

composed mainly of connective tissue containing collagen and elastic fiber surface area is greatly influenced by small, fingerlike projections dermal papillae all present in the dermal papillae are free nerve endings deeper part attached to the subcutaneous layer, consists of dense irregular connective tissue combination of collagen and elastic fibers in the deeper part of the dermis provides the skin with strength, extensibility ( ability to 64

stretch ), and elasticity (ability to return to original shape after stretching) Hypodermis

not a skin layer but lies below the dermis a subcutaneous tissue contains fat, blood vessels and sensory receptors

FUNCTIONS OF THE SKIN: 1. Body temperature regulation by liberating sweat at its surface and by adjusting the flow of blood in the dermis 2. Protection keratin in the skin protects underlying tissues and the tightly interlock keratinocytes resist invasion by microbes. Lipids released by lamellar granules inhibit evaporation of water from the skin surface thus, protecting the body from dehydration. Oily sebum prevents hairs from drying out and contains bactericidal chemicals that kill surface bacteria. The acidic pH of perspiration retards the growth of some microbes. Melanin provides some protection against the damaging effects of ultraviolet light. Hair and nails also have protective function 3. Cutaneous sensations include tactile sensation- touch, vibration, sensation, tickling- as well as thermal sensations such as warmth and coolness. Pain is usually an indication of impending or actual tissue damage 4. Excretion and absorption excretion is the elimination of substances from the body while absorption is the passage of materials from the external environment to body cells Accessory skin structures The skin has the following appendages: Skin Appendage Structure Hairs originate in the dermis and are shafts of modified keratinized epithelium which grow from the roots of hair follicles. Smooth muscle cells which extend from the hair follicle to the papillary layer of the dermis. There are two types; merocrine and apocrine. They consist of coiled tubes embedded in the dermis or hypodermis and open out onto the skin surface. The nail plate is composed of dead hard keratinized cells which lie on top of a nail bed and which grow from the nail matrix under the skin. Flask shaped glands, located 65 Function Sensory role, retains heat of the head and protects it from UV, advertises sexual maturity and disperses scents. Cause the hair to stand on end - "Goose Bumps".

Hair

Arrector pili muscles

Sweat glands

Produce a watery substance to cool the body, excretion of wastes, excretion of body scents. Allows the tips of our fingers to be soft and sensory. They serve as tools to aid in the manipulation of objects. Produce sebum, an oily

Nails

Sebaceous

glands

in the dermis and open into the hair follicles.

secretion which prevents the hair and skin becoming dry.

AGING AND INTEGUMENTARY SYSTEM

collagen fibers begin to decrease in number, stiffen, break apart, and disorganize into a shapeless, matted tangle elastic fibers lose some of their elasticity, thicken into clumps, and fray fibroblasts, which produce both collagen and elastic fibers, decrease in number as a result, the skin forms the characteristic crevices and furrows known as wrinkles Langerhan cells dwindle and macrophages become less- efficient phagocytes, thus decreasing the skins immune responses decreased size of sebaceous glands lead to dry and broken skin that is more susceptible to infection production of sweat diminishes, which probably contributes to increased incidence of heat stroke in the elderly decrease number of functioning melanocytes results in gray hair and atypical skin pigmentation increase in the size of some melanocytes produces pigmented blotching (age spots) walls of blood vessels in the dermis become thicker and less permeable, and subcutaneous fat is lost with the onset of old age, skin heals poorly and becomes more susceptible to pathological conditions

LYMPHATIC SYSTEM

Fig. A. 10 LYMPHATIC SYSTEM consists of lymph, lymphatic vessels, a number of structures and organs containing lymphatic tissue, and bone marrow Prmary functions: 1. Draining excess interstitial fluid 2. Transporting dietary lipids 3. Carrying out immune responses 66

LYMPHATIC ORGAN AND TISSUES Thymus two- lobed organ located posterior to the sternum and medial to the lungs and superior to the heart contains large numbers of T cells and scattered dendritic cells, epithelial cells, and macrophages immature T cells migrate from red bone marrow to the thymus where they multiply and begin to mature mature T cells leave the thymus via the blood and are carried to lymph nodes, the spleen, and other lymphatic tissues Lymph nodes bean- shaped and is located along lymphatic vessels scattered throughout the body, both superficially and deep, and usually occur in groups lymph flows through the node, substances are trapped by reticular fibers within the spaces between cells macrophages destroy some foreign substances by phagocytosis, and lyphocytes destroy others by a variety of immune responces Spleen largest single mass of lymphatic tissue in the body lies between the stomach and diaphragm and is covered by a capsule of dense connective tissue contains two types of tissue called white pulp and red pulp white pulp, a lymphatic tissue consisting mostly of lymphocytes and macrophages red pulp consists of blood-filled venous sinuses and cords of spleenic tissue consisting of red blood cells, macrophages, lymphocytes, plasma cells, and granular leukocytes Lymphatic nodules egg-shaped masses of lymphatic tissue that aresurrounded by a capsule some occur as large aggregations in specific parts of the body, for example: 1. tonsils in the pharyngeal region 2. aggregated lymphatic follicles ( Peyer's pathches ) 3. in the appendix The human lymphoid system has the following:

primary organs: bone marrow (in the hollow center of bones) and the thymus gland (located behind the breastbone above the heart), and secondary organs at or near possible portals of entry for pathogens: adenoids, tonsils, spleen (located at the upper left of the abdomen), lymph nodes (along the lymphatic vessels with concentrations in the neck, armpits, abdomen, and groin), Peyer's patches (within the intestines), and the appendix.

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IMMUNE SYSTEM

Fig. A. 11. IMMUNE SYSTEM

An antigen is any substance that elicits an immune response, from a virus to a sliver.

The immune system has series of dual natures, the most important of which is self/non-self recognition. The others are: general/specific, natural/adaptive = innate/acquired, cell-mediated/humoral, active/passive, primary/secondary. Normal Adult Blood Cell Counts Parts of the immune system are:

antigen-specific - they recognize and act against particular antigens systemic - not confined to the initial infection site, but work throughout the body, and have memory - recognize and mount an even stronger attack to the same antigen the next time.

Red Blood Cells Platelets Leukocytes Neutrophil Lymphocyte Monocyte Eosinophil Basophil

5.0*106/mm3

2.5*105/mm3 7.3*103/mm3 50-70% 20-40% 1-6% 1-3% <1%

Self/non-self recognition is achieved by having every cell display a marker based on the major histocompatibility complex (MHC). Any cell not displaying this marker is treated as non-self and attacked. The process is so effective that undigested proteins are treated as antigens.

Sometimes the process breaks down and the immune system attack selfcells. This is the case of autoimmune diseases like multiple sclerosis, systemic lupus erythematosus, and some forms of arthritis and diabetes. There are cases where the immune response to innocuous substances is inappropriate. This is the case of allergies and the simple substance that elicits the response is called an allergen.

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Fluid Systems of the Body There are two main fluid systems in the body: blood and lymph. The blood and lymph systems are intertwined throughout the body and they are responsible for transporting the agents of the immune system. Immunity can be either natural or artificial, innate or acquired=adaptive, and either active or passive.

Active natural (contact with infection): develops slowly, is long term, and antigen specific. Active artificial (immunization): develops slowly, lasts for several years, and is specific to the antigen for which the immunization was given. Passive natural (transplacental = mother to child): develops immediately, is temporary, and affects all antigens to which the mother has immunity. Passive artificial (injection of gamma globulin): develops immediately, is temporary, and affects all antigens to which the donor has immunity.

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THEORETICAL BACKGROUND Diabetes Type 2 Diabetes mellitus is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. Type 2 diabetes mellitus is, by far, the most prevalent type of diabetes. Type 2 diabetes usually occurs in people over 35 years of age, and 80% to 90% of patients are overweight at the time of diagnosis. However, because of the epidemic of childhood obesity, type 2 diabetes is now being seen in children. It has a tendency to run in families and probably has a genetic basis. Prevalence of type 2 diabetes increases with age, with about half of the people diagnosed being older than 55. In the past, type 2 diabetes was known as adult-onset diabetes. Prevalence of type 2 diabetes is greater in some ethnic populations. African Americans, Asian Americans Hispanic Americans, and Native Americans have a higher rate of this type of diabetes than whites.

Etiology and Pathophysiology In type 2 diabetes, the pancreas usually continues to produce some endogenous (self-made) insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly utilized by the tissues. (See Figure 3. B. 1) In contrast, there is a virtual absence of endogenous insulin in type 1 diabetes. The presence of endogenous insulin is the major pathophysiologic distinction between type 1 and type 2 diabetes. Figure 3. B. 1 Glucose transport to cell A multitude of factors contribute toward the development of membrane type 2 diabetes. The most powerful risk factor is believed to be obesity, specifically abdominal and visceral adiposity. Also, genetic mutations that lead to insulin resistance and higher risk for obesity have been found in many people with type 2 diabetes. It is likely that multiple genes are involved in this complex, multifactorial disorder. Four major metabolic abnormalities have a role in the development of type 2 diabetes. The first factor is insulin resistance in glucose and lipid metabolism, which is a condition in which body tissues do not response to the action of insulin. This is due to insulin receptors that are either unresponsive to the action of insulin and/or insufficient in number. A second factor in the development of type 2 diabetes is marked decrease in the ability of the pancreas to produce insulin, as the B-cells become fatigued from the compensatory overproduction of insulin or when B-cell mass is lost. A third factor is inappropriate glucose production by the liver. Instead of properly regulating the release of glucose in
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response to blood levels, the liver does so in a haphazard way that does not correspond to the bodys needs at the time. A fourth factor is alteration in the production of hormones and cytokines by adipose tissue (adipokines). Adipokines appear to play a role in glucose and fat metabolism and are likely to contribute to the pathophysiology of type 2 diabetes. Individuals with metabolic syndrome are at an increased risk for the development of type 2 diabetes. Metabolic syndrome is a cluster of abnormalities that act synergistically to greatly increase the risk for cardiovascular disease and diabetes. Metabolic syndrome is characterized by insulin resistance, elevated insulin levels, high levels of triglycerides, decreased levels of highdensity lipoproteins (HDLs), increased levels of low-density lipoproteins (LDLs), and hypertension.

Risk Factors One has a higher risk for diabetes if one has any of the following:

Age greater than 45 years Diabetes during a previous pregnancy Excess body weight (especially around the waist) Family history of diabetes Given birth to a baby weighing more than 9 pounds HDL cholesterol under 35 mg/dL High blood levels of triglycerides, a type of fat molecule (250 mg/dL or more) High blood pressure (greater than or equal to 140/90 mmHg) Impaired glucose tolerance Low activity level (exercising less than 3 times a week) Metabolic syndrome Polycystic ovarian syndrome A condition called acanthosis nigricans, which causes dark, thickened skin around the neck or armpits

Persons from certain ethnic groups, including African Americans, Hispanic Americans, Asian Americans, and Native Americans, have a higher risk for diabetes. Clinical Manifestations The clinical manifestations of type 2 diabetes are often nonspecific, although it is possible that an individual with type 2 diabetes will experience some of the classic symptoms associated with type 1. Some of the more common manifestation associated with type 1 diabetes include fatigue, recurrent infections, recurrent vaginal yeast or monilia infectious, prolonged wound healing, and visual changes. Unfortunately, the clinical manifestations appear o gradually that an individual may blame the symptoms on another cause, such as lack of sleep or increasing age, and before the person knows it, he or she may have complications. Diagnostic Studies

Fasting blood glucose level 126 mg/dl (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
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Random, or casual, plasma glucose measurement 200 g/dl (11.1 mmol/L), plus manifestation of diabetes, such as polyuria, polydipsia, and unexplained weight loss. Casual is defined as any time of day without regard to the time of the last meal. Two-hour OGTT level 200 mg/dl (11.1 mmol/L), using a glucose load of 75 g. The fasting plasma glucose (FPG) test, confirmed by repeat testing on another day, is the preferred method of diagnosis. When overt symptoms of hyperglycemia (polyuira, polydipsia, and polyphagia) coexist with FPG levels of 126 mg/dl (7.0 mmol/L) or greater, further testing using the OGTT may not be necessary to make a diagnosis.

Collaborative Care The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible. Diabetes is a chronic disease that requires daily decisions about food intake, blood glucose testing, medication, and exercise. Patient teaching, which enables the patient to become the most active participant in his or her own care, is essential for a successful treatment plan. Nutritional therapy, drug therapy, exercise, and self-monitoring of blood glucose are the tools used in the management of diabetes. The major types of glucose-lowering agents (GLAs) used in the treatment of diabetes are insulin and oral agents (OAs). All individuals with type 1 diabetes require insulin. For some people with type 2 diabetes, a regimen of proper nutrition, regular physical activity, and maintenance of desirable body weight will be sufficient to attain an optimal level of blood glucose control.

Some of the most common types of medication are listed below. They are taken by mouth or injection.

Alpha-glucosidase inhibitors (such as acarbose) Biguanides (Metformin) Injectable medicines (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin) Meglitinides (including repaglinide and nateglinide) Sulfonylureas (like glimepiride, glyburide, and tolazamide) Thiazolidinediones (such as rosiglitazone and pioglitazone). (Rosiglitazone may increase the risk of heart problems).

Diabetic Retinopathy Etiology and Pathophysiology:

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Diabetic Retinopathy refers to the process of microvascularization damage to the retina as a result of chronic hyperglycemia with Diabetes. (See Figure 3. B. 3). After 15 years of Diabetes Mellitus, nearly all patients with type I Diabetes and 80% with type II Diabetes will have some degree of retinal diseases. Diabetic Retinopathy is estimated to be the most common cause of new cases of blindness in people ages 20-74 years. Retinopathy can be classified as non proliferative or proliferative. In non proliferative retinopathy, the most common form, partial occlusion of the small blood vessels in the retina causes the development of microaneurysms in the capillary walls. The walls of these microaneurysms are so weak that capillary fluid leaks out, causing retinal edema and eventually hard exudates of intra retinal hemorrhage. Vision may be affected if the macula is involved. Table 3. B. 2 Diabetic Retinopathy Proliferative retinopathy, the most severe form, involves the retina and the vitreous. When retinal capillaries become occluded, the body compensates by forming new blood vessels to supply the retina with blood, a pathologic process known as neovascularization. These new vessels are extremely fragile and hemorrhage easily, producing vitreous contraction. Eventually, light is prevented from reaching the retina as the vessels become torn and bleed into the vitreous cavity. The patient sees black or red spots or lines. If these new blood vessels pull the retina while the vitreous contracts, causing a tear, partial or complete retinal detachment will occur. If the macula is involved, vision is lost. Without treatment, more than half of patients with proliferative diabetic retinopathy will be blind. Collaborative Care: The earliest and most treatable stages of Diabetic Retinopathy often produce no changes in the vision. Because of this, the patient with Diabetes must have regular dilated eye examination by an ophthalmologist or specially trained optometrists. As the time of diagnosis and annually thereafter for early detection and treatment. The most common forms of treatment for Diabetic Retinopathy are early photocoagulation of the retina, cryotherapy, and vitrectomy. Photocoagulation by laser destroys the ischemic areas of the retina that produce growth factors that encourage neovascularization, thereby preventing further visual loss.

Figure 3. B. 3 Cryotherapy of the eyes

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Cryotherapy is sometimes used to treat peripheral area of the retina that cannot be reached with lasers or with retinal hemorrhage prevents complete photocoagulation. (See. Figure 3. B. 3) In this procedure, topical anesthesia is used so that a cryoprobe can be placed directly on the surface of the eye. When the probe is properly located, its tip creates a frozen area that extends through the external tissue through the eyeball until it reaches a specific point on the retina. Multiple points on the retina can be treated in this way. Vitrectomy is the aspiration of blood, membrane and fibers from the inside of the eye through a small incision just behind the cornea. Vitrectomy is indicated when there is vitreal hemorrhage that does not clear in 6 months or when there is threatened or actual retinal detachement. (See Figure 3. B. 4) Persons with Diabetes are also prone to other visual problems. Glaucoma occurs a result of the occlusion Table 3. B. 4 of the outflow channels secondary to Vitrectomy neovascularization. This type of glaucoma is difficult to treat and often results in blindness. Cataracts develop at an early age and progress more rapidly in people with Diabetes.

End-Stage Renal Disease Definition Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function. It is defined as either the presence of kidney damage of glomerular filtration rate (GFR), 60ml/min for 3 months or longer. (Normal GFR is about 125 ml/min and is reflected by urine creatinine clearance measurements. Kidney damage is defined as either pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies. The last stage of kidney failure or End-stage kidney disease (ESRD) is the complete or almost complete failure of the kidneys to work. (See Figure 3. B. 5) The kidneys remove waste and excess water from the body. This occurs when the GFR is less than 15ml/min. At this point renal
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replacement therapy (dialysis or transplantation) is required. Figure 3. B. 5 Kidney Disease blood

Etiology/ Cause

The most common causes of ESRD are diabetes and high pressure. These conditions can affect the kidneys.

ESRD almost always comes after chronic kidney disease. The kidneys may slowly stop working over 10 - 20 years before end-stage disease results Symptoms may include: Clinical manifestations of CKD are apparent in multiple body systems. Fatigue, lethargy, and pruritus are often the early symptoms of CKD. Hypertension and proteinura are often the first signs. Other symptoms may include:

Abnormally dark or light skin Nail changes Bone pain Drowsiness and confusion Problems concentrating or thinking Numbness in the hands, feet, or other areas Muscle twitching or cramps Breath odor Easy bruising, nosebleeds, or blood in the stool Excessive thirst Frequent hiccups Low level of sexual interest and impotence Menstrual periods stop (amenorrhea) Sleep problems, such as insomnia, restless leg syndrome, or obstructive sleep apnea Swelling of the feet and hands (edema) Vomiting, especially in the morning

Diagnostic Studies Adverse outcomes of CKD can be often prevented or delayed through early detection and treatment. Because persistent proteinuria is usually the first indication of kidney damage, screening of CKD involves a dipstick evaluation of protein in the urine. A person with persistent proteinura (1+ protein on standard dipstick testing two or more times over a 3 month period) should have further assessment of risk factor and diagnostic workup with blood and urine test. A urine tests for albumin to creatinine ratio provides an accurate estimate of the protein and albumin excretion rate. A ratio greater than 300 mg albumin per 1 gram creatinine signals CKD. A urinalysis can detect RBCs, WBCs, protein, cast on glucose. Imaging of the kidneys to exclude obstruction and note size of the kidneys is usually achieved by ultrasound. Treatment/ Prevention
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Dialysis or kidney transplantation is the only treatment for this condition. Doctors may also put you on medicine to control the blood pressure. Other treatment depends on symptoms but may include:

Extra calcium and vitamin D (always provider before taking) Medicines called phosphate binders, levels from becoming too high Treatment for anemia, such as extra pills or shots, shots of a medicine blood transfusions.

talk to the health care to help prevent phosphorous iron in the diet, iron called erythropoietin, and

Hypertensive Cardiovascular Disease Hypertensive heart disease refers to heart problems that occur because of high blood pressure. These problems include:

Coronary artery disease Heart failure Thickening of the heart muscle

Causes/ Etiology High blood pressure increases the pressure in blood vessels. As the heart pumps against this pressure, it must work harder.Over time, this causes the heart muscle to thicken. The heart must work harder to pump blood out to the body. Without treatment, symptoms of congestive heart failure may develop. Figure 3. B. 6 Heart Disease

High blood pressure can cause ischemic heart disease because the thicker heart muscle needs an increased supply of oxygen.High blood pressure also contributes to thickening of the blood vessel walls. This may worsen atherosclerosis(increased cholesterol deposits in the blood vessels). This also increases the risk of heart attacks and stroke. Hypertensive heart disease is the leading cause of illness and death from high blood pressure. The heart complications that develop determine the symptoms, diagnosis, treatment, and outlook of hypertensive heart disease. Risk Factors

Age. Simply getting older increases your risk of damaged and narrowed arteries and weakened or thickened heart muscle, which contribute to heart disease.
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Sex. Men are generally at greater risk of heart disease. However, the risk for a woman increases after menopause. Family history. A family history of heart disease increases your risk of coronary artery disease, especially if a parent developed it at an early age (before age 55 for a male relative, such as your brother or father, and 65 for a female relative, such as your mother or sister). Smoking. Nicotine constricts your blood vessels, and carbon monoxide can damage their inner lining, making them more susceptible to atherosclerosis. Heart attacks are more common in smokers than in nonsmokers. Poor diet. A diet that's high in fat, salt and contribute to the development of heart disease. cholesterol can

High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the vessels through which blood flows. High blood cholesterol levels. High levels of cholesterol in your blood can increase the risk of formation of plaques and atherosclerosis. Plaques can be caused by a high level of lowdensity lipoproteins (LDLs), known as "bad" cholesterol, or a low level of high-density lipoproteins (HDLs), known as "good" cholesterol. Diabetes. Diabetes increases your risk of heart disease. Both conditions share similar risk factors, such as obesity and high blood pressure. Obesity. Excess weight typically worsens other risk factors. Physical inactivity. Lack of exercise also is associated with many forms of heart disease and some of its other risk factors, as well. High stress. Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for heart disease. Poor hygiene. Not regularly washing your hands and failure to establish other habits that can help prevent viral or bacterial infections can put you at risk of heart infections, especially if you already have an underlying heart condition. Poor dental health also may contribute to heart disease. Clinical Manifestations It usually takes some time for the problem of high blood pressure to eventually lead to hypertensive cardiovascular disease and therefore high blood pressure is often called the silent killer. Eventually hypertensive heart disease can also lead to congestive heart failure. Some symptoms of hypertension and the eventual congestive heart failure include arrhythmias, shortness of breath, weakness and fatigue, swelling in lower extremities and greater frequency of urination during the night. Hypertensive cardiovascular disease may also result in ischemic heart condition and in this case there might be chest pain, sweating and dizziness, nausea and shortness of breath. Hypertrophic cardiomyopathy could also be a result of hypertensive heart disease.
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Signs/ Tests Tests to diagnose heart disease can include:

Electrocardiogram Urinalysis Blood glucose and hematocrit levels Serum potassium, creatinine (or the corresponding estimated glomerular filtration rate [GFR]), and calcium measurements Lipid profile after a 9- to 12-hour fast - Includes high density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides Optional tests - Include measurement of urinary albumin excretion or albumin/creatinine ratio Treatment/ Prevention The primary aim of any treatment in hypertensive cardiovascular disease is reduction of blood pressure and then eventual control of the heart disease. The line of treatment will ordinarily depend on the condition such as whether there is angina or acute myocardial infarction. The line of treatment may include beta blockers, angiotensin converting enzyme inhibitors (ACE), calcium channel blockers, diuretics etc depending upon particulars of each individual case. The blood pressure is consistently required to be checked and kept under control in this condition. In addition to medications, recommended lifestyle changes include:

Diet changes: o Avoid trans fats and saturated fats o Increase fruits, vegetables, and low-fat dairy products o Reduce salt intake (may be beneficial) o Eat whole grains, poultry, and fish Exercise regularly Reduce excessive alcohol consumption Stop smoking -- cigarettes are a major cause of hypertensionrelated heart disease Lose weight if you are overweight or obese Coronary Artery Disease

This is a type of blood vessel disorder that is included in the general category of atherosclerosis. The term atherosclerosis is derived from two Greek words: athere, meaning fatty mush, and skleros, meaning hard. This combination indicates that atherosclerosis begins as soft deposits of fat that harden with age. Atherosclerosis is often referred to as, hardening of the arteries. Although this condition can occur in any artery in the body, the atheromas (fatty deposits) have a preference for the coronary arteries. Arteriosclerotic heart disease, cardiovascular heart disease, ischemic
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Figure 3. B. 7

heart disease coronary heart disease, and CAD are all terms used to describe this disease process.

Etiology Atherosclerosis is the major cause of CAD. It is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The genesis of plaque formation is the result of complex interaction between the components of the blood and the elements forming the vascular wall. Inflammation and endothelial injury play a central role in the development of atherosclerosis. Intact normal endothelium is more than a simple barrier between the vessel wall and the lumen of the vessel. Normally, it is nonreactive to platelets and leukocytes, as well as coagulation, fibrinolytic and complement factors. However, the endothelial lining can be injured as a result of tobacco use, hyperlipidemia, hypertension, diabetes, hyperhomocysteinemia and infection causing a local inflammatory response. C-reactive protein (CRP), a nonspecific marker of inflammation is increased in many patients with CAD. Chronic exposure to even minor elevations of CRP can trigger the rupture of plaques and promote the oxidation of low-density lipoprotein cholesterol leading to increase uptake by macrophages in the endothelial lining.

Developmental changes Fatty streaks, the earlier lesions of atherosclerosis, are characterized by lipid-filled smooth muscle cells. As streaks of fat develop within the smooth muscle cells, a yellow tinge appears. Fatty streaks can be observed in the coronary arteries by age 15 and involve an increasing amount of surface area as the patient ages. It is generally believed that treatment that lowers LDL cholesterol may reverse this process. Fibrous plaque stage is the beginning of progressive changes in the endothelium of the arterial wall. These changes can appear in the coronary arteries by age 30 and increase with age. Normally, the endothelium repairs itself immediately, but in the person with CAD the endothelium is not rapidly replaced, allowing LDLs and growth factors from platelets to stimulate smooth muscle proliferation, and thickening of the arterial wall. Once endothelial injury has occurred, lipoproteins (carrier proteins within the bloodstream) transport cholesterol and other lipids into the arterial intima. The fatty streak is eventually covered by collagen forming a fibrous plaque that appears grayish or whitish. These plaques can form on one portion of the artery or in a circular fashion, involving the entire lumen. The borders can be smooth or irregular with rough, jagged edges. The result is a narrowing of the vessel lumen and a reduction in blood flow to the distal tissues. Complicated lesion. The final stage in the development of the atherosclerotic lesion is the most dangerous. As the fibrous plaque grows, continued inflammation can result in plaque instability, ulceration and rupture.
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 Once the integrity of the arterys inner wall has become compromised, platelets accumulate in large numbers, leading to a thrombus. The thrombus may adhere to the wall of the artery, leading to further narrowing or total occlusion of the artery. Activation of the exposed platelets causes expression of glycoprotein IIb/IIIa receptors that bind fibrinogen. This, in turn leads to further platelet aggregation and adhesion, further enlarging the thrombus. At this stage, the plaque is referred to as complicated lesion. Collateral circulation. Normally some arterial anastomoses or connection, termed collateral circulation, exist with the coronary circulation. The growth and extent of collateral circulation are attributed to two factors: 1) the inherited predisposition to develop new blood vessels (angiogenesis) and 2) the presence of chronic ischemia. When an atherosclerotic plaque occludes the normal flow of blood through a coronary artery and the resulting ischemia is chronic, increased collateral circulation develops. When occlusion of the coronary arteries occurs slowly over a long period, there is a greater chance of adequate collateral circulation developing, and the myocardium may still receive an adequate amount of blood and oxygen. However the rapid onset of CAD or coronary spasm, the time is inadequate for collateral development and a diminished arterial flow results in a more severe ischemia or infarction. CAD develops over many, and clinical manifestation will not be apparent in the early stages of the disease. Therefore it becomes extremely important to identify people at risk so that therapeutic lifestyle changes and some treatment strategies can be initiated early. Risk factors for coronary artery disease Risk factors are characteristics or conditions that are statistically associated with a high incidence of a disease. Many risk factors have been associated with a high incidence of a disease. Many risk factors have been associated with CAD. Risk factor may be categorized as nonmodifiable and modifiable. Nonmodifiable rik factors ar age, gender, ethnicity, family history, and genetic inheritance. Mofifiable risk factors include elevated serum lipids, hypertension, tobacco use, physical activity, obesity, diabetes, metabolic syndrome, psychologic states, and homocysteine level. Treatment Goals for treating these conditions in people who have coronary artery disease: Blood pressure less than or equal to 140/90 (even lower for some patients with diabetes, kidney disease, or heart failure) Glycosylated hemoglobin (HbA1c) levels less than or equal to 7% for people with diabetes LDL cholesterol level less than or equal to 100 mg/dL (even lower for some patients)

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Treatment depends on the symptoms and how severe the disease is. Medicines to treat CHD includes: ACE inhibitors to lower blood pressure and protect the heart and kidneys Aspirin, with or without clopidogrel (Plavix) or prasugrel (Effient) to help prevent blood clots from forming in the arteries Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart Calcium channel blockers to relax arteries, lower blood pressure, and reduce strain on the heart Diuretics ("water pills") to lower blood pressure and treat heart failure Nitrates (such as nitroglycerin) to stop chest pain and improve blood flow to the heart Statins to lower cholesterol

Hypoxic Ischemic Encephalopathy Definition Hypoxic ischemic encephalopathy (HIE) is a condition in which the brain does not receive enough oxygen. This particular condition refers to an oxygen deficiency to the brain as a whole, rather than a part of the brain. Although the term most often refers to injury sustained by newborns, HIE can be used to described any injury from low oxygen. Figure 3. B. 8 Comparison of normal brain to that with HIE HIE can be fatal. Within as little as five minutes of oxygen deprivation, brain cells can begin dying. The disease can also cause long-term damage, including intellectual disability , delayed development, seizures , and cerebral palsy

Causes/ Etiology There are a variety of causes of HIE. Any injury and many health conditions can potentially cause oxygen deprivation to the brain. Some common causes are:

Injury or complication during birth Respiratory failure Blocked or ruptured blood vessel Carbon monoxide or cyanide poisoning Drug overdose Drowning Lack of oxygen due to smoke inhalation Extremely low blood pressure
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Strangulation Cardiac arrest Carbon monoxide poisoning High altitudes Choking Compression or injury to the trachea that reduces or stops breathing Complications from general anesthesia Diseases that cause paralysis of the respiratory organs or muscles (eg, myasthenia gravis , Guillain-Barre syndrome )

Risk Factors Any injury, complication, or condition that causes the brain to have a reduction in blood flow and oxygen deprivation is a risk factor for HIE. Clinical Manifestations Symptoms include:
o o o o o o o o o

Mild case: Difficulty concentrating or paying attention Poor judgment Poor coordination Euphoria Extreme lethargy

Severe oxygen deprivation: Seizures Coma No brain stem reflexes (eg, breathing, responding to light) Only blood pressure and heart function reflexes are functioning

Signs/ Tests There are no specific tests to confirm or exclude a diagnosis of hypoxic-ischemic encephalopathy (HIE) because the diagnosis is made based on the history, physical and neurological examinations, and laboratory evidence. Many of the tests are performed to assess the severity of brain injury and to monitor the functional status of systemic organs. As always, the results of the tests should be interpreted in conjunction with the clinical history and the findings from physical examination. Laboratory studies should include the following: Severe electrolyte imbalance- In severe cases, daily assessment of serum electrolytes is valuable until the infant's status improves. Markedly low serum sodium, potassium, and chloride levels in the presence of reduced urine flow and excessive weight gain may indicate acute tubular damage or syndrome of inappropriate antidiuretic hormone (SIADH) secretion, particularly during the initial 2-3 days of life.Similar changes may be seen during recovery; increased urine flow may indicate ongoing tubular damage and excessive sodium loss relative to water loss

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Renal function studies - Serum creatinine levels, creatinine clearance, and BUN levels suffice in most cases. Cardiac and liver enzymes - These values are an adjunct to assess the degree of hypoxic-ischemic injury to these other organs. These findings may also provide some insight into injuries to other organs, such as the bowel. In addition, early evidence suggests that cardiac troponin I may be correlated to HIE severity Coagulation system evaluation - This includes prothrombin time, partial thromboplastin time, and fibrinogen levels. ABG - Blood gas monitoring is used to assess acid-base status and to avoid hyperoxia and hypoxia as well as hypercapnia and hypocapnia.

Imaging Studies Brain MRI - Decreased signal in the posterior limb of the internal capsule (PLIC) on T1w images may be noted. The absence of normal signal (high intensity on T1w images) in the PLIC of infants older than 38 weeks' gestation is a strong predictor of abnormal motor outcomes in these infants. Cranial ultrasonography - Findings include global increase in cerebral echogenicity and obliteration of cerebrospinal fluid (CSF) containing spaces suggestive of cerebral edema. Head CT scanning - Areas of reduced density that indicate evolving zones of infarction may be present. Evidence of hemorrhage in the ventricles or in the cerebral parenchyma may also be seen.

Treatment/ Prevention Treatment depends on the underlying cause of the condition, as well as the severity of the damage to the brain. Treatment options include:

Life-sustaining treatmentIf brain function has stopped but damage is not yet extensive, life-sustaining treatment is administered. Mechanical ventilation This may be needed to sustain breathing. Treatments for the circulatory systemTreatments are administered to maintain heart function and control blood pressure. Seizure controlMedicine and general anesthesia may be administered to control seizures. CoolingHypoxic brain damage is often caused by heat. Cooling blankets or other means of cooling may be applied to reduce the body's temperature.
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Hyperbaric oxygen treatment This treatment is used in cases of carbon monoxide poisoning.

In most cases, HIE is unexpected and cannot be prevented. To prevent significant or long-term brain damage once the oxygen supply has been reduced, CPR may be administered.

Health-care related, Ventilator acquired and Aspiration Pneumonia Definition It is an acute inflammation of the lung parenchyma cause by microbial organisms. Risk Factor predisposing to Pneumonia Resulting when defense mechanism become incompetence Virulence or quantity of infectious agent Decrease consciousness depressing epiglottal reflexes Tracheal intubation interfering normal cough reflex Impairment of mucousilliary mechanism due to air pollution, cigarette smoking, viral upper respiratory infection and normal changes of aging

How to acquire pneumonia Aspiration Inhalation Hematogenous spread Types of Pneumonia 1.Hospital Acquired pneumonia Figure 3. B. 9 Hospital-acquired pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization. (Figure 3. B. 9) 2.Ventilator associated- refers to pneumnonia that occurs more than 48-72 hours after endotracheal intubation.(Figure 3. B. 10) 3.Healthcare associated Pneumonia- includes any patients with a new onset of pneumonia: who was hospitalized in an acute health care hospital for 2 or more days with 90 days of infection, resided in a long term care facility, received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection and attended a hospital or hemodialysis clinic. Figure 3. B. 10

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Organisms associated with Hospital acquired and ventilator acquired pneumonia and how it is acquired: Pseudomonas aeruginosa- common bacterium that can cause disease in animals, including humans. It is found in soil, water, skin flora, and most man-made environments or machines. (See Figure 3. B. 11) Figure 3. B. 11 Klebsiella pneumoniaE- gram-negative, nonmotile bacteria found in soil, water, cereal grains, and the intestinal tract of humans and other animals. commonly implicated in nosocomial urinary tract infections, especially in immunocompromised patients. (See Figure 3. B. 12) Candida tropicalis- one of many types of yeasts that naturally exist within animals and humans, particularly in the gastrointestinal and urinary tract. (See Figure 3. B. 13) Figure 3. B. 12 Figure 3. B. 13 Burkholderia cepacia- found naturally in wet soil and decaying plants, such as rotting onions. B. cepacia can live on surfaces such as sinks, counter tops, clothing and chairs for up to 2 hours if the droplets are dry and up to 24 hours if they are wet. While it is possible for B. cepacia to be transmitted through indirect contact with these objects, person to person contact is by far the most common mode of transmission. (See Figure 3. B. 14) Figure 3. B. 14 Risk Factors Alcoholism Being on a breathing machine Breathing saliva or food into the lungs (aspiration) Chest surgery Immunosuppression (immune system does not work well) Long-term (chronic) lung disease Not being fully alert Older age Recent illness Clinical Manifestations Cough that may produce mucus-like, greenish, or pus-like phlegm (sputum) Chills Easy fatigue Excessive sweating (rare) Fever
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General discomfort, uneasiness, or ill feeling (malaise) Headache Joint stiffness and pain (rare) Loss of appetite Muscle stiffness (rare) Nausea and vomiting Sharp or stabbing chest pain that gets worse with deep breathing or coughing Shortness of breath Signs/ Tests A physical examination shows: Crackles or decreased breath sounds when listening to the chest with a stethoscope Decreased oxygen Respiratory distress Tests performed may include: Arterial blood gases Blood cultures Chest x-ray or CT scan Complete blood count (CBC) Sputum culture Sputum gram stain Aspiration Pneumonia

Definition It is an acute inflammation of the lung parenchyma caused by a microbial organism from the nasopharynx or oropharynx. It refers to the sequelae occurring from abnormal secretions or substances into the lower airway. Causes/Etiology Usually following aspiration of material in the mouth or stomach into the trachea and subsequently into the lungs. Risk Factors for aspiration or breathing in of foreign material into the lungs are: Being less alert due to medicines History of loss consciousness(seizure, stroke and anesthesia) Disorders of the esophagus, the tube that moves food from the mouth to the stomach (esophageal stricture, gastroesophageal reflux) Old age Tube feeding Clinical Manifestations Bluish discoloration of the skin caused by lack of oxygen Chest pain Cough With foul-smelling phlegm (sputum) With sputum containing pus or blood With greenish sputum Fatigue Fever Shortness of breath
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Wheezing Other symptoms that can occur with this disease: Breath odor Excessive sweating Swallowing difficulty

Signs/ Tests A physical examination may reveal: Crackling sounds in the lungs Decreased oxygen Rapid pulse (heart rate) The following tests may also help diagnose this condition: Arterial blood gas Bronchoscopy Chest x-ray CT scan of the chest Sputum culture Treatment/ Prevention: Antibiotic therapy Supportive measures: Oxygen therapy to treat hypoxemia Analgesic- to relieve chest pain for patient comfort. Antipyretic (aspirin or acetaminophen) for significantly elevated temperature. Rest should be encourage during acute febrile case. Antiviral drugs: Amantadine (Symmetrel)and rimantadine (flumadine) Vaccination against influenza is the mainstay of prevention. Pneumococcal vaccine Fluid intake of at least 3 liters per day for the supportive treatment of pneumonia. Meet nutritional needs of the patient. Small frequent meals for dyspneic patient.

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CHAPTER IV: CASE ANALYSIS AND INTERVENTIONS Pathophysiology

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CHAPTER IV MANAGEMENT

Medical Management 1. INTRAVENOUS THERAPY a. D5 0.3% NaCl Generic name: Dextrose 5% Classification: Hypertonic solution Indication: Replacement therapy especially in extracellular fluid deficit accompanied by acidosis. Contraindications: -Renal failure -Liver dysfunction -Diabetes mellitus -Lactic acidosis -Alkalosis hyperkalemia Nursing Responsibilities: -Never stop hypertonic solutions abruptly. -Dont give concentrated solutions I.M. or subcutaneously. -Monitor glucose level carefully. -Monitor vital signs frequently. Report adverse reactions. -Monitor intake and output and weight carefully. Watch closely for signs and symptoms for fluid overload. -Monitor patient for signs of mental confusion. b. PNSS Generic name: 0.9% sodium chloride Brand name: Normal saline solution Classifications: Isotonic Intravenous Solution Contraindications: No known contraindications. Nursing Considerations: -It should be use with great care, if at all, in all patients with congestive heart failure, severe renal insufficiency, and clinical state in which there is existing edema with sodium retention. -Do not connect flexible plastic containers of IV solution in series connections, such as in air embolism due to residual that are being drawn from one container before administration of the fluid from a second container that is completed. c. Isoket Drip Generic Name: Isosorbide Dinitrate Classification:Anti-anginal, Nitrate, Vasodilator Action: Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease arterial BP which reduces left ventricular workload and decreases myocardial oxygen consumption. Indication: Treatment and prevention of angina pectoris Contraindication: Hypersensitivity to Nitrates.
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Nursing Responsibility: -Monitor effectiveness of drug in relieving angina. -Chronic administration of large doses may produce tolerance and thus decrease effectiveness of nitrate preparations. -Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking. d. Nicardipine drip Classification:anti-anginal, anti-hypertensive, channel blocker Action: -Inhibits the movement of calcium ions across the membranes and arterial muscle cells. -decreases cardiac work, decreases cardiac energy consumption, and increases delivery of oxygen to myocardial cells. Indication: -Management of hypertension, chronic stable angina. Contraindication: Nursing Responsibility: -Monitor vital signs carefully. -Report irregular heartbeat, shortness of breath, swelling of hands or feet, dizziness, constipation. 2. OXYGEN THERAPY - The administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.

Hypoxia - the blood oxygen levels < 92% Hypercapnia - increased carbon dioxide levels

Indication for oxygen therapy: Any individual with one or more of the following:

Peri and post cardiac or respiratory arrest Hypoxia - diminished blood oxygen levels (oxygen saturation levels of <92%) Acute and chronic hypoxemia (PaO2 < 65mmHg, SaO2 < 92%) Signs and symptoms of shock Low cardiac output and metabolic acidosis (HCO3 < 18mmol/l) Chronic type two respiratory failure (hypoxia and hypercapnia)

Despite a lack of supportive data, oxygen is also administered in the following conditions:

Dyspnea without hypoxemia Postoperatively, dependent on instruction from surgical team. Treatment of pneumothorax .
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Method of administration oxygen given to patient: Endotracheal tube -is a breathing tube. It is used temporarily for breathing because it keeps your airway open. This curved is placed through the patients nose or mouth into his trachea. Tape or soft strap holds the tube in place. An endotracheal tube is used : -To attach a ventilator if the patient is unable to breathe on its own. -To keep the patient's trachea (windpipe) open. -To allow the staff to remove mucus from the patient's lungs that he is unable to cough up himself. -This can help when a patient is unconscious and by maintaining a patent airway, especially during surgery. -It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations. Nursing Responsibilty: - Suctioning down the tube every two hours or as needed. - The patient must also be monitored for skin breakdown in either the oral or nasal cavity (depending on where the tube is inserted). - Thorough oral care should be provided every eight hours and as needed. - The tube should be repositioned so that it is not continuously exerting pressure in the same area. - The tape must be removed and replaced on the opposite side of the face at least once per day and as needed. Bag valve mask - Hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. - used extensively in the operating room to ventilate an anaesthetized patient in the minutes before a mechanical ventilator is attached. -The device is self-filling additional oxygen (O2) can be added. with air, although

-Flow-inflating bags termed "anesthesia bags" or "flowinflating bags" these bags require an external flow source to inflate.
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-Self-inflating bags the bag portion of the BVM is rigid and self-inflates when released; this does not require an external flow source. Nursing Responsibilities: - Synchronized with patients breathing pattern. - Do not over inflate the bag. Risk Oxygen is not addictive and causes no side effects when used as prescribed. Complications from oxygen therapy used in appropriate situations are infrequent. Respiratory depression, oxygen toxicity, and absorption atelectasis are the most serious complications of oxygen overuse. A physician should be notified and emergency services may be required if the following symptoms develop:

frequent headaches anxiety cyanotic (blue) lips or fingernails drowsiness confusion restlessness slow, shallow, difficult, or irregular breathing

3. BLOOD TRANFUSION THERAPY A blood transfusion is a safe, common procedure in which the body receive blood through an intravenous (IV) line inserted into one of the blood vessels. Blood transfusions are used to replace blood lost during surgery or a serious injury. A transfusion also might be done if the body can't make blood properly because of an illness. During a blood transfusion, a small needle is used to insert an IV line into one of the blood vessels. Through this line, the body receive healthy blood. The procedure usually takes 1 to 4 hours, depending on how much blood is needed. Packed RBC - Used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems. - Carries oxygen from the lungs to the rest of the body.
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- One of the most important blood components used in transfusion medicine. - Provides nutrients and preserves the functionality of the living cells. Nursing Responsibility: - Insure that the right unit of blood is to be administered to the right patient after typing and cross matching by the lab by checking the lot, serial numbers, blood type, and expiration date. - The unit of blood has to be checked off with another nurse before administration. - Monitor vital signs of the patient.

3. Hemodialysis Cleansing the blood of accumulated waste products. -One of the diagnosis of the patient was end stage renal disease so the kidney can no longer do its normal function. Uses 1. Short term therapy in acutely ill clients 2. Long term use in clients with end-stage renal disease Hemodialysis requires five things: 1. Access to patients circulation (usually via fistula). 2. Access to a dialysis machine and dialyzer with a semipermeable membrane. 3. The appropriate solution (dialysate bath). 4. Time: 12 hours each week, divided in 3 equal segments. 5. Place: home (if feasible) or a dialysis center. Three ways to access to clients circulation for dialysis: Arteriovenous Fistula- A section of vein is directly sutured to an artery. It is usually placed in the nondominant arm, using the cephalic vein and radial artery. Arteriovenous Graft- Connection tube is clients own (autologous) saphenous vein, or made from polytetrafluoroethylene (PTFE). Central Venous Catheter- Catheter inserted by directly cannulating the vein. Usual CVC sites are: femoral, internal jugular, or subclavian veins. Procedure for hemodialysis 1. Patients circulation is accessed 2. Unless contraindicated, heparin is administered 3. Heparinized (heparin: natural clot preventer) blood flows through a semipermeable membrane in one direction 4. Dialysis solution surrounds the membranes and flows in the opposite direction
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5. Dialysis solution is: a. Highly purified water b. Sodium, potassium, calcium, magnesium, chloride and dextrose c. Either bicarbonate or acetate, to maintain a proper pH 6. Via the process of diffusion, wastes are removed in the form of solutes (metabolic wastes, acid-base components and electrolytes) 7. Solute wastes can then be discarded or added to the blood 8. Ultrafiltration removes excess water from the blood 9. After cleansing, the blood returns to the client via the access.

Complications related to vascular access in Hemodialysis 1. 2. 3. 4. 5. 6. Infection Catheter clotting Central venous thrombosis Stenosis or thrombosis Ischemia of the affected limb Development of an aneurysm

Nursing interventions for Hemodialysis 1. Explain procedure to client 2. Monitor hemodynamic status continuously 3. Monitor acid-base balance 4. Monitor electrolytes 5. Insure sterility of system 6. Maintain a closed system 7. Discuss diet and restrictions on: a. Protein intake b. Sodium intake c. Potassium intake d. Fluid intake 8. Reinforce adjustment to prescribed medications that may be affected by the process of hemodialysis 9. Monitor for complications of dialysis related to: a. Arteriosclerotic cardiovascular disease b. Congestive heart failure c. Stroke d. Infection e. Gastric ulcers f. Hypertension g. Calcium deficiencies (bone problems such as aseptic necrosis of the hip joint) h. Anemia and fatigue i. Depression, sexual dysfunction, suicide risk
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Nursing Considerations: Patient Preparation: 1. Allow the client to void before catheter insertion. 2. Institute abdominal skin preparation 3. Document the clients weight before the dialysis 4. Take baseline vital signs During the Procedure: 1. Monitor the level of electrolytes. 2. Obtain samples of return dialysate for culture 3. Compare the clients weight before and after the procedure 4. Monitor the vital signs every 30 minutes and report any deviations 5. Provide proper positioning for the dialysate to return from the peritoneal cavity. Place the patient in semi-Fowlers position. 5. Foley bag catheter -Urinary catheter is inserted into patient's bladder via his or her urethra. -Catheterization allows the patient's urine to drain freely from the bladder for collection. It may be used to inject liquids used for treatment or diagnosis of bladder conditions. -The catheter may be a permanent one (indwelling catheter), or an intermittent catheter removed after each catheterization.

6. Nasogastric tube -Nasogastric intubation refers to the process of placing a soft plastic nasogastric (NG) tube through a patient's nostril, past the pharynx and down the esophagus into a patient's stomach. Purpose: -Nasogastric tubes are inserted to deliver substances directly into the stomach, remove substances from the stomach or as a means of testing stomach function or contents. -To deliver tube feedings to a patient when they are unable to eat. - is used to remove air that accumulates in the stomach during cardiopulmonary resuscitation (CPR). -It is used to remove stomach contents after major trauma or surgery to prevent aspiration of the stomach contents. -Placing a NG helps prevent nausea and vomiting by removing stomach contents and preventing distention of the stomach when a patient has a bleeding ulcer, bowel obstruction or other gastrointestinal diseases.

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Nursing Responsibility: -Always check the tube positioning by instilling air and listening for gurgling sounds using stethoscope before giving feedings to prevent aspiration. - Keep the patients in an upright or semi-upright sitting position when delivering tube feeding to enhance peristalsis and avoid regurgitation of the feeding. - Cap or clamp off the NG tube when not in use to prevent backflow of stomach contents or accumulation of air in the stomach.. - If the amount of gastric aspirate is more 100ml, discontinue feeding. - After feeding, position position for 30 minutes. patient into high-fowlers

7. Suctioning -removing mucus and fluids from the nose, mouth, or back of the throat with a bulb syringe or a catheter (thin flexible tube). It aims to assist in the removal of bronchial secretions that cannot be expectorated by the patient spontaneously Nursing Considerations: Maintain sterile technique while doing the procedure. Do not allow suctioning to continue for more than 10 seconds. Hyperventilate three to five times between suctioning or encourage patient to cough and deep breathe between suctioning. Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. 8. Complete Blood Count - A common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets. Red blood cells: The CBC's measurements of red blood cell (RBC) count, hemoglobin (the oxygen-carrying protein in RBCs), and mean (red) cell volume (MCV) provides information about the RBCs, which carry oxygen from the lungs to the rest of the body. These measurements are usually done to test for anemia, a common condition that occurs when the body has insufficient red blood cells.
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White blood cells: The white blood cell (WBC) count measures the number of WBCs (also called leukocytes) in the blood. The WBC differential test measures the relative numbers of the different kinds of WBCs in the blood. WBCs, which help the body fight infection, are bigger than red blood cells and there are far fewer of them in the bloodstream. An abnormal WBC count may indicate an infection, inflammation, or other stress in the body.

Platelets: The smallest blood cells, platelets play an important role in blood clotting and the prevention of bleeding. When a blood vessel is damaged or cut, platelets clump together and plug the hole until the blood clots. If the platelet count is too low, a person can be in danger of bleeding in any part of the body.

Purpose - The CBC provides valuable information about the blood and to some extent the bone marrow which is the blood-forming tissue. The CBC is used for the following purposes: As a preoperative test to ensure both adequate oxygen carrying capacity and homeostasis. To identify persons who may have an infection. To diagnose anemia. To monitor treatment for anemia and other blood diseases.

Nursing Responsibility: - Identify patient, ask if the patient is taking anticoagulant medication like aspirin. - Assess the site for CBC test if skin was intact. - After the test, apply pressure for 15 minutes. - The result will be available after 1hour and the physician will be the one who will explain for the results. - As a nurse, reinforced learning to both patient and significant others.

9. Anti-embolism stockings Designed specifically for bed bound (non-ambulatory) patients to help prevent blood from pooling in the veins of the leg. Pooling of blood in the veins of the leg may contribute to blood clots forming in the veins. Made for short duration of wear during a hospitalization.
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Provide graduated pressure on the lower leg and foot and, in some cases, the thigh, to alleviate circulatory problems such as edema, phlebitis and thrombosis.

Nursing Responsibilities Do not offer anti-embolism stockings to patients who have: suspected or proven peripheral arterial disease peripheral arterial bypass grafting peripheral neuropathy or other causes of sensory impairment .

any local conditions in which stockings may cause damage, for example fragile tissue paper skin, dermatitis, gangrene or recent skin graft. known allergy to material of manufacture. cardiac failure. 10. Mechanical Ventilator a method to mechanically assist or replace spontaneous breathing. divided into negative-pressure ventilation, where air is essentially sucked into the lungs, or positive pressure ventilation, where air (or another gas mix) is pushed into the trachea. There are two main divisions of mechanical ventilation; Invasive ventilation, and non-invasive ventilation. Negative Pressure Ventilation
This negative pressure leads to expansion of the chest, which

causes a decrease in intrapulmonary pressure, and increases flow of ambient air into the lungs. As the vacuum is released, the pressure inside the tank equalizes to that of the ambient pressure, and the elastic coil of the chest and lungs leads to passive exhalation. Positive Pressure Machine Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube. The positive pressure allows air to flow into the airway until the ventilator breath is terminated. Indications patient's spontaneous ventilation is inadequate to maintain life. prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs.
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 Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to Guillain-Barr syndrome,Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs. Increased work of breathing as evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress Hypoxemia with arterial partial pressure of oxygen (PaO2) < 55 mm Hg Hypotension including sepsis, shock, congestive heart failure Neurological diseases such as Muscular Dystrophy and Amyotrophic Lateral Sclerosis Complications pneumothorax, airway injury alveolar damage ventilator-associated pneumonia.

Positive end-expiratory pressure An adjuvant to the mode of ventilation used to help maintain functional residual capacity (FRC). The PEEP exerts pressure to oppose passive emptying of the lung and to keep the airway pressure above the atmospheric pressure. Indications PEEP can cause significant haemodynamic consequences through decreasing venous return to the right heart and decreasing right ventricular function. If a PaO2 of 60 mmHg cannot be achieved with a FiO2 of 60% If the initial shunt estimation is greater than 25%

The nurse must be able to do the following: - Identify the indications for mechanical ventilation. - List the steps in preparing a patient for intubation. - Determine the FIO2, tidal volume, rate and mode of ventilation on a given
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- ventilator. - Describe at least two complications associated with patients response to mechanical ventilation and their signs and symptoms. - Describe the causes and nursing measures taken when troubleshooting ventilator alarms. - Describe preventative measures aimed at preventing selected other complications related to endotracheal intubation. - Complete the care of the ventilated patient checklist.

SURGICAL MANAGEMENT a. Venous cut down -an emergency procedure in which the vein is exposed surgically and then a cannula is inserted into the vein under direct vision. It is used to get vascular access in trauma and hypovolemic shock patients when peripheral cannulation is difficult or impossible. Nursing Responsibility: - Assess the dressing after the procedure. - Note for any signs of infection on the site like redness and swelling and fever. - Change dressing regularly. b. Insertion of Intrajugular Catheter -indicated for: Central venous access for confusion of vasoactive drugs, TPN, high dose KCL, etc. Hemorrhagic disorder where large volumes of blood or blood products needed. Measurement of central venous pressure. Need for frequent blood draws where peripheral access limited. Lack of peripheral access.

Contraindicated to: Severe coagulopathy; the femoral or the IJ site is preferred with coagulopathy or anticoagulation due to the ability to compress the vein in the event of serious hemorrhage. Infected skin site. In patients with higher risks for pneumothorax or inability to tolerate pneumothorax, the IJ or femoral sites may also be preferred.

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Nursing Responsibility: -Assess the site for any signs of infection like swelling, redness and fever. -Avoid any procedure near the site.

c. Perm catheter - Insertion is the placement of a special IV line into the blood vessel in your neck or upper chest just under the collarbone. -This type of catheter is used for short-term dialysis treatment. ---The catheter is then threaded into the right side of your heart (right atrium). -The procedure involves creating a tunnel under the skin to thread the other portion of the catheter out through the skin. This tunneling process greatly reduces the risk of an infection and allows the catheter to remain in for a long period of time (one12 months). Nursing Responsibility: -Do not shower the day of your procedure or perform heavy activities such as lifting. Do not remove the dressing until you are instructed to do so. -Will need to continue your routine dialysis treatments. -Please inform your doctor of any fever or pain, redness or drainage at the catheter site. -May have a small amount of bleeding at the site. Report any bleeding that continues or increases to your physician. -May have mild pain for one to two days. May take whatever pain medications you use for minor aches and pains. d. AV fistula - An arteriovenous fistula (AV fistula) is the connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis, a procedure that performs the functions of the kidneys in people whose kidneys have failed. -the fistula develops over a period of months after the surgery.
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- AV fistula provides a long-lasting site through which blood can be removed and returned during hemodialysis. - allows the person to be connected to a dialysis machine. Nursing Responsibility: - Inform the client that the arm where the AVF should not be used for BP taking because the pressure exerted by the BP cuff may interfere with the blood flow and normal healing process of the anastomossed artery and vein.

e. Embolectomy Embolectomy is the emergency surgical removal of emboli which are blocking blood circulation. It usually involves removal of thrombi (blood clots), and is then referred to as thrombectomy. The removal of the clot with a catheter. The catheter, which is guided up from an artery in the groin to the site of the clot, deploys a special wire with loops in it. This wire threads through the embolus, gripping it so it can be pulled out. Indications Patients with pulmonary embolism (formed from venous embolisms). Used for patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy. Nursing Responsibilities: - Monitor vital signs of the patient.

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