Leukemia

Introduction :-

• It is also known as blood cancer.
• It is the type of cancer of blood and bone marrow with excess WBC.
• It is unregulated proliferation of WBC in bone marrow.

Definition:-

• "A malignant progressive disease in which the bone marrow and other blood organs produce increase number of immature or abnormal WBC.these suppress the production of normal blood cells."

Etiology :-

• Exact cause is unknown.

Risk factor :-

• Genetic predisposition.
• Viral pathogenesis.
• Bone marrow damage from radiation exposure or chemicals such as benzene and alklyle agent.

Classification of leukemia :-

• According to involvement of stem cells -

1. Myeloid (myeloblastic, myelocytic)
2. Lymphoid (lymphoblastic, lymphocytic)

• Based on time -

1. Acute (sudden onset within few weeks)
2. Chronic (gradual onset take several weeks to months)

Myeloid leukemia :-

Definition:-

Myeloid leukemia is a cancer of myeloid cells (stem cells) characterized by rapid growth of a normal cells that build up in the bone marrow and blood and interfere with the normal blood cells.

Myeloid leukemia is progressive malignant disease in which there are too many immature blood forming cells in the blood and bone marrow. In this type of granulocyte and monocyte do not mature that fight against infection.

Introduce Acute Myeloid leukemia :-

It result from defect in the hematopoietic stem cell that differentiate into all stem cell . (monocyte, granulocyte, eosinophil,basophil, neutrophil).

Incidence of Acute Myeloid leukemia:-

• All age groups are affected.
• The peak incidence is at 60yrs.
• It is the most common type of leukemia.
• Fever.
• Infection (due to neutropenia).
• Weakness and fatigue due to anemia.
• Bleeding tendency due to thrombocytopenia.
• Abdominal pain due to hepatosplenomegaly.
• Bone pain (due to proliferation in bone marrow).

Diagnostic evaluation of Acute Myeloid leukemia :-

1. CBC.
2. Decrease RBC, platelets and neutrophils.
3. Bone marrow biopsy to confirm the type of cell involve.

Management of Acute Myeloid leukemia:-

1. Chemotherapy :- It include induction and consolidation chemotherapy.

• Induction chemotherapy :- It aims at eradicating all leukemic cells. It involve administration of high dose of chemotherapeutic agents such as cytorebine,deunorubicin,ideribicin,etoposide etc.
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Oral cancer

Introduction:-

• Oral cancer is also known as mouth cancer.
• Oral cancer is cancer that develops in tissue of the mouth or throat. It belongs to a large group of cancer called head and neck cancer. Most develop in squamous cell found in your mouth, tongue and lips. It can be fatal if not diagnosed in early stages.

Definition:-

• "Oral cancer is defined as uncontrolled growth or sore in mouth.that does not go away. "
• Oral cancer and high includes cancer of lips, tongue, cheeks,floor of mouth hard and soft palate, sinuses and pharynx (throat).
• Oral cancer is a type of head and neck cancer is any tissue growth located in oral cavity.
• It may arises as from distent site of origin or by extrusion from neighboring anatomic site such as nasal cavity.

Common sites of oral cancer :-

• Lower lips.
• Lateral or under surface of tongue.
• Buccal mucosa.
• Hard and soft palate.
• Pharyngeal wall.

Incidence:-

• More common after 45 yr of age - male : female is 2:1.
• Oral cancer accounts for 50% of 70% of total cancer mortality.

Clinical manifestation:-

1. Leukoplakia :- White patches on the mucosa of the mouth or tongue.
2. Hyperkeratosis :- Hard and lethargy White patches.
3. Erythroplakia :- Rad velvety patch on the mouth or tongue.

• Painful ulceration.
• Soreness of tongue.
• Increased salivation.
• Dysphagia.
• Slurred speech.
• Tooth ache.
• Ear ache.
• Difficulty in chewing/mastication.
• Mouth,lip,tongue,may be pale or dark color or disorder.

Diagnostic evaluation :-

• P.E.T.
• X-ray.
• CT scan.
• MRI.
• Biopsy.
• Oral exfoliative cytology.
• Toluidine blue test.

Management :-

Surgical management :-

• remove tumor.
• Removal of cancerous lymph node.
• Glossectomy (partial /complete).
• Removal of lower jaw.

Medical management:-

• Radiation therapy.
• Chemotherapy.
• Immunotherapies.
• Molecularly target therapy :- Targeted cancer therapies are drugs or other substances that block the growth and the spread of cancer by interfering with specific molecules that are involved in the growth progression and spread of cancer.

Management in case of metastatic cancer :-

• Radial neck desection:- It includes wide excision of involved area.
• Lesion with removal of regional lymph nodes the deep cervical lymph nodes and their lymphatic Channels (depending upon the extendiveness) the sternodomastoid muscle,internal jugular vein mendible,the sub maxillary gland.
• Modified neck desection:- It involves desection of major cervical lymphatic vessels and lateral cervical space with preservation of nerve blood vessels and jugular vein.

Palliative care :-

• It aims to treat symptoms and make patient more comfortable.
• Dysphagia - Gastrostomy
• Pain - Analgesic and narcotics.
• Increased salivary secretion :- Frequent suction of oral cavity .

Nursing management :-

• Risk for ineffective airway clearance related to oral surgery.
• Risk for imbalance nutrition less than body requirement related to oral surgery.
• Impaired verbal communication related to glossectomy.
• Disturbed body image related to surgical excision of tongue.

Breast cancer

Introduction :-

• Breast cancer is the cancer that forms in the cells of the breast.
• After skin cancer breast cancer is the most common cancer diagnosed in the women.

Definition :-

• "Breast cancer is a disease that occur when cells in breast tissue change or mutate and keep reproducing, these abnormal cells usually cluster together to form a tumor."
• A tumor is cancerous or malignant when these abnormal cells invade other parts of the breast.

Types :-

1. Ductal carcinoma in situ :- DCTS is a non-invasive condition.The cancer cells are confined to the ducts in the breast have not invade.
2. Lobular carcinoma in situ :- Lobular carcinoma in situ is cancer that grows in the milk producing glands of the breast , have not invade.
3. Invasive ductal carcinoma :- IDC is the most common type.This type of breast cancer begins in the breast milk duct and then invade nearby tissue in the breast.
4. Invasive Lobular carcinoma :- ILC first develops in breast lobules then invade near by tissue.

Etiology :-

• Breast cancer is caused by a genetic mutation in the DNA of breast cell.
• Inherited mutated genes known are breast cancer Gene 1 (BRCA 1), Breast cancer gene 2 (BRCA 2).

Risk factor :-

• Gender and Age :- the risk begin after 40 year in women.
• family history.
• Inherited genes :- the most well known gene mutation -BRCA 1,BRCA 2.
• Radiation therapy.
• Obesity.
• Beginning period at a younger age (before age 12).
• Beginning menopause at an older age.
• Have never been pregnant.
• Post menopausal hormone therapy (estrogen and progesterone).
• Alcohol Consumption.

Incidence :-

1. Most common malignancy in women.
2. Only 1% breast cancer occur in men.
3. 1/8 post menopausal women or at rest.
4. Occurrence of breast cancer according to the location.

Pathophysiology :-

• Majority of the breast cancer are adenocarcinomas.They are classified as ductal or lobular.

1. Intraductal.
2. Intralobular ( lobe or part or portion of an organ). 
3. Invasive ductal.
4. Invasive lobular.

Stages :-

• Stage 1 :-

1. tumor less than 2 cm.
2. Confined to breast.
3. No positive symptoms.
4. No metastasis present.

• Stage 2 :- Tumors less then 2cm with positive lymph-node.No metastasis evident. or tumor 2-5cm with or without positive lymphnode not metastasis evident or tumor greater then 5cm with lymphnodes ,not metastasis evident.
• Stage 3 :- Tumor >5cm with positive lymphnode,no metastasis present.
• Stage 4 :- Any distend metastasis to brain,lung,liver,or bone with or without positive lymphnode.

Sign and symptoms :-

• A breast lumps or tissue thickning that feel different than surrounding tissue.
• Breast pain.
• Red,pitted skin over entire breast.
• Swelling in all or part of breast.
• A nipple discharge other than breast milk.
• Blood discharge from nipple.
• A sudden change in the shape and size of breast.
• Inverted nipple.
• A lump or swelling in the arm.
• Peeling,scaling, or blaking of skin on nipple.  

Diagnostic evaluation:-

• Mammography :- It is the process of using low energy X-ray to examine the breast for diagnosis.during the procedure the breast is compressed using a dedicated mammogra[hy unit.Parallel plate compression evens out the thickness of breast tissue to increase image quality by reducing the thickness of tissue that X-ray penetrate.
• Breast biopsy :-During this test doctor will remove a tissue sample from the suspicious area to have it tested.The doctor uses a needle to take the tissue sample.then send to laboratory to test the sample.
• Ultrasound :- A breast ultra sound uses sound waves to create a picture of the tissue deep in the breast.A ultrasound distinguish between a solid mass or tumor.
• Breast self examination :- Breast self exam or regularly examining your breast on your own.there are following steps :-(done before warm bath)  

1. Step 1 :-Begin by looking at ypur breast in the mirror with your shoulders straight an arms on your hips.(breast that are their usual size,shape and color) (Dimpling ,bulging of skin,redness,rashes or swelling ,a nipple that has changed position or an inverted nipple)
2. Step 2 :-Now raise your arm and look for the same changes.
3. Step 3 :- While you are at the mirror look for any sign of fluid come out of one or both nipples.(this could be a watery,milky or yellow fluid or blood).
4. Step 4 :- Next fell your breast while lying down using your right hand to feel your left breast and then let hand to feel right breast.use a firm,smooth  touch with the first few fingers pads of your hand,keeping the fingers flat and together.Use a circular motion about the size of a qurter.
5. Finally feel breast while you are standing or sitting.

Management :-

Surgical management :-

• Lympectomy :-This procedure remove the tumor and surrounding tissue.
• Mastectomy :- In this procedure a surgeon remove an entire breast.
• Sentinal node biopsy :- This surgery remove a few of the lymph node.
• Contralateral prophylactic mastectomy :- Even though breast cancer may be present in only one breast this surgery remove healthy breast to reduce risk of developing breast cancer again.

Medical management :-

• Medication used after and in addition to surgery are adjuvant therapy.
• Hormone blocking therapy :- some breast cancers require estrogen to continue growing.they can be identified by the presence of estrogen receptors (ER+) and progesterone receptors (PR+) on their surface.these ER+ cancer can be treated with drugs that either block the receptors. Example :- Tamoxifen , Toremifene (Prvent estrogen from binding to estrogen receptors),Aromatase Inhibitor (stop estrogen production).
• Chemotherapy :- The chemotherapy medication are administered in combinations.Usually for periods of 3-6month. Example:- Cyclophosphamide with Doxorubin.
• Radiation therapy :-Radiation is given after surgery to the region of the tumor bed and regional lymphnode to destroy microscopic tumor cells.Radiation therapy can be delivered as external beam radiotherapy or as Brachytherapy (internal radiotherapy).

Nursing management :-

Pre-operative Nursing care :-

1. Knowledge deficit about breast cancer and treatment.
2. Anxiety related cancer diagnosis.
3. Fear related specific treatment ,body images change or possible death.
4. Decisional conflict related treatment option.
5. Risk for ineffective copping related diagnosis of breast cancer.

Post -operative nursing diagnosis :-

1. Pain related to surgical incision and manifestation of tissue.
2. Impaired skin integrity due to surgical incision.
3. Risk for infection related presence of surgical drain.
4. Body image disturbance related loss or alteration of the breast related surgical procedure.
5. risk for sexual dysfunction related loss of body part ,change in self image.
6. Self care deficit related partial immobility of upper extremity on operative side.

Lung Cancer

Introduction :-

• Lung cancer is cancer that start in the cells that make up the lungs.many other types of cancer such as breast or kidney can spread to the lungs.
• lung cancer are the fourth most common cancer reportedly in the Indian males.It account for 6.8% of all malignancies in india.
• The incidence is estimated to be about 6.6 per 100000 in males and 1.7 per 100000 in females.
• Commonly occur in individual more than 50yrs of age who have a long history of  cigrate smoking.

Definition :

• "Lung cnacer also known as lung carcinoma is a malignant lung tumor characterized by uncontrolled cell growth in tissue of the lung."
• "Lung cancer is neoplasm of the lung."

Etiology :-

• Exact cause is unknown.

Risk factor :-

• Genetic (transformation from one generation to another generation.)
• Age (mostly in older age, 65 or older age, average age is 70 year)
  
• Past lung disease ( can cause inflammation and scarring in the lung, eg: Tuberculosis, COPD)
• Radiation therapy to the chest (eg. breast therapy,Non-hodgkin's lymphoma)
• Second Hand Smoking
• Smoking
• Diet (low intake of vitamin-A, unbalanced diet)
• Environmental factor :- Asbestosis,Radon,Tar,Arsenic,Vinyl chloride) 
  
     

Types of Lung cancer :-

Non-Small cell Lung Cancer (NSCLC) :-

•  NSCLC is any type of epithelial lung cancer other than small cell lung carcinoma.
• NSCLC is accounts for about 85% of all lung cancer.
• NSCLC are relatively insensitive to chemotherapy compared to small cell lung cancer.
• When possible they are primarily treated by surgical resection with curative intent ,although chemotherapy has been used increasingly both pre-operative and post operative.

The most common type of NSCLC are :-

• Squamous cell carcinoma
• Adenocarcinoma
• Large cell carcinoma

1. Squamous cell carcinoma :- Arrives from bronchial epithelium & is more centrally located and its growth rate is slow.

Characteristics :- 

• Accounts for 20-30% of lung cancers.
• more common in men. Centrally located producing early symptoms of non productive cough and hemoptysis.
• do not have strong tendency to metastasis.

Response to therapy :-

• Surgically resection may be attempted.
• Adjuvant chemotherapy and radiation .

      2. Adenocarcinoma :- It arrives from the perifery of the lung and looks like nodules often metastasizes.Its growth rate is moderate.

Characteristics :-

• Accounts for 30-40% of lung cancer.
• Most common lung cancer in people.who have not smoked more common in women.
• Peripherally located often has no clinical manifestation until widespread metastasis is present.

Response to therapy :-

• Surgical resection may be attempted depending on the staging.
• Does not respond well to chemotherapy.

      3. Large cell carcinoma (undifferentiated) :- It is the fast growing carcinoma that arrive from the periphery branches of bronchi.

characteristics:- 

• Accounts for 10% of lung cancers.
• Composed of large cell that are anaplastic and often arise in the bronchi.
• It is highly metastatic via lymphatics and blood.

Response to therapy :-

• Surgery is not usually attempted.because of high rate of metastasis.
• Tumor may be radio sensitive but often recurs.

Small cell lung cancer (SCLC):-

1. Small cell carcinoma (SCC):- Arrives from the major bronchi & spread by infiltration along with bronchial walls.Growth rate is very rapid.

Characteristics :-

• Accounts for about 20% of lung cancers.
• Most malignant form of lung.
• Spread early via lymphatics & blood stream,frequent metastasis to brain.
• Associated with endocrine disturbances.

Response to therapy :-

• Chemotherapy main stay of treatment but over all poor prognosis.
• Radiation is used as adjuvant therapy and palliative measure.

Pathophysiology :-

• The carcinogens binds to the DNA
• Damage it.
• Cellular changes and abnormal growth
• Malignant cells.

As the damaged DNA is passed on to daughter cells,the DNA under goes further changes and become unstable with the accumulation of genetic changes the pulmonary epithelium under goes malignant transformation.

Stages of cancer :-

1. T o :- No evidence of tumor.
2. T x :- Tumor proved by cytologic studies ,but visualize by radiography.
3. T is :- Carcinoma in situ.
4. T 1 :- Tumor 3cm or less.
5. T 2 :- Tumor grater than 3cm.
6. T 3 :- Direct extension of chest wall.
7. T 4 :- Tumor invading mediastinal.
8. N o :- No nodule metastasis.
9. N 1-3 :- According to the progress of nodule involvement.
10. M o :- NO known metastasis.
11. M 1 :- Presence of distant metastasis.  

Enlist clinical manifestation :-

• Asymptomatic till diagnosis.
• Persistent.
• Non productive cough at earlier and in later productive cough.
• Blood tinged sputum.
• Chest pain.
• Dyspnoea.
• Wheezes.
• Palpable lymphnodes in neck or axilla.
• Unilateral paralysis of diaphragm.
• Superior venacava obstruction.(Due to intx. thorasic spread of malignancy )
• Pericardial effusion and dysrrhythemia. (if media stinum is involved)
• Annorexia.
• Fatigue.
• Weight loss.
• Fever.
• Nausea,Vomitting.

Diagnostic evaluation :-

• Chest x-ray :- shows presence of tumor or evidence of metastasis to ribs or vertebrae.
• CT-Scan and MRI :- shows the location and extent of masses.
• PET :- Helps in early detection of cancer staging and monitoring effects of treatment.
• Sputum specimen for cellular studies.
• Bronchoscopy :-Helps in direct visualization ,allows to take biopsy specimen.
• Mediastenoscopy :- Involve insertion of scope through a small anterior chest incision into the mediastinum.It is done to examine metastasis in the anterior mediastinum or in the chest extrapluraly.
• Biopsy.
• Pulmonary Angiography.
• Lungs scan.
• Fine needle aspiration.

Management of Lung cancer :-

Surgical management :-

1. lobectomy
2. wedge resection
3. Pneumonectomy
   
   

Medical management :-

1. Radiation therapy 
2. Chemotherapy
3. Laser surgery
   

Complication :-

• Airway obstruction
• Atelectosis
• Plural effusion
• Pulmonary Abscess
• Pneumonia
• Paraneoplastic syndrome

Prognosis :- 

Prognosis is generally poor ,13%of patients with lung cancer survive.

Nursing management :-

1. Ineffective breathing pattern resulting from compression of lung tissue.
2. Impaired gas exchange resulting from retained secretion and occluded bronchial.
3. Acute pain related to surgical incision tissue trauma and disruption of inter-coastal nerves ,presence of chest tube.
4. Fear and anxiety related to situational crises, change in health status and perceived threat of death.     

Hodgkin's Lymphoma

Introduction :-

• Hodgkin's lymphoma (HL) also known as Hodgkin's disease is a cancer of lymphatic system.
• It was first discovered by Thomas Hodgkin's in 1832.
• HL is a type of lymphoma in which cancer originates from a specific type of WBC called Lymphocytes.
• Lymphoma is a group of blood cancer that develop from lymphocytes.

Definition:-

• "Hodgkin's Lymphoma is also known the cancer of the lymphatic system in which the lymphocytes (WBC cells)grow abnormally and spread beyond the lymphatic system."
• "Hodgkin's lymphoma is a chronic disease the growth of tumor cells take place mainly in the lymphatic node."
• "Hodgkin's lymphoma is a type of lymphoma in which cancer originate from specific type of WBC called lymphocytes."

Types and stages of Hodgkin's disease:-

1. Classical Hodgkin's lymphoma :-(more common type) In this lymphoma people is diagnosed with this disease have large ,abnormal cells called Reed-sternberg cells in their lymph node.
2. Nodular lymphocyte -predominant Hodgkin's lymphoma :-(have better chance of cure) This much rare type of hodgkin's lymphoma involve large ,abnormal cells that are sometimes called Popcorn cells lymphoma.

Staging describe the extent and severity of the disease:-

• Stage 1 (Early stage):- Means that cancer is found in one lymph node region on the cancer is found in only one area of a single organ.
• Stage 2 (locally advanced disease) :- Means that cancer is found in two lymph node region on one side of diaphragm which is the muscle beneath your lung or that cancer was found in one lymph node region as well as in a near by organ.
• Stage 3 (Advanced disease) :- Means that cancer is found in lymph node region both above and below your diaphragm or that cancer was found in one lymphnode area and in one organ on opposite side of your diaphragm.
• Stage 4 (wide spread disease) :- means that cancer was found outside the lymph node and has spread widely to other parts of your body,such as your bone marrow liver or lung.

Causes or etiology of Hodgkin's disease :-

• The main cuase of HL is unknown.
• Disease ha sbeen linked to DNA or genetic mutation. [ Mutation tell the cell to multiply rapidly ,causing many diseased cells that continue multiplying.] 

Risk factor of Disease :-

Factors that can increase the risk of HL :-

• Age :- HL is most often diagnosed in people between 15 to 40 year and these over 55.
• A family History of Lymphoma :- Having a blood relative with lymphoma, increase the risk of developing disease .
• Gender :- male are slightly more likely to develop Hodgkin's lymphoma than are female.
• Epstein Bar Infection :- People who have illness causes by Epstein bar virus such as mononucleosis are more likely to develop HL.
• Weak Immune System.

Sign and Symptoms of Hodgkin's disease :-

• The most common symptoms -swelling of the lymph nodes.
• Night sweats
• Itchy skin 
• fever
• fatigue
• unintended weight loss
• persistent cough,trouble breathing 
• chest pain
• pain in lymph-node after consuming alcohol 
• Enlarged sp;een
• severe Dyspnoea

Diagnostic Evaluation or Investigation:-

• Family history
• physical examination
• Imaging test such as x-ray or CT scan
• Lymph node biopsy for abnormal cells 
• blood test (CBC) to measure of ,RBC,WBC and platelets
• Bone marrow biopsy (to see cancer spread)
• Immunophenotyping to determine the type of lymphoma cells are present.
• lung function test (to determine how well your lungs are working)
• Echocardiogram (to determine how well your heart are working)

Management :-

Hodgkin's lymphoma treatment are right for you depends on the type and stage of your disease and health.

• Chemotherapy :- Chemotherapy is a drug treatment that uses chemicals to kill lymphoma cells (belomycin).Chemotherapy is often combined with radiation therapy in people with eatrly -stage classical type Hodgkin's lymphoma.
• Radiation therapy :- Radiation therapy uses high-energy beams such as x-ray and protons to kill cancer cells.
• Bone marrow transplantation :- also known as stem cell transplant is a treatment to replace with healthy stem cells.
• Other drug therapy :- Drugs used to treat H.D. such as immunotherapy that works to activate your immune system to kill lymphoma cells.  

Nursing Diagnosis:-

1. Risk of infection related to immunodeficiency.
2. Ineffective therapeutic regimen management related to insufficient knowledge.
3. Imbalance nutrition less than body requirement related to malabsorption or pain.
4. Activity intolerance related to weakness.
5. Disturbed body image due to swelling of lymph node or disease condition .
6. Risk for impaired skin integrity due to weakness or immunodeficiency.

 

Myocardial Infarction

                           Myocardial Infarction 

• M.I. is define as Damage or Death of myocardial muscle due to Abrupt blood flow to the Heart.
• the blockage may be cause by formation of thrombus in coronary artery ,sudden progression of atherosclerosis,prolong narrowing of arteries.

Etiology:

• atherosclerosis
• arteries
• prolong narrowing
• thrombus
• agnoist

Risk factor:

• genetic cardial disorder
• smoking 
• alcohol consumption
• diet - like high cholesterol, high fat
• activity - low physical exercise

Pathophysiology:

• due to etiological factor
• myocardial ischemia 
• decrease myocardial oxygen supply
• increase cellular hypoxia
• decrease myocardial contractility
• decrease arterial pressure
• stimulation of baro-receptor and chemo-receptor 
• sympathetic response
• increase myocardial contractility
• increase heart rate
• increase myocardial oxygen demand 
• further myocardial ischemia
• necrosis of myocardial cells
• myocardial infarction or Heart Attack

Clinical manifestation:

• sever chest pain(more then angina pectoris )
• pain may radiant to the chest, shoulder, neck , jaw , back
• nausea
• unexplained anxiety
• dizziness
• dysponea
• sweating

Diagnostic Evaluation:

• ECG (elevated S & T segment)
• laboratory test : serum createnin kinase, myoglobin, cardiac troponin, ESR, (all level is increased)

Management:

Early management :

• morphine sulfate
• Anti-hematic : Domperidon, Alizapride
• Acute deperfusion therapy
• Primary percutaneous coronary intervention
• Maintaining vessel potassium
• Adjuncentive therapy

late management :

• life style modification : Diet control, stop smoking, regular exercise
• Secondary prevention : Anti-platelets , beta-blocker

Nursing management :

       The probable nursing diagnosis will be :

• pain related to an imbalance in oxygen supply and demand.
• Anxiety related to chest pain, fear of death, threatening environment.
• Decrease cardiac output related to impaired contractility.
• Activity intolerance related to insufficient oxygenation to perform ADL and deconditioning effect of bed-rest.
• Risk for injury related to dissolution of protective clot.

Angina Pectoris

                                 Angina Pectoris

• Angina pectoris occurs when myocardial demands exceeds, myocardial oxygen supply decreased usually caused by obstruction of coronary artery.
• chest pain due to an inadequate supply of oxygen to the heart muscle is characterized by feeling of suffocation.

Etiology :

• atherosclerosis
• prolong narrowing

Risk factor :

• thromboanxietis abliterance (inflammation of small and medium vein and thrombosis of extrimities.
• Polycythemia vera (thickness of blood)
• Polyarthritis nodosa (inflammation of aretery due to infiltraion of eosonophils.)

{Note : Angina can be triggered by exercise ,cold, or anything that incfreases the work load of heart}

Clinical manifestation :

• Pain : -  location: 90% of the clients experience pain slightly left to the sternum 

                        duration : Angina usually last fir 10 min. however attacks precipitate by emotional                                                 disturbance last for 15-20 min.

                        Severity : the pain is described as mild or moderate or often called as Discomfort.

• Dyspnea, weakness, light headache, nausea, vomiting, emptyness, restlessness.

Pattern of Angina :

1.  Stable Angina :- it is a acute chest pain triggered by exercise or emotion.
2. Unstable Angina :- it is also acute pain but unpredictable degree or cause.
3. Varient Angina:- it is also called as perinzmetals angian and it is for longer                                        duration.
4. Noctural Angina :- it is possibly associated with rapid eye movement during                                       sleeping or dreaming.
5. Angina Decubitis :- it is proximal chest pain that occur when client stand up.
6. Post Infarction Angina :- pain occur after heart attack.

Diagnostic Evaluation :-

• ECG
• Coronary Angiography
• Blood test
• Echo cardio gram
• Electron beam computed domography [EBCD]

Management :-

• the objective of the medical management in angina are to decrease oxygen demand of the myocardial and to increase the oxygen supply.
• medically these objectives are meet through pharmacological therapy and control of risk factor. Medical management focus on these three points :-

1. Relieve the acute pain.
2. Risk of coronary blood flow.
3. Prevent further attack to reduce the risk of myocardial infarction.

      A : Aspirine and anti-anginal therapy
      B : beta-blocker and blood pressure control
      C : cigarette smoking and cholesterol control
      D : Dietary modification
      E : Education and exercise.  

• Restore blood supply
• PTCA
• Intracoronary straind
• Laser ablation
• CABG (coronary artery bypass grafting)

Nursing management :-

          Diagnosis :

• Acute chest pain related to decrease blood supply to the heart resulting from coronary artery obstruction,
• Ineffective tissue perfusion related to decreased cardiac output as evidence by cyanosis ,decrease arterial oxygen and dyspnea.
• Risk of heart failure related to disease process.
• Anxiety and fear related to hospital admission, fear of death, fear of treatment procedure and disease process.
•  Risk of impaired skin integrity related to bed rest, edema, and decrease tissue perfusion.

Varicose vein

                                Varicose Vein (varicoty)

• Varicose vein or varicoty are abnormally dilated, tortuas superficial vein cause by incompetent venous valve.
• varicose vein are permanently distended veins that develop from the loss of valvular competence faulty valves elevated venous pressure causing distention and torluosity of superficial veins.
• varicose vein is divided in two types according to cause :-

1. Primary
2. Secondary

1. Primary varicose vein :-  vein after resting from congenital, genetic, or familial predisposition that                                               leads to loss of elasticity of the veins valve.

2.Secondary varicose vein :- it occurs when trauma , obstruction deep vein thrombosis or                                                                   inflammation cause damage of valves.

Etiology and Risk factor :-

• Prolong standing 
• Genetic predisposing factor
• Weakness of vein valves
• Congenital deformities
• Pregnancy

Clinical manifestation :-

• Dull-ache
• weakness
• moderate swelling
• malaise
• fever
• noctural cramps
• edema
• Pigmentation
• Ulceration
• susceptibility to injection
• Unslightly appearance of legs

Diagnostic evaluation :-

• Duplex scan :- to asses or find out anatomy of veins
• Venous blood pressure
• Venography

Management :-

1. General management :-

• the patient is instructed to avoid activity that cause venous stasis such as wearing light shocks or constructive griddles crossing. the legs at the thigh or sitting or standing at the long period. Instruct the client for changing the position frequently, elevating the legs which feels tired & getting up to walk for several minutes of every hour to promote circulation.
• the patient should be encouraged to walk 1-2 mile per day.
• Elastic wrap need to be wrapped twice daily so that greatest pressure is at the ankle with lessor pressure gradually applied at the level of knee.

     2.  Surgical management :-

• Sclerotherapy :- (using a fine therapy) :-  Sclerotherapy is the injection of a sclerosis agent      into varicose vein. The agent damage the vein and endothelial causing to swell the blood to clot. the vein turn into sear tissue that many eventually fade from view.It is used for spider veins of varicose veins up to 15 millimeter in diameter have been treated successfully.  
• Vein ligation and Stripping :- surgical management of varicose vein consist of ligation of        greator sphenous vein with its tributaries at the sphenofemoral junction. Combind with removal of the sphenous vein (stripping) & ligation of incompetent performance vein.Removal of vein is performed through multiple short incision. An increase made at the ankle over the sophenous vein and a nylon wire is threaded up vein to groin.
• Saphenofemoral ligation :- some client requires only typing of the junction of the saphenous  & femoral vein at the groin. this involves one short incision often local anesthesia & no hospital stay.

Nursing management:-

• Maintain firm elastic pressure over whole limb.
• Promote regular movement &exercise of legs.
• Elevate the foot to bed 6-9 inches so the legs are above the heart level which the client is in bed rest.
• Instruct client to walk rather than stand or sit.
• Asses for any signs of complications such as infection , hemorrhage , nerve damage etc. 

Rheumatic Heart Disease

                                 Rheumatic Heart Disease

•    Rheumatic Heart Disease is usually affect the children and it is still the most common cause of acquired heart disease in childhood and adolescence.

Incidence :-

• R.H.D. is usually affects 5-15 years child.
• 1-2 case / lakh in developed countries.
• 100 case/ lakh in developing countries.
• 3% people affect after the beta-hemolytic strptococci infection.

Pathophysiology :-

• due to etiological factor
• persistent infection of through streptococci.   
• Antigen of beta-hemolytic streptococci react.
• cross react with myosin and sarcolema membrane.
• bind the receptor on the heart.
• Inflammatory response in the cardiac muscle.
• severe & permanent heart damage.

Clinical Manifestation  :-

• carditis 
• cardiomegaly
• murmur
• pericarditis
• chest pain
• AV deffect
• Arterial fibrillation
• fever
• dysrhythmia
• Pnemonia signs
• Involuntry movement or speach after 3 month of disease.

Diagnostic Evaluation :-

• blood test
• throat swab
• chest x-ray
• ECG
• 2D echo

Management :-

Medical management :-

• Anti-biotics
• Aspirine
• Corticosteroid
• Bed rest & Supporting therapy

Nursing Management :-

• Chronic pain related to inflammatory response.
• Activity intolerance related to reduce cardiac pressure and inforced bed-rest.
• Imbalanced nutrition less the body requirement related to sever inflammation & fatigue.
• Risk for ineffective therapeutic resimen management related to need for life long threapy.    

Coronary Heart Disease

                                 Coronary Heart Disease

In coronary heart disease atherosclerosis develop in coronary arteries causing them to becoming narrow and block this leads to decrease or stop blood supply to the heart muscles.

Etiology :-

1. Non modifiable :-

• Genetic Heredity :- Children whose parents had heart disease are at a higher risk of C.H.D.
• Race :- The African & American have 45% greater chances of developing CHD.
• Age:- with increasing age risk & severity of CHD are increases.
• Gender :- males of younger age and females after menopause are at high risk of CHD.

     2. Modifiable factor :-

• Elevated serum lipid level
• Habitual diet high in fat and cholesterol
• Obesity 
• Cigarette smoking 
• Heavy alcohol consumption  
• Personality types
• Sedatory live
• Psychological strem
• Improper life style

Pathophysiology :-

• Due to etiological factor
• Localized accumulation of lipid, fibrous tissue, or thrombus
• Arterial narrowing or occulusion
• vascular changes occur that affect the functional ability or coronary arterial
• Deficit in myocardial oxygen supply
• Angina pectoris M.I. / cardiac arrest 
• Death

Types :-

• Type 1 st :- fatty, streaks lipid deposit in the int em of arteriol wall.
• Type 2 nd :- Inflammatory response takes macrophage to ingest lipid.
• Type 3rd :- Smooth muscle cell proliferate and form a fibrous capat are the deal fatty cell.
• Type 4th :- Fibrotic layer and plaque formation.
• Type 5th :- Distributed internal structure along with moderate disease that cause decrease in                         the size of lumen.
• Type 6th :- Rupture of plaque producing cavity thrombus with partial occlusion of lumen.

Clinical Manifestation :-

• Disrhythmia 
• Restlessness
• Fatigue
• Malase

Complication :-

• \Heart Failure
• Heart block
• Angina pectoris

Diagnostic Evaluation :-

• ECG
• 2D Echo
• Angiography
• Blood Investigation
• LFT

Management :-

1. Reduce Risk Factor :-

• Primary and secondary prevention cause are use for all major risk factor.
• Health professionals provide guidance & counselling related to disease condition.
• Health profession team motivate the client to stop smoking and alcohol consumption.
• maintain ideal body weight through the physical exercise
• Dietary modification according to disease condition & according to dietitian prescription.
• Encourage the client to perform physical activity and participate in exercise.
• Behavioral therapy or diversional therapy to reduce stress.

     2. Restore blood supply :-

• PTCA
• PCA
• Intra coronary stent
• laser ablation

    3. Pharmacological management :-

• Analgesics to relieve pain
• Vasoldilatiors
• ACE inhibitors

Raynaud's Disease

                                    Raynaud's Disease

Ranaud diseaseis a condition in which the small arteries and arterioles causing temporarily pallor or cynosis of digits & change in skin temperature.

Etiology :-

the exact cause of Raynaud disease is unknown but believe that some risk factor are responsible this condtion :-

• Hypersensitivity of digital arteries to clot.
• Reduce of serotonin [ Normally release in trauma for vasoconstriction ]
• Congenital predisposition
•  Eating disorder [ Anorexia nervosa ]
• Obstructive disorder

Types :-

1. Primary Raynaud Disease  :- The cause of primary raynaud disease is unknown. It is vasoseptive disorder & rarely lead to impaired tissue perfusion.
2. Secondary Raynaud Disease :- It is associated with connective tissue and collagen vascular disorder such as :-

• Scleroderma  [ hardening of skin]
• Systemic lupus Erythromatus  
• Rheumatoid Arthritis
•  Dermatomycitis [ inflammation of skin]
• Poliomyelitis

Clinical Feature :-

• Palor skin become bluish
• Numbness
• Tingling, sensation
• Burning pain
• Cynosis
• Gangrene formation

{ Note :- Raynaud's phenomena is used to localized intermittent episode of vasoconstriction of small arteries of feet and hand }

Management :-

• Avoid the particular stimuli such as cold , tobacco, drugs, etc.
• keep hand and feet warm and dry.
• Protecting all parts of body from cold, and exposure to prevent reflex, symptomatic vasoconstriction of the digits.
• Exposure to cold must be minimize and the patient remain indoor as much as possible.
• Provide protection with less of cloth , when comes out.
• Hat and gloves should be wore at all the times when outside.

  

 

Acute Venous Disorder

                                 Acute Venous Disorder

Acute venous disorder are due to thrombus formation that obstruct venous flow and develop blockage when occur in both superficial and deep veins.

Types :-

1. Superficial Venous Disorder :-It is resulting from careless insertion of intravenous line, intravenous catheter or performing diagnostic procedure.
2. Deep Venous Disorder :- Deep vein thrombosis refer to the thromboflabitis of deep vein with obstruction of veins , edema, and swelling of the extremity because of the outflow of the venous blood in inhibited.

Etiology :-

1. Venous stasis
2. Hyper coagulator
3. Trauma injury of venous wall
4. Obstruction Disease
5. Inflammatory Conditions 

{ Note :- these three phenomena(1,2,3) are together called VirChow's syndrome.}

Venous Stasis :- Immobilization or absence of the calf muscles pump or tight bending or tight clotting causes the venous stasis.

other condition that may cause stasis are surgery , paralysis , immobility , obesity , pregnancy.

Hypercoagulity :- It is often accomplished by malegnent , dehydration , and blood dyscariasis may rise the platelet count.                                                                                       Decrease fibrinolysis increase clotting factor and increase the viscosity of blood.oral contraceptives and hematogenic disorders may also cause the coagulity of the blood.

 Vein Wall Trauma :- condition that may cause the vein wall trauma are IV injection , thromboangitis obliterance fracture , chemical injury, from sclerotic agent, radiographics and certain antibiotics.

Risk Factor :-

• Surgery , specially orthopedic surgery, abdominal surgery, and renal transplantation.
• Congesting heart disease
• Cardiomyopathy
• Immobilization
• Stronger prolong travel
• Malignancy
• Previous deep vein thrombosis
• Pregnancy , particularly in purperium period and after cesarean section.
• Trauma
• Estrogen Therapy and contraceptives 
• Obesity

Pathophysiology :-

• Injury ,trauma, inflammation 
• Thrombus formation by platelets
• Adherence to endothelium
• Platelet adhere to collagen
• Adinosindiphosphate release from damage tissue
• Venous Obstruction
• Acute Venous Disorder   

    

  

Aneurysm

                                          Aneurysm

Aneurysm is defined as a permanent localized dilation , stretching and ballooning of an artery or blood vessels to around 50% increases in the size.

Etiology :-

The exact cause is unknown.

Risk factor :-

• Atherosclerosis 
• congenital defect is arterial wall
• Genetically weakness of wall
• Hypertension
• Trauma or injury
• Micro-tic infection
• Elevated cholesterol level
• Impaired nutrition

Classification :-

1. According to location :- they are described according to specific vessels in which they develop. Example: Aortic aneurysm , iliac aneurysm , thoracic aneurysm , lastly more preciously according to the area of vessels they affect.
2. According to Etiological factor :- Aneurysm is classified according to cause such as atherosclerotic aneurysm,microtic, aneurysm, hypertension aneurysm, traumatic aneurysm.
3. According to Appearance :- Classification of aneurysm is sometime based on shape and anatomic feature or size.
4. Sacular Aneurysm :- Sacular aneurysm involves all three layers of artery. A out pouching of an artery at point where the media is thin.
5. Fusiform Aneurysm :- Fusiform aneurysm involves the entire circumference of the vessels. It is localized uniform dilation of an artery.
6. Dissecting Aneurysm :- In disecting aneurysm hematoma is present in the arterial wall that separates the layers of arterial wall.
7. False Aneurysm :- False aneurysm results from the development of a sac around a hematoma that maintain a communication with the leumen of an artery where wall has been ruptured or penetrated.

Pathophysiology :-

Abdominal aortic aneurysm four types more often then the thorasic aneurysm. the Natural cause of untreated aneurysm is to expand or rupture.The aorta is under greater stress then the rest of the arterial system because of its large diameter and its exposure to high pressure during each systolic ejection of blood.

Clinical Manifestation :-

• Awareness of pulsation mask in the abdomen.
• Abdominal pain and back pain
• Pain in lower abdomen , groin, and genitalia
• Decrease hemoglobin
• Sign of hemorrhage
• Shock
• Abdominal Distension

Diagnostic Evaluation :-

• Physical Examination
• USG
• CT Scan
• Abdominal Aortography

Complication :-

• Coronary artery disease
• Pulmonary obstructive disease
• Pre-renal failure
• Spinal cord ischemia
• Change in sexual function
• Severe bleeding

Management :-

1. Surgical Management :-  Surgery is usually not perform on clients with a less symptomatic abdominal aortic aneurysm smaller then 4-5cm. In Every six month a USG is indicated to determine whether any change in the size occurred.

• Endovascular Procedure :- It is a newer method for lower emergency treatment to repair abdominal aneurysm. small incision are made in the groin and a vascular into the aorta. deflated balloon and tightly wrapped polyester cloth graft is placed , when properly position the graft is securely place by inflation the balloon and opening the graft of the diameter needed to prevent blood clot in the aneurysm then the balloon is deflated and remove along with the catheter at the each end of the graft hooks are present that help secure it to the inner walls of aorta.
• Aneurysm Repair :- Surgical repair is usually recommended for all aneurysm greater then 6cm. find 

Benign Prostate Hypertrophy / Hyperplasia (B.P.H.)

BPH is also called Benign Enlargement of Prostate or Benign Prostate Enlargement is a non-cancers increase in the size of the prostate .

It is Enlargement of prostate gland and obstruct the out flow of the urine.

Incidence :- 

• Approximately 50% clients after 50 years of age and after 80 years of age BPH develops in 90% of males. 

Etiology :- 

• the exact cause is unknown / idiopathic.

Risk Factor :- 

• Aging ( fibrosis and beginning of the muscular tissues in the prostate)
• Hormonal change / imbalance : specially DHT ( di-hydro testosterone). A metabolite of testosterone is the critical mediator of pro-static growth.
• Diet :( Animal protein)
• Hereditary / genetic
• malfunction of testis
• Sexual activity
• Local or abnormal growth

Pathophysiology :-

• Due to any risk factor
• Enlargement of prostate gland
• Obstruction and compression on urethra and bladder
• Bladder can not expel complete urine on each voiding
• Urinary obstruction
• Hydronephrosis
• Renal damage

1. The enzymes aromatase and 5-alpha reductase increase in activity. Aromatase and 5-alpha reductase of enzyme are responsible for converting androgen or testosterone hormones into estrogen and di-hydro testosterone.
2. This metabolism of androgen hormone leads to decrease in testosterone but raised level of DHT and estrogen. estrogen and DHT has a keep role in the growth of cells in the prostate.

Sign and Symptoms :-

• Anorexia 
• Nausea
• Vomiting
• Dysurea
• Increase frequency of urination
• Nocturis
• Acute urinary retention
• Decrease muscle tone of urinary
• Bladder leads to loss pf bladder control or inability to urinate
• Fatigue
• Hydronephrosis
• U.T.I.

Investigation :- 

• Physical examination
• History collection
• Urine Analysis
• U.S.G. of testis , prostate, kidney

1. Translateral ultrasound :- It is done to identify or visualization of prostate gland through the rectum,
2. P.S.A. test ( Prostate specific antigen) :- To identify the kidney damage or prostate cancer.
3. Cytosopy
4. R.F.T. or K.F.T.
5. C.B.C.

Acute Kidney Injury [ Acute Renal Failure]

Definition :- 

AKI Previously called Acute Renal Failure is an abrupt loss of kidney functions that develops within 7 days.

It is characterized or manifested by decrease glomerular filtration rate, level of serum creatinine and urea nitrogen rise and oligourea or anurea. 

 Etiology :-

It's cause are numerous. Generally it occurs because of damage to kidney tissue caused by decreased blood flow (ischemic kidney), low blood pressure or hypotension, exposure to substance harmful to kidney, inflammatory process or an obstruction of the urinary tract.

The causes of AKI can be categorized by into 3 major area's :-

1. Pre-Renal cause
2. Intra-Renal cause
3. Post Renal cause

     1. Pre-Renal Cause :-

• Pre-Renal causes are those that decrease effective blood flow to the kidney and cause to decrease in GFR.
• Low blood volume in the body (hypovolemia) [due to vomiting, diarrhea, hemorrhage, burns and excessive use of diuretics.]
• Hypotension
• Decreased cardiac output
• Heart failure
• Renal artery stenosis

      2. Intra-Renal / Intrinsic cause :-

Process which directly damage kidney itself :

• Glomerular Nephritis
• Tubular Necrosis
• Renal Surgery
• Injury, Trauma, Crush
• Electric Shock
• Diabetes Malitus
• Infectious Disease
• Rejection of transplant kidney
• Genetic Factors

      3. Post Renal cause :-

Caused by disease states / condition down stream of the kidney.

• Urinary tract obstruction.
• Uritral or urethral structures (stenosis)
• B.P.H.
• calculi
• cancer or tumor of bladders & uretor's
• Surgical Accidents
• Spinal cord injury leads to decrease bladder emptying of functional obstruction.

Mechanism / Pathogenesis :- 

The mechanism of AKI is not specific or not clear there are some mechanism which are :-

• Ischemic kidney
• Activation R.A.S.
• Tubular injury or infection
• Fibrosis and scare formation
• Renal Calculi
• Decreased osmotic pressure

Clinical Manifestation :-

• Headache 
• Fatigue
• Nausea , Vomiting
• Diarrhea
• Constipation 
• Loss of Apetite
• Flank pain
• Edema
• Shortness of breath
• Hematuria
• Oligurea or Anurea 
• Hypertension
• Hand tremors
• Decrease G.F.R.
• Increase Serum Keratinine
• Acidosis
• Ureanitrogen level Increase
• Fluid and Electrolyte Imbalance
• Hyperkelemia
• Hyponatriemia
• Hypocalcemia
• Hyperattrisemia

Investigation :-

• Serum Creatinine level (increases)
• Blood ureanitrogen
• Serum pottasium
• Urine analysis
• Radiological study (CT, MRI, X-ray)

Management :-

The management of AKI is divided into 4 stages or phases :-

1.  Initiating / onset phase :-  This phase covers the period from the precipitation event to the development of renal manifestation and continue until the sign and symptoms.It can last for few hours to week.
2. Oliguric phase :- The most common initiative manifestation of AKI is oligurea caused by a reduction in the G.F.R. oligurea usually occur within 24 hours. The longer oliguric phase clast the poor prognosis for recovery of complete renal function. (1 to 8 week).
3. Diuretic phase :- The diuretic of AKI begin with a gradual increase of urine output of 1 to 3 lit. per day but may reach to 3 to 5 liter per day or more although output increased in case nephrones are still  not fully functioning. At this stage the uremia may still be serve as infected by the low creatinine clearance , elevated serum creatinine, BUN level, and persistent sign and symptoms of dehydration because of large of loss of fluid and electrolyte . ( 25- 30 % of death dehydration)
4. Recovery phase :- The recovery phase begins when the GFR increases allowing the BUN and serum creatinine level decrease some individual do not recover or progress to chronic kidney failure. The older adults patient are less likely recovery to fully kidney function.The treatment of recovery phase last for some month or a year in severe cause dialysis or kidney transplantation may be prescribed.

Medical Management :-

• Avoidance of substance that are toxic to the kidneys called Nephrotoxics, it include NSAID.
• Iodinated contrast or contrast medium use in radio-graphic examination specially CT scan and MRI.
• Antibiotics 
• In lower BP :- Non epinephrine, Inotrops, steroid, Dobutamine
• In high BP :- calcium channel blocker, ACE inhibitor, Diuretics.
• In metabolic acidosis administer sodium bicarbonate 

Surgical management :-

• Nephrotomy
• Catheterization
• Dialysis
• Renal Transplantation

Nursing Management :-

• Fluid volume excess related to inability to kidney to promote or excrete urine.
• Fluid volume deficit.
• Altered  nutrition level .
• Risk for infection.
• Disturb thought process.
• Risk for impaired normal skin integrity related to edema.    

   

  

Chronic kidney disease ( chronic Renal failure )

Definition :-

CKD is a type of kidney disease in which there is gradual loss of kidney function over a period of months or years.

CKD is progressive irreversible destruction and dimension in renal function resulting in uremia and azotemia.

It occurs from several days or months to years.

Etiology :-

• Diabetes mallitus 
• Hypertension
• Recurrent episodes of AKI
• Chronic glomerulo nephritis
• Recurrent polynephritis
• Hypotension
• Polycystic kidney Disease
• Obstruction in urinary tract
• Renal artery obstruction or stenosis
• Autoimmune disease (SLE)
• Vasico uretral reflex
• Medication or Drugs
• Poor intake of fluids

Pathophysiology :-

• Due to etiological factor
• Deterioration or destruction of nephrone with progressive loss of renal function
• GFR falls and clearance of waste is reduced.
• Serum creatinine and urea nitrogen level rise 
• Hypertrophy in remaining nephrones as they required to filter large load of solutes.
• kidney losses their ability to concentrate urine adiquatening 
• In an attempt to continue excreting the solutes. large volume of dilute urine may be passed.
• fluid depletion (loss)
• Tubules gradually loss their ability to reabsorb electrolytes.
• Polyurea and results large amount of Na and water excretion 
• Disease progress toxic condition or toxicity
• Renal Failure

 Clinical Manifestation :-

Nervous System :-

• Confusion
• Disorientation 
• Weakness
• Fatigue ,malaise, restlessness

Cardio vascular system :-

• Hypertension
• cardia Disrrhythemia
• Pericarditis
• Pericardial Effusion
• Myocarditis
• Endocarditis

Intiguimatory System :-

• Palor appearence
• Orange,green, or grey in color of skin (because of retaining of Urochrome ligand)
• Thin and brittle nails and hair
• Ecchymosis (bruise) >1cm
• Petechie
• Purpura
• Puritis (severe form of itching)
• Edema of Enasarca

G.I. Tract :-

• Nausea ,Vomiting
• Constipation,Diarrhea
• Hiccups
• Anorexia
• Mouth ulcers
• Gastritis
• Stomatitis 
• Gingivitis
• Esophagitis
• Bitter or salty taste
• Ammonic or fishy odor from the breath 

Respiratory System:-

• Respiratory Distress
• dyspnea
• Shortness of breath

Blood or Hematology :-

• Anemia

Reproductive System :-

• amnorrhea
• Infertility (impotence & sterility)
• Oligospermia
• Testicular atrophy
• Decreased livido

Musculo skeletal System :-

• Fatigue
• Muscular cramps
• Decrease muscular strength
• Bone pain

Urinary system :-

• Polyurea
• Oligurea
• Hematurea
• Renal insufficiency with azotemia

Metabolic changes :-

• Metabolic acidosis
• Increased BUN
• Serum creatinine
• Serum uric acid
• Decreased GFR

Investigation :-

• History collection
• Physical examination
• Urine culture and urine routine
• Urine measurment
• BUN
• CT scan of K.U.B.
• I.V.P. (Intravenous pylography)
• Renal Angiography

Medical Management :-

• Calcium preparation and phosphorus binders .
• Aluminium based Antacids
• Antihypertensive 
• Diuretics
• Vitamine and minerals supplements
• Iron sulfate and follic acid (in severe anemia)
• Sodium bicarbonate (administered to correct metabolic acidosis)

Surgical management :-

• Catheterization
• Dialysis
• Renal transplantation

Nursing Management :-

• Fluid volume excess related to inability to kidney to promote or excrete urine.
• Fluid volume deficit.
• Altered  nutrition level .
• Risk for infection.
• Disturb thought process.
• Risk for impaired normal skin integrity related to edema.    

 

  

  

   

Osteoporosis

• Abnormal rarefaction of bone which may be idiopathic or secondary to other condition.
• This disorder leads to thinning of skeletal and decrease precipitation of lime salt.
• Osteoporosis is defined as systemic skeletal disease characterized by low bone mass and micro-architectural determination of bone tissue that leads to increase bone fragility and susceptibility to fracture or breakdown (hips,vertebrae,forearm)

Etiology :-

• increase aged
• Poor diet(low calcium and vitamin D)
• chronic alcoholism
• Tobacco,smoking
• Lack of exposure to sunlight
• lack of physical exercise
• Hyperthyroidism
• Estrogen deficiency after menopause
• surgical removal of ovaries
• Excessive secretion of parathyroid hormone 
• Certain medication (chemotherapy,Anti-seizure)
• Family history of genetic 
• Excessive consumption of soft drinks(increase amount of phosphoric acid)

Pathophysiology :-

1. Due to any etiological factor
2. calcium resorption
3. increase in osteoclast activity
4. Brittle or fragile bones
5. Reduction in resistance of bone towards physical stress
6. Fracture ,improper gait and reduction in height 

•   Bone is dynamic tissue that undergoes that continue remodeling (the process by which old bone is replaced by new bone)
• the remolding sequence start with activation of osteoclast which resorb a small portion of bone over a relatively short period of time (7-10 days)bone formation then take place as osteoblast form an organic matrix that is subsequently mineralized.

Clinical Manifestation :-

• Sudden onset of severe back pain .
• Kyphosis (posterior curvature of spine or humpback)
• Abdominal distention 
• Impaired respiration due to restricted lung expansion
• Loss of denture or teeth (due to loss in mandible) and finally fracture specially hip,vertebrae,forearm
• Improper gait, and reduction in height

Investigation :-

• Physical examination 
• Family history
• dual energy X-ray 
• Blood test 
• Urine calcium level
• CT,MRI

Management :-

Medial management :-

• Bisphosphonate
• Estrogen therapy (in early menopause)

Nursing management :-

• Pain related to fracture
• Altered nutrition less then body requirement related to calcium and vitamin D deficiency
• Risk of fracture due to disease condition softening of bone
• Impaired physical activity due to disease condition.

Nursing Responsibility :-

• Adequate intake of calcium and vitamin D
• Regular weight bearing exercise 
• Avoidance of alcohol and tobacco
• Assess clients at risk of fracture for activity level and dietary adiquency and programme appropriate teaching to prevent fracture
• Assessment include visual assessment medication that may cause dizziness or postural HTN.
• Difficulties with balance or co-ordination as well as the home environment for potential safety from hazards.
• Evaluation of the bone setting is performed via admission assessment discussion with the client consultation with specialist in social service and home safety evaluation by visiting nursing.
• Instruct the client who are prompt to dizziness to get up slowely from a lying position sitting on the site of the bed first.
• An aid to ambulation such as a cane or walker may also the indicated to prevent falling.
• Hand rails should be also available or provided specially in bathroom or toilets.