Research Korner: Pathophysiology

Reduction of Pressure Ulcers by Risk Assessment and Prevention in Hospital Setting

Introduction             Pressure ulcers continue to be a distressing medical problem. Not only do patients experience pain and discomfort but intensive wound care also incurs considerable costs to both patients and hospitals. Therefore both health care professionals and patients should consider the prevention of pressure ulcers of extreme importance. Hospital nursing teams are especially concerned with the prevention of pressure ulcers that develop during hospitalization, i.e. the nosocomial pressure ulcers.             The aim of this project is to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations, many of which related to accurate and timely documentation of risk, adequate care planning and the provision and review of appropriate equipment. To achieve this, clinical audit will be used. The clinical areas audited provided care to patients identified anecdotally at higher risk of pressure ulcer development due to their physical condition. A quantitative form of research is applied in this project.   Background of the medical condition Pressure ulcer is most commonly known as bedsore. Other names for it include pressure sore, decubitus ulcer and trophic ulcer. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed, wheelchair, cast or splint for example (Bickley & Szilagyi, 2003). The condition results to impaired skin integrity related to unrelieved, prolonged pressure (Potter & Perry, 2004). Such a condition is seen most frequently in patients who have diminished or absent sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition can therefore be at risk for pressure ulcer development. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible but other sites may be involved, depending on the patient’s position. Pressure ulcers can affect not only superficial tissues, but also muscle and bone.             Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include loss of pain and pressure sensations that ordinarily prompt the patient to shift position and relieve the pressure, and the thinness of fat and muscle padding between bony weight-bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection play contributory roles. The most important of the extrinsic factors is pressure. Its force and duration directly determine the extent of the ulcer. Pressure severe enough to impair local circulation can occur within hours of an immobilized patient, causing local tissue anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.             The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be relieved. Unless a full-flotation bed such as a water bed is used, providing even distribution of the patient’s weight. If the patient is using braces or plaster casts, a protective padding at bony prominences should be used under braces or plaster casts, and a window in the cast should be cut over potential pressure sites.             Skin inspection is also important. Pressure points should be checked for erythema or trauma at least once/day in an adequate light. Able patients, mobile or immobile, and their families must be taught a routine of daily visual inspection and palpation of sites for potential ulcer formation. Exquisite skin care for neurologically damaged parts is necessary to prevent maceration and secondary infection. Maintaining cleanliness and dryness helps to prevent maceration.             The prevention of pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity may not be a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients. Prompt identification of the high-risk patients and their risk factors aids in prevention of pressure ulcers. A well-balanced diet, high in protein, is important in the treatment of pressure ulcers. Blood transfusions may be needed for anemia. Threatened pressure sores require energetic use of all the above mentioned prophylactic measures to prevent tissue necrosis. The area should be kept exposed, free from pressure, and dry.             The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small visible surface with an extensive unknown base, and there is no good method of determining the extent of tissue damage.             More advanced ulcers require surgical treatment. Surgical debridement and closure is required for fat and muscle involvement. Affected bone tissue requires surgical removal; disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and delay healing, so it should be removed. An exception may be eschar or necrotic tissue on a heel ulcer because an open heel wound can easily become infected and lead to osteomyelitis. Several debridement methods are available; the choice depends on the amount of necrotic tissue, absence or presence of infection, patient preferences, and economic considerations (Baranoski, 2006).   Evidence-based pressure ulcer prevention and treatment             Evidence-based practice, which is often referred to as evidence-based nursing or evidence-based medicine, is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (1) It involves integrating the individual clinical expertise of the physician or nurse with the best available external clinical evidence from systematic research and individual patient preferences. (2) Research shows that patients' outcomes are at least 28% better when clinical care is based on evidence rather than tradition or common sense (Bryan-Brown, 2006). The following paragraphs would discuss health care practices and interventions on pressure ulcers which are evidence-based and are widely used in health care settings today. A major aspect of nursing care is the maintenance of skin integrity. Consistent, planned skin care interventions are critical to ensuring high quality of care (Kozier & Erb, 2004). Nurses constantly observe their patient’s skin for breaks or impaired skin integrity. Impaired skin integrity occurs from prolonged pressure, irritation of the skin, or immobility, leading to the development of pressure ulcers. Nursing care interventions aimed at the prevention, assessment and treatment of pressure ulcers should be based on research (Potter & Perry, 2004) or evidence-based practice.             There are several instruments for assessing patients who are at high risk for developing a pressure ulcer. Patients with little risk for pressure ulcer development are spared the unnecessary and sometimes costly preventive treatments and the related risk of complications.             Prevention and treatment of pressure ulcers are major nursing priorities. The incidence of pressure ulcers in a facility or agency is an important indicator of quality of care. There is evidence that a program of prevention guided by risk assessment can simultaneously reduce the institutional incidence of pressure ulcers by as much as 60% and bring down the costs of prevention at the same time (Potter & Perry, 2004).             Evidence-based practice shows that lack of documentation of patients at risk demonstrates the need for hospitals to increase prediction and prevention strategies. Use of a risk scale can provide triggers to plan care to decrease risk factors.             As a predictive measure, individuals should be assessed for risk of pressure ulcer development upon admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities (Kozier & Erb, 2004). Pressure ulcer risk assessment should be done systematically.             Evidence-based practice also shows that extended stays of over 7 days increase the risk of pressure ulcer development (Lyder, et al, 2001). Nurses must therefore remain vigilant in the prevention of pressure ulcers in patients with longer hospital stays.             Evidence-based practice shows that the use of care practices such as daily skin assessment, use of pressure-relief surfaces and objective risk assessment measures, such as the Braden scale, identified at risk patients and reduce evidence of pressure ulcers (Lyder, et al, 2001). The Braden scale was developed based on risk factors in a nursing home population. It is highly reliable when used to identify patients at greatest risk for pressure ulcers. It is also the most commonly used assessment scale for pressure ulcer (Potter & Perry, 2004).             Evidence-based practice also shows that the use of nutritional consultation was associated with decreased incidence of pressure ulcers, suggesting a nutritional consultation may sensitize the staff that the older adult is at risk for pressure ulcer development (Lyder, et al, 2001).             Nursing interventions for reducing and treating pressure ulcers are evaluated by determining the patient’s response to nursing therapies and by determining whether each goal was achieved. To evaluate outcomes and responses to patient care, the nurse measures the effectiveness of interventions. The optimal outcomes are to prevent injury to the skin and tissues, reduce injury to the skin and underlying tissues, and restore skin integrity (Potter & Perry, 2004). The care of a patient with a pressure ulcer requires a multidisciplinary team approach.             There is a strong relationship between nutritional status and pressure ulcer development, yet nutrition is an area often overlooked by clinicians in pressure ulcer care. Nutrition, including adequate hydration, plays an important role in pressure ulcer prevention and healing, and is critical in maintaining tissue integrity. Patients defined as malnourished at hospital admission are twice as likely to develop pressure ulcers as well-nourished patients. Therefore, nurses and dietitians should work together to assess the patient's nutritional and hydration status and ensure that these factors are addressed in the patient's care plan (Voss, 2000).             Pressure ulcers, regardless of their origin, represent negative outcomes for patients. These negative outcomes may include pain, additional treatments and surgery, longer hospital stays, disfigurement or scarring, increased morbidity; and increased costs. Although all negative outcomes are of concern, a hospital-acquired pressure ulcer can result in increased cost of treatment, patient dissatisfaction with care, and a potential litigious situation (Schultz, 2005).   The project plan   Objectives             The aim of this research is to improve pressure ulcer risk assessment and prevention to reflect the guideline recommendations. The objectives are: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Develop a dissemination and implementation strategy to accompany the guideline;</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Audit care in pressure ulcer risk assessment and prevention, using criteria based on the guideline; and</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Make recommendations for practice and future research based on the findings of the study.</li> </ul>   Defining quality In keeping with the classical audit cycle this project seeks to identify current best practice in prescribing, survey the actual practice, and then institute measures to improve prescribing up to the identified standards. The audit tool was used to collect data on length of stay, mattresses and repositioning provided to patients in each of the following hospital wards: medical, orthopedic or older patients ward, groups considered to have a higher risk of pressure ulcer development, recovery room for the postoperative stay until first ambulation. This audit tool included demographic data as well as data on the modified norton scale for evaluation of a patient's risk of developing a pressure ulcer. A score of 16 or less indicates increased risk for developing a pressure ulcer. The audit tool will also include data on accompanying medical conditions, i.e. continence, diabetes, heart insufficiency and peripheral vascular diseases. Continence means that a patient has full control on urine and feces. Inserting a Foley catheter into the bladder can bypass the problem of urine incontinence. In case of urine incontinence, continued contact between skin and urine weakens the cell wall and may alter the skin pH, making it more susceptible to breakdown (Peich & Margalit, 2004).   Recruitment of pilot sites and link nurses As the project had a short timeframe, a decision was taken with the advisory panel that four to six sites would provide sufficient patient numbers to allow improvement in practice to be detected between the audits. Sites were included if they provided tare to medical, orthopedic or older patients, groups considered to have a higher risk of pressure ulcer development. As this was an audit project, ethics committee approval will not be required, however, confirmation of this will be sought and obtained from all hospital sites involved in the project.             The audit criterion is that a practitioner with 'appropriate and adequate training' should undertake the initial risk assessment and document findings. For audit purposes, the grade of the nurse or health care professional will be recorded.   Dissemination and implementation strategy The dissemination and implementation strategy was informed by evidence and reflected the advice of site link nurses and staff from the clinical areas on possible barriers to change. This ensured the strategy reflected best evidence to bring about change, and encouraged local ownership of the guideline. Dissemination comprised the identification of a nurse from each clinical area who could support clinical staff involved in the project and assist with the audits; circulating copies of the project proposal, quarterly newsletters and summaries of the guideline recommendations to all relevant staff.   Implementation Implementation focused on the development of an evidence-based resource pack by the project team and provision of education sessions by the project manager. A resource pack was given to each senior member of staff in the clinical area to be audited, the site link nurses and directors of nursing, and included an implementation guide and copies of the audit tools.             The project manager shall lead education sessions at each site, with the assistance of the site link nurse, following audit 1. The sessions were to be attended by nursing staff from the clinical areas to be audited, senior nurses and/or ward managers. The sessions focused on a description of evidence-based practice and clinical guideline development; the development and recommendations of the RCN guideline; an outline of the project; site specific feedback and recommendations for practice from audit 1.             To ensure standardization of pressure ulcer grading for the audit, the EPUAP tool was used by the project team (Stephens, 2003). Reduction in pressure ulcer prevalence is not a study outcome due to the time constraints and need to take account of potential contributory factors. Nevertheless, it is considered important to assess prevalence to enable audit findings to be more generalizable. Each site will be asked to identify clinical areas that met inclusion criteria and arrange dates for the project manager to undertake audit 1. Audit 2 will commence at each site five to six months later.             Development of Audit Tools             Two audit tools will be developed; one for the patient and one for the clinical area. The tools are developed using recommendations for audit criteria proposed by Baker and Fraser (1995), which included the following: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Criteria should be based on evidence where possible.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Criteria should be prioritized according to the strength of the evidence and effect on patient outcome.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Criteria should be measurable and appropriate to the clinical setting.</li> </ul>   Audit criteria will then be derived from the guideline. This will be followed with a consultation with the advisory panel where and agreement will take place on what the audit would comprise.   Measuring and comparing             On the first audit and data analysis, to be included are all patients admitted to the hospital with no skin breakdown during a six-month period, but are at risk for pressure ulcer development. The nurse will collect the data, using the audit tool. The information sources are patients' records, interviews with patients and/or patients' families, and nurses. This is quantitative form of research wherein patient age range and mean will be computed both in the first and second audit. Pressure ulcer risk was elicited using clinical assessment and a tool to obtain a risk assessment score. Risk assessment scores for each patient were verified by the auditors (Stephens, 2003).             Data from audit 2 will then be compared with audit 1. Data will be coded and entered onto an Excel spreadsheet, and results collated in an anonymised form using simple descriptive statistics to enable comparative analysis to be undertaken. Each site will then receive feedback comparing results from both audits by clinical area in an anonymised form.   Taking action to improve             An intervention program will be prepared and implemented based on the results of the project. The program will be prepared as an addition to the basic health care practice that is common for bedridden patients and other patients at risk for pressure ulcer development.   Conclusion Patient safety should be the number one concern during hospital stay and also before, during and after each hospital procedure performed. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective in preventing and treating pressure ulcers. The principles of general preventive measures such as the implementation of standard and isolation precautions, following guidelines, and the control of antibiotic use should be reviewed. Some patients are more at risk for pressure ulcer development than others, and this should be taken into account by health care professionals. The necessity to audit is seen in the high prevalence of pressure ulcer development in hospital stays despite established clinical guidelines. There is a need to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations, many of which related to accurate and timely documentation of risk, adequate care planning and the provision and review of appropriate equipment involved. The success of the health care professional who practices pressure ulcer prevention and control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the patients’ response with expected outcomes determines the success of the health care interventions.   References Baker, R. & Fraser, R. 1995. Development of Review Criteria: Linking Guidelines and Assessment of Quality. British Medical Journal. 311, 7001, 370-373. Baranoski, S. 2006, Pressure Ulcers: A Renewed Awareness. Nursing. Bickley, L. and Szilagyi, P. 2003. Bates’ Guide to Physical Examination and History Taking 8th Edition. Lippincott Williams and Wilkins. Bryan-Brown, C.W. 2006, Evidence-Based Practice is Wonderful.. Sort Of. American Journal of Critical Care. Education, Training, and Research Evidence for Better Health Care. 2006. Retrieved from: http://www.york.ac.uk/healthsciences/ Franz, R.A. 2003, Pressure Ulcer Prevention and Treatment: Competency-Based Nursing Curricula. Dermatology Nursing. Kozier, B. and Erb, G. 2004. Fundamentals of Nursing: Concepts, Process, and Practice 7th Edition. Pearson Education Inc. Lyder, C.H., J. Peterson, et al. 2001. Quality of care for hospitalized medical risk for pressure ulcers. Arch Intern Med. 161(12):1549-54 Olade, R.A. 2004, Evidence-Based Practice and Research Utilization Activities Among Rural Nurses. Journal of Nursing Scholarship. Peich, S. & Calderon-Margalit, R. 2004. Reduction of Nosocomial Pressure Ulcers in Patients with Hip Fractures: A Quality Improvement Program. International Journal of Health Care Quality Assurance Vol 17, No 2. Potter, P. and Perry, A. 2004. Fundamentals of Nursing. Mosby. Schultz, A. 2005, Predicting and Preventing Pressure ulcers in Surgical Patients. AORN Journal. Stephens, F. 2003. Pressure Ulcer Risk: Audit Findings. Nursing Standard. Voss, A. 2000. Pressure Ulcer Management: The Importance of Nutrition. MedSurg Nursing.

Reduction of Pressure Ulcers by Risk Assessment and Prevention in Hospital Setting

Introduction Pressure ulcers continue to be a distressing medical problem. Not only do patients experience pain and ...

Maternal Child Pathophysiology :Bilateral Tubal Ligation

Bilateral Tubal Ligation     1 Bilateral Tubal Ligation Bilateral tubal ligation (BTL) is one method of contraception that could either be permanent or reversible. Having the ligation reversed, however, has a varied possibility that the procedure will be completely successful. It depends on the type of tubal ligation that was previously performed. Going back to BTL, this is an interference of both the Fallopian tubes so that the up-flow current of the sperm and the downstream of the egg will not meet. This is done surgically by either fastening a clip or tying knots with a suture and then cutting, around any portion of the Fallopian tube on each of the sides, or burning a segment of the tube location in the middle using a cautery. The outcome is the failure of the sperm to fertilize the egg because of the roadblock. Connecting this procedure to the patient’s state, BTL was performed due to the high risk of the mother to experience preeclampsia again if she gets pregnant. This disorder affects not only the mother, but also the unborn baby. Preeclampsia occurs during and after the mother has delivered the child. This condition is characterized by blood pressure that is high and proteinuria. Symptoms include sudden weight gain, edema in the face and/or limbs, blurring of vision, and headaches.   Pathophysiology of Bilateral Tubal Ligation To trace the pathophysiology of bilateral tubal ligation, we have to take note why the patient was taken to a health institution. Upon admission, due to the elevated blood pressure of the pregnant mother, she was induced with Pitocin to facilitate labor. Contractions were adequate but failed to progress beyond 6.7 cm after a number of Bilateral Tubal Ligation     2 hours, which resulted to the artificial rupture of the membranes. The cervix did not fully efface and the head of the baby remained unengaged. Continued maternal and fetal monitoring was maintained. As a result of unprogressing labor, she had to undergo primary low segment transverse cesarean section to deliver her baby so that no further complications will result. After the operation, she went through another procedure that would provide female sterility. The procedure that was done was Bilateral Tubal Ligation.   Medical Treatment Plan for Caesarean Section Since Bilateral Tubal Ligation is not an alteration in the health of a postpartum woman, we delve into the abnormal condition which was done to the preeclamptic mother which is delivery through Caesarean Section. Usually after the surgical procedure, pain in the incision site is normal. This pain is related to disruption of skin and tissue integrity secondary to primary low segment transverse caesarean section. Manifestations include reports of pain and guarding behaviors. After giving the necessary medical and nursing interventions, the desired outcomes of the patient will be the verbalization that pain has been relieved or controlled, or the patient will display nonverbal cues like appearing relaxed, able to rest or sleep, or participate in other interventions or activities appropriately. Rather than having dependent interventions that don’t require the involvement of the nurse, there is already a collaborative team effort. This team comprises of the doctor and the nurse. Collaborative interventions include administering of medcations as Bilateral Tubal Ligation     3 indicated: analgesics IV (after reviewing anesthesia record for contraindications and/or presence of agents that may potentiate analgesia); provide around-the-clock analgesia with intermittent rescue doses; patient-controlled analgesia (PCA) or epidural analgesia (PCEA); local anesthetics like epidural block or infusion; and nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen or diflunisal. Monitoring the use or effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) may be useful in reducing pain and amount of medication required postoperatively. Additional interventions could be done by the nurse independently. These are checking if the dressing is intact; inspecting for postpartum hemorrhage; evaluating pain regularly following the procedure, noting its characteristics, location, and intensity; emphasizing that it is the patient’s responsibility of reporting pain or relief of pain completely; assessing the vital signs, noting tachycardia, hypertension, and increased respiration, even if patient denies pain; assessing causes of possible discomfort; providing information about transitory nature of discomfort as appropriate; repositioning as indicated; providing additional comfort measures like back rub or heat/cold applications; encouraging use of relaxation techniques like deep-breathing exercises, guided imagery, or music; providing oral care like occasional ice chips or sips of fluids as tolerated; and documenting effectiveness and side or adverse affects of analgesia.   New Baby, New Life             On family life, the impact of the infant is generally perceived as a thrilling, most pleasant event. More often than not, the modification from being a non parent into a Bilateral Tubal Ligation     4 parent serves as a stress point for most people. There are a lot of responsibilities involved, with regard to the parents, the new child, and to the whole family.             The decision to bear a child and rear it involves the effort of the husband and wife. A number of factors influence their judgment, whether their social clock is ticking or the pressure of the grandparents-to-be is sinking in. Some also consider their financial status.             The total transition and adjustment period for the couples takes time. Some may consider it a very stressful phase because the couple is still not really used to taking care of a newborn child. Tensions may build up between them because they each have different ways of how the baby will be disciplined and raised. But through effective communication and a mature joint effort, they will be able to discuss together how it should be done. The coming of the baby also affects the relationship of the husband and wife in such a way that the infant will be ultimately the first priority. They will be spending lesser time together and will experience sleepless nights because of the looking out for the baby. Also, the extended family of the couple will be very pleased because they have another family member to take care of.             The impact on the mother after having done a tubal ligation is irregularity in the menstrual cycle, cramps, decrease in sexual frequency and desire in the long term run but increase in frequency after the procedure, and a decrease of 50% incidence of cancer of the ovaries.     Bilateral Tubal Ligation     5 Discharge Plan for the Mother and for the Family             Usually, the postpartum mother and the child is discharged three days prior to delivery. But with this patient’s condition, it may take a week because of the invasive procedure. Hospitals implement protocols that require written discharge plans for postpartum women and their infants. This type of practice is discussed together with the patient, the father of child, and the extended family members. Proper referrals are made and recorded, and follow-up care is a must. Discharge planning is done upon admission. It is practical for a nurse or healthcare provider to make a discharge plan early so as to facilitate desired outcomes.             When the mother and the infant are now advised to go home, a number of instructions should be followed. The level of activity at home should be kept to a minimum until the health care provider says otherwise. Normally, the lochia will change eventually from bright red to a lighter or yellowish color so nothing to be worried about. Drink plenty of fluids as they keep the woman well-hydrated and eat healthily to restore lost weight and energy. Adequate bed rest and watching out for pain or fever (as this is a sign of infection) is needed. Pain medications that are used to relieve pain may be discussed or prescribed already by the health care provider. Heavy bleeding (lochia) will be experienced that needs extra napkin pads. No need to be really alarmed because this normal and may run for up to six weeks. Avoid sexual intercourse until health care provider says so, tampon use or douching is a no-no, taking a bath until incision is healed and no longer bleeding, public pools or hot tubs, lifting heavy things other than your baby, frequently using the stairs, and exercise. Bilateral Tubal Ligation     6 References   A Guide for Hospitals and Health Care Providers Perinatal Substance Use. February 17, 2008, from http://www.dss.virginia.gov/files/division/dfs/cps/publications/perinatal.pdf About Preeclampsia. February 17, 2008, from http://www.preeclampsia.org/about.asp Caesarean Birth After Care. February 17, 2008, from http://www.americanpregnancy.org/labornbirth/cesareanaftercare.html Doenges, M., Moorhouse, M.F., Geissler-Murr, A. Nursing Care Plans Guidelines for Individualizing Patient Care Edition 6. F.A. Davis Company: Philadelphia: 2002. pages 776-778. Jelovsek, F. Post Tubal Ligation Review. February 17, 2008, from http://www.wdxcyber.com/nbleed9.htm Longo, M. The Impact of Infants on Family Life. February 17, 2008, from http://ohioline.osu.edu/hyg-fact/5000/5169.html Sterilization. February 17, 2008, from http://gynob.com/steriliz.htm

Maternal Child Pathophysiology :Bilateral Tubal Ligation

Bilateral Tubal Ligation 1 Bilateral Tubal Ligation Bilateral tubal ligation (BTL) is one method of contraception that could eithe...

Discuss the comon causes of heart failure.

Introduction     The heart is one of the amazing human organ as functions to continuously pumps oxygen and nutrient rich blood throughout the human body to sustain life adhering in the fist-sized powerhouse beats which expands and contracts everyday, pumping 5-6 quarts of blood each minute of about 2,000 gallons per/day[1], as heart beats, it pumps blood through a system of blood vessels, called the circulatory system and each vessels are elastic, muscular tubes that carry blood to every part of the body. The heart is located under the rib cage, to the left of human’s breastbone and between the lungs, and are made of muscles, the heart is four-chambered, hollow organ[2], divided into the left and right side by muscular wall as right and left sides of the heart are divided into top chambers called the atria, which receive blood from the veins, two bottom chambers called ventricles, which pump blood into the arteries. It can be that heart failure is condition which results in the heart being unable to pump enough blood around the body to meet its needs. Although it can develop with sudden onset of symptoms, there typically develops slowly and is chronic, long-term condition with signs and symptoms that persist. Congestive cardiac failure is the term used to describe blood backing up in the liver, lungs, abdomen and legs as a result of heart failure. Coronary artery disease, heart attack, problems with the heart valves or disorders that affect the electrical system of the heart can precipitate heart failure. Other conditions such as lung problems, severe anemia, high blood pressure and infection can also affect the heart leading to the development of heart failure. Diabetes and hormonal problems such as an overactive or under active thyroid gland can also trigger the condition.   Main body – Discuss hypertension as one major cause of heart failure It can be that, hypertension is one common causes of heart failure approximately about 70 percent leads to heart failure assuming in high blood pressure in the arteries, which carry blood from person’s heart to every part of his body as it makes it harder for the heart to pump blood because of the increased pressure in the arteries and the increased pressure truly leads to a failing heart function as there is no leveling towards young, old, male or female as any person can be a victim of hypertension causing heart failures as in certain pathophysiology means pointing to the hypertensive heart disease, there implies to interplay of hemodynamic, structural and other related factors as the integral role may certainly develop hypertension and its complications. For instance, such elevated blood pressure can modulate such factors leading to adverse changes in cardiac structure and function in 2 ways like, as directly by increased after load and indirectly by associated neurohormonal and vascular changes. The presence of heart failure becomes common with increasing age as about 1 in 35 people aged 65-74 years have heart failure, increases to about 1 in 15 of people aged 75-84 years, and to just over 1 in 7 people aged 85 years but can be uncommon in younger people of healthy living. There can be drugs are used to treat heart failure for example, Angiotensin Converting Enzyme Inhibitors – ACE inhibitors (British Heart Foundation[3]), as some people with heart failure are prescribed an ACE inhibitor which prevent build up of fluid by interfering with the enzyme angiotensin which is involved in regulating body fluid. ACE inhibitors have protective effect on the heart and may slow down the progression of heart failure. After the very first dose, on the first day you start an ACE inhibitor, stay indoors for about four hours as occasionally some people feel dizzy. After the first dose on the first day of treatment, there is no need to take any special precautions. A blood test is usually done before starting an ACE inhibitor, and about 7-10 days after the first dose. This checks the function of the kidneys. The kidneys are affected in a small number of people who take an ACE inhibitor. A blood test about every six months is then usual. Research studies have shown that ACE inhibitors and beta blockers not only help to ease symptoms, but can improve the outlook and extend life expectancy for people with heart failure and that, even if symptoms go, continue to take these drugs if they are prescribed[4]. The internal function change can impede to severe symptoms like for instance, those being associated with chronic heart failure adhering to fatigue and weakness, shortness of breath allowing in the lack of appetite, decreased alertness and weight gain of the human body. Fluid retention in the body mainly affects the legs due to the effect of gravity, there may notice some swelling of ankles and feet at the end of the day as well as having in gradual build up of fluid as water retention develops quickly outcomes in a mild heart failure. Hypertension (HT) is major risk factor for coronary heart disease, among the numerous risk factors associated with CHD, HT plays a major role given its high frequency and its physiopathogenesis as roughly 15 percent of the general adult population manifest HT with a net male predominance, and 25 percent of patients with CHD have HT[5]. Thus, affecting in other organs mostly the liver, lungs and others damaging the normal functioning of these organs as the collapse of the heart the latter organs also collapses and that treatment and proper immediate medication is to be given to patient experiencing heart failure or any other diseases that leads to the failure, the other organs cannot function well and can’t support the body to remain active, stable and strong[6]  There indications of severe heart failure as the internal system is changing impacting in nerve impulses and adequate functioning of the central nervous system upon which, systems do collapse during incidence of heart failure with major changes happening within the cardiovascular system, as the heart failure begins with an insult to pump function, such as a myocardial infarction, inflammation, severe hemodynamic overload from hypertensive disease, genetic causes, or idiopathic myocardial dysfunction. In addition, activation of both the adrenergic and renin-angiotensin systems causes vasoconstriction, which serves to stabilize central blood pressure and redistribute cardiac output to the brain and the heart, which in large part have auto regulatory control of flow. Although redistribution of fluid to these vital organs is obviously advantageous in the short term, the increase in peripheral resistance and left ventricular wall stress actually decreases myocardial performance, particularly in the presence of any degree of pump dysfunction.   Prognosis if the condition continues to deteriorate The prognosis can assume presence of such systolic dysfunction of individual cardiac myocytes is by definition due to a change in gene expression. In rodent systems, the constellation of alterations in gene expression that accompanies cardiac hypertrophy and its transition to myocardial dysfunction has been termed activation of fetal program because the changes recapitulate embryonic or neonatal patterns[7], since humans do not exhibit major changes in gene expression during development, they do not exhibit the dramatic fetal program activation that characterizes hypertrophy or failure in rodent hearts[8].  Indeed, there can be hard to give outlook for individual as the more severe heart failure, the worse the prognoses is, in cases, the symptoms remain at stable level for quite some time before becoming worse and indeed, severe heart failure can lead to death and treatment not just ease symptom but can improve prognosis and prolong human life.   References Collins R, McMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull 1994; 50: 272-98 Katz A. The cardiomyopathy of overload: an unnatural growth response in the hypertrophied heart. Ann Intern Med. 1994;121:363-37Parks, R. Heart Matters by Healthwise in British Heart Foundation, 2006 available at: www.bhf.org.uk Schmieder RE, Messerli FH. Hypertension and the heart. J Hum Hypertens 2000; 14: 597-604 Schwartz K, Carrier L, Mercadier J-J, Lompre A-M, Boheler KR. Molecular phenotype of the hypertrophied and failing myocardium. Circulation. 1993;87(suppl VII):VII-5-VII-10 WebMD Medical Reference (2009) http://www.webmd.com/heart-disease/guide/how-heart-works?page=2 	 		 		 		 		[1] 		WebMD Medical Reference 		(2009) 		 		 		http://www.webmd.com/heart-disease/guide/how-heart-works?page=2 	 		 		 		 		[2] 		WebMD Medical Reference 		(2009) 		 		 		http://www.webmd.com/heart-disease/guide/how-heart-works?page=2 	 		 		 		 		[3] 		Parks (2006) at British Heart Foundation 	 		 		 		 		[4] 		Parks (2006) at British Heart Foundation 	 		 		 		 		[5] 		Collins R, McMahon S. Blood pressure, antihypertensive drug treatment 		and the risks of stroke and of coronary heart disease. Br Med Bull 1994; 		50: 272-98 	 		 		 		 		[6] 		Schmieder RE, Messerli FH. Hypertension and the heart. J Hum Hypertens 		2000; 14: 597-604. 	 		 		 		 		[7] 		Katz A. The cardiomyopathy of overload: an unnatural growth response in 		the hypertrophied heart. Ann Intern Med. 1994;121:363-37 		 		Schwartz K, Carrier L, Mercadier J-J, Lompre A-M, 		Boheler KR. Molecular phenotype of the hypertrophied and failing 		myocardium. Circulation. 1993;87(suppl VII):VII-5-VII-10 	 		 		 		 		[8] 		Schwartz K, Carrier L, Mercadier J-J, Lompre A-M, Boheler KR. Molecular 		phenotype of the hypertrophied and failing myocardium. Circulation. 		1993;87(suppl VII):VII-5-VII-10

Discuss the comon causes of heart failure.

Introduction The heart is one of the amazing human organ as functions to continuously pumps oxygen and nutrient rich blood throug...

Acupressure – A Therapuetic Technique

Literature review   Acupressure is acupuncture without needles. Acupressure is a therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function (Potter & Perry, 2004). Pressure applied to the traditional acupuncture points with the thumbs, tip of the index finger, or palm of the hand or pinching and squeezing as means of applying pressure stimulate the nerves and close the gate or trigger the release of the body's natural endorphins (Ebersole & Hess, 1998).             The gate theory, among the most readily accepted, integrated the specific and pattern theories and proposed that an anatomic gate modulates the pain experience. Simply stated, the peripheral nerve fibers carrying pain impulses to the spinal cord can have their input modified at the spinal cord before the impulses are transmitted to the brain. Stated another way, the gate theory suggests that pain impulses that travel up the spinal cord can be blocked before reaching the brain by a mechanism that acts like a gate closing. This latter theory helps explain why such interventions as acupressure relieve certain types of pain (Ebersole & Hess, 1998).             The interest in alternative therapies like acupuncture has increased significantly in the past 15 years (Potter & Perry, 2004). The majority of people using and seeking information about complementary and alternative therapies are well educated and have a strong desire to actively participate in the decision making about their health care.             This increased interest comes not only from health care consumers, but also from allopathic physicians who have increasing concerns that current Western medicine is not meeting the needs of their clients (Potter & Perry, 2004). The role of the nurse in here is that many nurses already practice the use of touch and this is very essential in alternative and complementary therapies like acupressure.             While medical literature reflects an interest in the use of complementary therapies, there is a paucity of studies in the nursing literature addressing the use of therapies by nurses, either on themselves or on their clients. While the utilization rate of complementary therapies by the general population has been estimated to be as high as 45%, and nurses are interacting with clients who use these therapies on a daily basis, little is known about nurses' attitudes, knowledge, or perceived efficacy of the therapies (Reed 1999). Many complementary therapies have limited scientific research support resulting in little data about rationale for use, action, effects, and side effects. Since some therapies may be unsubstantiated by science, nurses must be alert to the increasing use of these therapies and include questions about them as a routine part of the assessment interview. Nurses need to assess the client's use of therapies, including why the therapies are used, the source of the therapy, as well as the client's knowledge of side effects. Nurses must be aware of the positive and negative effects that complementary therapies have, as well as any interactions with traditional medical treatments. This knowledge base will aid the nurse in assisting the client with appropriate health decisions (Reed 1999).   Acupressure applied to my Nursing Philosophy               While health care literature reflects an interest in the use of complementary therapies, there are a limited number of studies in the nursing literature addressing the use of therapies by nurses for self-care or use with clients. If significantly more health care providers are using some form of complementary therapy, it is imperative that nurses have a knowledge base of a variety of therapies in order to assist clients with decision making related to the therapies. Alternative therapies like acupressure can be used by nurses for treatment of clients. Many complementary therapies like acupressure contain diagnostic and therapeutic methods specific to the field, whereas others are easily learned and applied.             Alternative therapies base interventions on conventional pathophysiology, anatomy, and kinesiology but at the same time, they also explore mind-body connections that may cause or contribute to the physiological condition. Some alternative therapies are not supported by scientific data and therefore must be regarded by the nurses with caution. This could relate to my nursing philosophy that nursing is a profession dedicated to the promotion of health and prevention of illness. Caution is needed because nurses should only do what is best for their clients.             Nurses should be knowledgeable of alternative and complementary therapies in order to make appropriate recommendations to allopathic primary and health care providers about which therapies are most useful for specific clients.             As nurses, there is a need to work very closely with their clients and are in the unique position of becoming familiar with the client’s religious and cultural viewpoints. As pointed out in my nursing philosophy, being from a different cultural background I am aware how it may affect the delivery of my nursing care. Therefore there is the need to be familiar and understand other values, cultures and beliefs. It is inevitable that clients will be of different cultures. I am aware of the importance to individualize my nursing care to the person and their specific needs and culture. Nursing provides care in a nonjudgmental manner; it’s about being a patient advocate. As an effective patient advocate, a nurse should view the person as whole: physically, spiritually, and emotionally. Nurses may be able to determine which therapies and if acupressure would be more appropriately aligned with the clients beliefs and offer recommendations accordingly. This way, we nurses can provide better care to our clients.             In conclusion, alternative and complementary therapies like acupressure require commitment and regular involvement by the client and the nurse alike in order to be most effective and have prolonged beneficial outcomes. These kind of therapies should be appropriately chosen according to a client’s functional status; culture, belief or religious perspectives; access to health care; and insurance coverage.   Credit:ivythesis.typepad.com

Acupressure – A Therapuetic Technique

Literature review Acupressure is acupuncture without needles. Acupressure is a therapeutic technique of applying digital p...

PNEUMONIA

Introduction Pneumonia is an acute infection of the alveolar spaces of the lungs. The term includes any inflammatory condition of the lung in which some or all of the alveoli are filled with fluid and blood cells.             The patient experienced bacterial pneumonia. This is a common type of pneumonia, caused most frequently by pneumococci. This disease begins with infection in the alveoli; the pulmonary membrane becomes inflamed and highly porous so that fluid and even red and white blood cells leak out of the blood into the alveoli. Thus, the infected alveoli become progressively filled with fluid and cells, and the infection spreads by extension of bacteria from alveolus to alveolus. Eventually, large areas of the lungs, sometimes whole lobes or even a whole lung, become “consolidated,” which means that they are filled with fluid and cellular debris (Guyton & Hall, 2000).             The patient had a history of acute febrile illness associated with chill, chest pain and cough, especially with expectoration of viscid, rusty sputum which is practically diagnostic of pneumonia itself. The diagnosis is confirmed after physical examination of the patient discloses tachycardia, tachypnea, cyanosis, and signs of consolidation.   Cellular Pathophysiology             Pneumococci reach the lungs via the respiratory passages. They lodge in the alveoli, proliferate, and initiate an inflammatory process that begins with an outpouring of protein-rich fluid into the alveolar spaces. This fluid acts as a culture medium for the pneumococci and as a vehicle for their spread to other alveoli, segments (lobules), and lobes (Robbins, 1998).             Pathologically, the early stage of pneumonia (the first 12 to 48 hours) is called red hepatization because of the liver-like, reddish appearance of the consolidated lung that results from the characteristic widespread dilation of pulmonary blood vessels and the extravasation of erythrocytes into the alveoli (Robbins, 1998).             A few hours after the pulmonary capillaries dilate and the edema fluid pours into the alveoli, polymorphonuclear leukocytes enter the alveolar spaces, rapidly fill the alveoli, and consolidate the lung (grey hepatization). Surface phagocytosis occurs, without antibodies, by leukocytic trapping of the bacteria against an alveolar wall or another leukocyte; the process is more active when large numbers of leukocytes are present (Robbins, 1998). Tissue sections show few pneumococi in the consolidated lung, but many in the advancing margin of the lesion where edema fluid is abundant and leukocytes are sparse (Bloom & Fawcett, 1994).             The macrophage reaction occurs next, as large mononuclear cells enter the alveoli, engulf any remaining pneumococci, and phagocytized the cellular debris of the exudate. This process continues until resolution is complete, which is indicated by physical examination and x-ray evidence that the lungs are clear (Bloom & Fawcett, 1994).             The pathogenesis of other bacterial pneumonias resembles that of pneumococcal infections, but abscess formation may occur when infection is caused by organisms that destroy pulmonary tissue.   Systemic Pathophysiology             The patient who has pneumonia would experience a sudden, with a shaking chill, sharp pain in the involved hemothorax on the onset. Along with this are the appearance of cough with early sputum production, fever, and headache. All these symptoms are usually present as an effect of the cellular events that took place: red hepatization, grey hepatization, surface phagocytosis, and macrophage reaction.             All these cellular events lead to changes in the gas exchange functions of the lungs. In pneumonia, the gas exchange functions of the lungs change in different stages of the disease. In the early stages, the pneumonia process might well be localized to only one lung, with alveolar ventilation reduced while blood flow through the lung continues normally (Ganong, 2001). This results in two major pulmonary abnormalities: (1) reduction in the total available surface area of the respiratory membrane and (2) decreased ventilation-perfusion ratio. Both these effects cause hypoxemia (low blood oxygen) and hypercapnia (high blood carbon dioxide).             Human Pathophysiology             The effect of the resulting decreased ventilation-perfusion ratio in the patient with pneumonia is that the blood passing through the aerated lung becomes 97 per cent saturated with oxygen, whereas that passing through the unaerated lung is about 60 per cent saturated, causing the mean saturation of the blood in the left heart and in the aorta to be about 78 per cent, which is far below normal (Guyton & Hall, 2000).             Oxygen is one of the most necessary nutrients in the body. Whenever the availability of oxygen to the tissues decreases, such as in pneumonia, the blood flow through the tissues increases markedly.             Pneumococcal pneumonia is the most common bacterial pneumonia; many of its features are similar to those of pneumonia caused by other organisms. The disease is generally sporadic. Healthy carriers are usually responsible for the infection of others, but there is no practical way to identify carriers and eliminate the organisms (Robbins, 1998).   Interesting News Credit:ivythesis.typepad.com

PNEUMONIA

Introduction Pneumonia is an acute infection of the alveolar spaces of the lungs. The term includes any inflammatory condition of the lu...