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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA


C • Assist patient and family in making decisions about hospice care buy generic tadacip 20 mg line erectile dysfunction doctor in mumbai, and initiate referrals purchase 20mg tadacip with visa erectile dysfunction treatment cincinnati. Cancer of the Lung (Bronchogenic Carcinoma) Lung cancers arise from a single transformed epithelial cell in the tracheobronchial airways discount tadacip 20 mg visa erectile dysfunction fun facts. A carcinogen (cigarette smoke tadacip 20mg with mastercard erectile dysfunction guidelines, radon gas, other occupational and environmental agents) damages the cell, causing abnormal growth and development into a malignant tumor. Most small cell cancers arise in the major bronchi and spread by infiltration along the bronchial wall. Risk factors include tobacco smoke, second-hand (passive) smoke, environmental and occupational exposures, gender, genetics, and dietary deficits. Newer and more speciflc therapies to modulate the immune system (gene therapy, therapy with deflned tumor antigens) are under study and show promise. Managing Symptoms Instruct patient and family about the side effects of speciflc treatments and strategies to manage them. Relieving Breathing Problems • Maintain airway patency; remove secretions through deep breathing exercises, chest physiotherapy, directed cough, suctioning, and in some instances bronchoscopy. Reducing Fatigue • Assess level of fatigue; identify potentially treatable causes. Providing Psychological Support • Help patient and family deal with poor prognosis and progression of the disease (when indicated). Cancer of the Oral Cavity and Pharynx Cancer of the oral cavity and pharynx can occur in any part of the mouth (lips, lateral tongue, floor of mouth most common) or throat and is highly curable if discovered early. Risk factors for cancer of the oral cavity and pharynx include cigarette, cigar, and pipe smoking; use of smokeless tobacco; and excessive use of alcohol. Other factors include gender (male), age (older than 50 years), and African American descent. Clinical Manifestations • Few or no symptoms; most commonly a painless sore or mass that will not heal. Assessment and Diagnostic Methods Oral examination, assessment of cervical lymph nodes, and biopsies of suspicious lesions (not healed within 2 weeks) Medical Management Management varies with the nature of the lesion, preference of the physician, and patient choice. Resectional surgery, Cancer of the Oral Cavity and Pharynx 179 radiation therapy, chemotherapy, or a combination may be effective. Nursing Management Preoperative • Assess the patient’s nutritional status preoperatively; a dietary consultation may be necessary. Cancer of the Ovary Ovarian cancer is the leading cause of gynecological cancer deaths in the United States, with peak incidence in the early 1980s. Despite careful physical examination, ovarian tumors are often difflcult to detect because they are usually deep in the pelvis. No deflnitive causative factors have been determined, but pregnancy and oral contraceptives appear to provide a protective effect. Most (90%) ovarian cancers are epithelial in origin; other tumors include germ cell tumors and stromal tumors. Risk factors include a history of breast cancer, a family history of ovarian cancer, older age, low parity, and obesity. Cancer of the Pancreas 181 Medical Management • Surgical removal is the treatment of choice. Nursing Management • Perform nursing measures, including treatments related to surgery, radiation, chemotherapy, and palliation. See “Nursing Management” under “Cancer” and under “Preoperative and Postoperative Nursing Management” in Chapter P. Cancer of the Pancreas Cancer may develop in the head, body, or tail of the pancreas. Symptoms vary depending on the location of the lesion and whether functioning insulin-secreting pancreatic islet cells are 182 Cancer of the Pancreas involved. It is very rare before the age of 45 years, and most patients present in or beyond the sixth decade of life. Risk C factors include cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both. Pancreatic cancer is also associated with diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis. Tumors that originate in the head of the pancreas are the most common and obstruct the common bile duct; functioning islet cell tumors are responsible for the syndrome of hyperinsulinism, particularly in islet cell tumors. Pancreatic carcinoma has a 5% survival rate at 5 years, regardless of the stage of disease at diagnosis. Clinical Manifestations • Pain, jaundice, or both are present in more than 80% of patients and, along with weight loss, are considered classic signs of pancreatic carcinoma but often do not appear until the disease is far advanced. Medical Management • Surgical procedure is extensive to remove resectable localized tumors (eg, pancreatectomy, Whipple resection). Nursing Management See “Preoperative and Postoperative Nursing Management” in Chapter P for additional information. Discharge to a long-term care setting with communication to staff about prior teaching. Cancer of the Prostate Cancer of the prostate is the most common cancer in men (other than nonmelanoma skin cancer) and is the second most common cause of cancer deaths in American men. African American men are twice as likely than men of any other racial or ethnic group to die of prostate cancer. Risk factors include increasing age, a family history, and possibly a high-fat diet. Endogenous hormones, such as androgens and estrogens, also may be associated with the development of prostate cancer.

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If respiratory muscles are involved Auscultation may reveal hypoventilation if the respiratory muscles are involved purchase 20mg tadacip with visa erectile dysfunction doctor dc. This may lead to cheap 20mg tadacip with mastercard impotence urology decreased tidal volume purchase tadacip 20 mg without prescription erectile dysfunction doctors san antonio, making breathing difficult and predisposing the patient to purchase 20 mg tadacip with amex erectile dysfunction caused by heart medication pneumonia and other respiratory tract infections. Progressive weakness of the diaphragm and the intercostal muscles may eventually lead to myasthenic crisis (an acute exacerbation that causes severe respiratory distress). In myasthenia gravis, the amplitude of motor unit potential falls off with continued use. Battling illness Treating myasthenia gravis the main treatment for myasthenia gravis is anticholinesterase drugs such as pyridostigmine (Mestinon). These drugs counteract fatigue and muscle weakness and restore about 80% of muscle function. Options and alternatives If medications aren’t effective, some patients undergo plasmapheresis to remove acetylcholine-receptor antibodies and temporarily lessen the severity of symptoms. Patients with thymomas require thymectomy, which leads to remission in adult-onset disease in about 40% of patients if done within 2 years after diagnosis. Endotracheal intubation and mechanical ventilation, combined with vigorous suctioning to remove secretions, usually bring improvement in a few days. Because anticholinesterase drugs aren’t effective in myasthenic crisis, they’re discontinued until respiratory function improves. Parkinson’s disease Parkinson’s disease produces progressive muscle rigidity, loss of muscle movement (akinesia), and involuntary tremors. Parkinson’s disease is one of the most common crippling diseases in the United States. It affects more men than women and usually occurs in middle age or later, striking 1 in every 100 people over age 60. However, some cases result from exposure to toxins, such as manganese dust and carbon monoxide, that destroy cells in the substantia nigra of the brain. A defect in the dopamine pathway Parkinson’s disease affects the extrapyramidal system, which influences the initiation, modulation, and completion of movement. The extrapyramidal system includes the corpus striatum, globus pallidus, and substantia nigra. In Parkinson’s disease, a dopamine deficiency occurs in the basal ganglia, the dopaminereleasing pathway that connects the substantia nigra to the corpus striatum. Neurotransmitter action in Parkinson’s disease Degeneration of the dopaminergic neurons and loss of available dopamine lead to rigidity, tremors, and bradykinesia. What to look for Important signs of Parkinson’s disease include: • muscle rigidity • akinesia • a unilateral “pill-roll” tremor. Muscle rigidity results in resistance to passive muscle stretching, which may be uniform (lead-pipe rigidity) or jerky (cogwheel rigidity). The patient walks with his body bent forward, takes a long time initiating movement when performing a purposeful action, pivots with difficulty, and easily loses his balance. Akinesia may also cause other signs that include: • masklike facial expression • blepharospasm, in which the eyelids stay closed. It begins in the fingers, increases during stress or anxiety, and decreases with purposeful movement and sleep. Getting complicated Common complications of Parkinson’s disease include injury from falls, food aspiration due to impaired swallowing, urinary tract infections, and skin breakdown due to increased immobility. What tests tell you Diagnosis of Parkinson’s disease is based on the patient’s age, history, and signs and symptoms, so laboratory tests are generally of little value. Battling illness Treating Parkinson’s disease Treatment for Parkinson’s disease aims to relieve symptoms and keep the patient functional as long as possible. It consists of drugs, physical therapy, and stereotactic neurosurgery in extreme cases. Looking to levodopa and other drugs Drug therapy usually includes levodopa, a dopamine replacement that’s most effective in the first few years after it’s initiated. It’s given in increasing doses until signs and symptoms are relieved or adverse reactions develop. Because adverse effects can be serious, levodopa is commonly given along with carbidopa to halt peripheral dopamine synthesis. When levodopa is ineffective or too toxic, anticholinergics, such as trihexyphenidyl or benztropine (Cogentin), and antihistamines, such as diphenhydramine, are given. Antihistamines may help decrease tremors because of their central anticholinergic and sedative effects. Amantadine, an antiviral agent, is used early in treatment to reduce rigidity, tremors, and akinesia. Patients with mild disease are given deprenyl to slow the progression of the disease and ease symptoms. Stalevo, a drug that combines carbidopa, levodopa, and entacapone, is used when carbidopa and levodopa are no longer effective throughout the dosing interval. The added component entacapone prolongs the time that levodopa is active in the brain. Deep brain stimulation In the past, pallidotomy and thalamotomy were the only available surgical options. With deep brain stimulation, electrodes are implanted into the targeted brain area.

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Gravida refers to buy cheap tadacip 20mg on line erectile dysfunction etiology any pregnancy regardless of the duration tadacip 20mg visa low libido erectile dysfunction treatment, including the present one trusted 20 mg tadacip erectile dysfunction psychological causes treatment. Para refers to buy tadacip 20 mg without prescription erectile dysfunction treatment massage past pregnancies that continue to the period of viability (usually considered to be 24–28 weeks). The new mother asks about how her older child will react to having a new baby in the household. The nurse cheerfully replies, “Don’t worry, Kirsten will be so happy to have a new baby to play with. When a patient has a realistic concern, false reassurance that there is nothing to worry about may discourage open communication. She knows that many of them feel depressed about their decreased ability to perform activities of daily living. In planning their care, a priority nursing diagnosis would be: (1) Disturbance in body image related to aging process and decreased mobility (2) Denial related to normal process of aging (3) Activity intolerance related to decreased functional capacity (4) Self-care deficit related to aging process Rationale: the correct answer is (1). Older people may have problems coping with their decreasing physical capabilities, and interventions aimed toward helping them deal with these changes and providing the opportunity for them to remain as independent as possible can help them adjust. When you touch her she feels cold and clammy and she doesn’t recognize you when you call her name. These symptoms, including decreased urinary output, are the classic symptoms of shock. He refuses to take his meds or cooperate with you during range of motion exercises. You understand that: (1) He had better get used to this because he will probably never regain full use of his right arm or leg. Not only has he lost his physical independence, but also his financial income has been compromised. A 54-year-old woman was diagnosed with multiple sclerosis nine months ago and has had no symptoms during that time. Your initial interaction should be to (1) inform her that she was lucky to have had nine months without symptoms. It is important to allow her to express any of these concerns, and then you may give her appropriate information. Karas has never been a complainer, but today he is experiencing severe pain in his left foot. It is due to an accumulation of uric acid due to impaired excretion by the kidneys. The patient is scheduled to receive a 300cc bolus feeding through a gastric feeding tube. You aspirate 125cc of fluid from the stomach prior to giving the scheduled feeding. The most appropriate action would be to (1) throw out the fluid you aspirated from the stomach and instill the new solution. Return the original stomach contents to maintain fluid and electrolyte balance and hold the scheduled feeding. Delayed gastric emptying may be indicative of other problems and the doctor should be notified. Your instructions would include: (1) Use two separate syringes when administering these two forms of insulin. You do not want to contaminate the pure form of regular insulin, which could affect its absorption time. Nursing has the responsibility of adjusting O2 delivery rates based on the oxygen saturation level determined by the pulse oximeter. The nurse admits a patient who has a head injury and is at risk for increased intracranial pressure. Acetominophen would not help and could mask symptoms; however elevating the head of the bed can help reduce intracranial pressure by promoting venous drainage. The first sign of increased intracranial pressure is a change in the level of conciousness. Reading the notes on her new patient, the nurse sees that she is described as “alert and oriented x 3”. The nurse is assisting the anesthesiologist during the administration of epidural anesthesia. Johnson, a 68-year-old man with congestive heart failure, has been prescribed a low sodium diet. Fresh fruits and vegetables (apple, spinach) are usually low sodium, as are whole grain breads. The expectant mother is complaining to the nurse that she feels sick to her stomach when she gets up in the morning and cannot bear the thought of breakfast. Low blood sugar is thought to play a role in morning sickness, therefore the suggestion of dry crackers is good because they are generally well tolerated. Increased fluid intake may well make vomiting more likely, and apple juice before bed is not only a fluid, but it may well decrease the morning blood sugar. The nurse notes that he has several characteristics that put him at high risk for thrombophlebitis. Risk factors include surgery—especially abdominal—prolonged bed rest, elevated hemoglobin and high platelet count, both of which make the blood more prone to clotting. The public health nurse is assessing the food intake of a low income family, and finds that it is protein deficient. Beans are a low cost source of protein, while bacon is expensive and mostly fat, and rice and bananas are not good protein sources. Diet pills on the market claim to reduce the amount of fat absorbed by 30 percent. The nurse explains to the young woman interested in taking them that they also reduce the amount of fat-soluble vitamins that are absorbed.

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Gastric ulcers—food may cause the pain 20 mg tadacip visa erectile dysfunction treatment houston tx, vomiting may relieve it; duodenal ulcers discount 20 mg tadacip amex erectile dysfunction medication costs, pain with an empty stomach buy generic tadacip 20 mg on-line impotence propecia, relieved by eating c order 20mg tadacip with amex erectile dysfunction doctor mumbai. Signs of perforation: hypotension (blood presssure decrease of 10 mm Hg or more), sudden severe upper abdominal pain, rigid abdomen, absent bowel sounds, shallow, rapid respirations 3. Dietary modification—often highly individual, foods that cause pain are avoided c. Medications—antacids, H2 receptor antagonists, acid pump inhibitors, prokinetics, anticholinergics 4. Dumping Syndrome—a post-gastric surgery condition in which the intestine is unable to handle a large amount of food that has been adequately mixed with gastric secretions 1. Weakness, dizziness, tachycardia, diaphoresis after meal; followed by epigastric fullness, abdominal cramping, and diarrhea. Self-limiting Drug Treatment for Peptic Ulcer Drug Classification Generic and Trade Names Nursing Considerations Antacids Magnesium and aluminum hydroxide (Maalox) Administer after meals. Dicyclomine (Bentyl) Monitor for drowsiness, urinary retention, constipation Histamine2 Receptor Cimetidine (Tagamet) Take 1 hour before meals. Antagonists Ranitidine (Zantac) Monitor blood count, kidney, Famotidine (Pepcid) and liver function Prostaglandin Misoprostol (Cytotec) Do not give during pregnancy. Gastric Cancer—Symptoms are often not apparent until the disease has metastasized into adjacent organs. More common in men, Asians; associated with highly salted or smoked foods, peptic ulcer, low intake of vegetables and fruits, chronic gastritis 1. Do: place in position of comfort on bed rest, assess hydration, abdominal distention, bowel sounds, pain, passage of flatus or stool. Assess drainage, monitor abdomen for distention and assess peristaltic activity. Intestinal Obstruction—complete or partial blockage of the small or large intestine; can be due to mechanical problems such as tumors, neurological difficulties such as paralytic ileus; increased pressure above blockage and decreased peristalsis below; higher the obstruction, the more severe the symptoms. Small intestine obstruction (1) Vomiting—possibly fecal (2) Abdominal distention (3) Absence of stools (4) Dehydration b. Large bowel obstruction—slower progression of symptoms (1) Constipation (2) Abdominal distention (3) Cramplike pain in lower abdomen 2. Record intake and output, including amount and character of drainage from decompression tube c. Diverticular Disease (Diverticulosis/Diverticulitis)—Diverticulosis is an outpouching of the mucosa of the colon; diverticulitis is an inflammation of the outpouching (diverticulum). Drug treatment—bulk laxatives, antibiotics, stool softeners, and anticholinergics c. Teach patient about dietary restrictions, avoidance of constipation, and activity that increases intra-abdominal pressure L. Hernias—protrusion of an organ (usually refers to the intestines) through an abnormal opening 1. Types—categories (1) Reducible—may be manually replaced into its normal position (2) Irreducible—may not be manually replaced into position (3) Incarcerated—obstruction of intestinal flow (4) Strangulated—blood supply is cut off (surgical emergency) b. Types—location (1) Inguinal—a weakness in the groin area where the spermatic cord (men) or round ligament (women) passes through the abdominal wall; more common in men (2) Femoral—the intestine protrudes through the femoral ring; more common in women (3) Umbilical—common in babies where the umbilical opening doesn’t close adequately, or in adults with weak abdominal muscles (4) Incisional—weakness in the abdominal wall due to a previous incision 2. Surgical repair (1) Herniorrhaphy—surgical repair of the hernia (2) Hernioplasty—surgical reinforcement of the weakened area b. Teaching, which includes need to avoid activities that increase intraabdominal pressure such as heavy lifting c. Inflammatory Bowel Disease—Crohn’s Disease (primarily affects the small bowel) and Ulcerative Colitis (primarily affects the large bowel) 1. Gastroenteritis—inflammation of the intestinal tract, with diarrhea, vomiting, and abdominal cramping. Antiemetics (should not be given to patients with viral or bacterial enteritis) 4. Provide patient teaching about avoiding infection—washing hands, eating only thoroughly cooked foods, avoiding drinking water or eating raw fruits or vegetables in a foreign country Teach patients symptoms to report to physician (1) Pain (2) Change in stool or bleeding (3) Weight loss (4) Sustained vomiting or diarrhea P. Hemorrhoids—varicose veins of the anus or rectum; may occur internally, externally or both; can be caused by straining due to constipation, diarrhea, increased venous pressure from heart failure, increased abdominal pressure (as in pregnancy), or prolonged sitting 1. Postoperative care—give sitz baths, other comfort measures, maintain position of comfort on side, increase liquids, bulk and stool softeners b. Preicteric (before the appearance of jaundice) (1) Anorexia, constipation, and diarrhea (2) Fatigue, fever, headache (3) Hepatomegaly, splenomegaly (4) Nausea and vomiting (5) Pruritis (6) Right upper quadrant abdominal pain b. Icteric (1) Clay-colored stools (2) Dark urine (3) Fatigue (4) Jaundice (5) Symptoms of pre-icteric phase: weight loss, hepatosplenomegaly, pruritis, fatigue c. Posticteric (1) Decreased hepatomegaly (2) Decreased jaundice (3) Fatigue (4) Improved appetite 3. Positive Hepatitis A antibody, positive Hepatitis B surface antigen, positive immunoglobulin (Ig) antidelta antigens (type D), positive Hepatitis E antigen c. Cirrhosis—cell degeneration of the liver in which scar tissue replaces functioning tissue; a complication of alcoholism, hepatitis, certain metabolic disorders 1. Portal hypertension (1) Esophageal varices—bleed easily (2) Hemorrhoids (3) Visible veins on abdominal wall (4) Development of edema and ascites j. Prevent encephalopathy by decreasing ammonia formation: decreasing dietary protein, neomycin to sterilize intestine to reduce protein breakdown 3. Help patient get proper diet, with adequate nutrients and low protein, encourage rest b. Cholelithiasis (gallstones) and Cholecystitis (gallbladder inflammation usually associated with gallstones) 1. Lithotripsy (use of shock waves to disintegrate stones)—useful if only a few stones.

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