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Pharmacological Treatment At the primary care: Corneal Abrasion: A: Chloramphenical eye ointment 1% cheap motrin 600 mg without prescription pain medication for dogs with kidney disease, 8 hourly to the injured eye until no fluorescein staining Steps Guiding Management of Complicated Blunt Trauma Complicated blunt trauma is a trauma where the vision is poor 600 mg motrin amex treatment for dog pain in leg, patinets experiences pain and there is hyphaema cheap motrin 400 mg with amex holistic treatment for shingles pain. It is best managed by eye specialist as surgery may be required in the management discount motrin 600 mg with mastercard treatment guidelines for diabetic neuropathic pain. The management of these injuries is guided by history from the patient and While waiting for referral, use the following in the affected eye: ocular findings by the clinicians. A: Paracetamol 1 gm 4–6 hourly to a maximum of 4 doses in 24 hours, for 3 days in adults, the dosage in children is 10–14 mg/kg 4–6 hourly for 3 days. Investigations this is done after the first aid measures Referral indicated if Test the visual acquity Intraocular foreign body is suspected Examine the injured eye with slit lamp or magnifier including fluorescein There is globe or intracocular penetration evidenced by: staining to reveal foreign body or corneal laceration o Poor vision, o Distorted pupil Non-Pharmacological Treatment o Ocular contents of foreign body is seen Provide first aid measures to the patients as per presentation o Circumferential subconjunctival haemorrhage If no penetration, irrigate the eye with clean water or Ringers Lactate to o Hyphaema with or without raised intraocular pressure reduce chemical substance in the eye Conjuctival laceration requiring suturing (>1 cm) Remove foreign body if visible with a cotton bud or surgical blade if Laceration/perforation or diffuse damage to the cornea and sclera shallow. It is best managed by eye specialist as surgery may be required in Do not apply pressure on the eye in perforating injuries of the eyeball the management. Hyphema, no pain Refer No hyphema, normal vision, Paracetamol, observe for 2 days, refer if 14. It occurs when chemicals such as acid or alkali Poor vision and pain Paracetamol, refer urgently (e. Standard Treatment GuidelinesStandard Treatment Guidelines 197197 Diagnostic Criteria Diagnosis relies mostly with patients history Patients may present with photophobia Inability to open the eyes Excessive tearing/watery eye Cloudiness of cornea with blurred vision Loss of conjunctival blood vessels Traces of chemical substance such as cement or herbs and blisters or loss of eyelid skin in open flame injuries. Non-Pharmacological Treatment If a patient gives you history of being in contact with the items mentioned above, the following should be done: Irrigate the eye with clean water or Ringers lactate continually for a minimum of 20–30 minutes to reduce chemical substances. Diagnostic Criteria Acute unilateral painful eye Blurring of vision Reduced corneal sensation Dendritic corneal ulcer seen on staining with fluorescein Pharmacological Treatment C: Acyclocir 3%, ophthalmic ointment inserted in the lower conjunctival sac, 4 hourly. Diagnostic Criteria Painful and red eye of acute onset Non-Pharmacological Treatment Excessive tearing If a patient gives you history of being in contact with the items mentioned above, the Severe photophobia following should be done: Poor vision Irrigate the eye with clean water or Ringers lactate continually for a Gray/white spot on the cornea staining with fluorocein minimum of 20–30 minutes to reduce chemical substances. Irrigate longer Hypopyon (Pus or white cells in anterior chamber) for severe alkali burn. Give antifungal, if fungal infection is suspected or confirmed Diagnostic Criteria C: Natamycin 5%, ophthalmic drops, instil 1 drop 1–2 hourly for 3–4 days Acute unilateral painful eye (specialist use only. Pharmacological Treatment C: Acyclocir 3%, ophthalmic ointment inserted in the lower Then reduce to 1 drop 3–4 hourly. Majority of the cases are idiopathic where by other cases are due to autoimmune diseases. Diagnostic Criteria It has three main clinical presentations namely acute, chronic and acute on chronic. In acute type, patients present with: Painful red eye Excessive tearing Severe photophobia Visual acuity is usually reduced and the pupil is small or it may be irregular due to syneachia Slit lamp biomicroscopic examination reveals cells and keratic precipitates and hypopyon may be seen in the anterior chamber Investigations these are indicated in bilateral and granulomatous uveitis as they may not be helpful in unilateral and non granulomatous. Pharmacological Treatment Treatment for uveitis is mainly steroids and specific treatment according to the cause. This should be initiated in a facility where workup and close monitoring can be done. Note: Diagnostic Criteria Treatment of uveitis must involve various specialists It has three main clinical presentations namely acute, chronic and acute on chronic. The Acute uveitis is a serious problem and the patient should be referred urgently commonest form is anterior uveitis. In acute type, patients present with: for specialist treatment Painful red eye Recurrences may occur or acute disease may end up becoming a chronic Excessive tearing uveitis Severe photophobia Visual acuity is usually reduced and the pupil is small or it may be 14. Clinical features and and hypopyon may be seen in the anterior chamber treatment guideline depends on the type and cause of conjunctivitis. Investigations Note: these are indicated in bilateral and granulomatous uveitis as they may not be helpful in If conjunctivitis is due to an infection, counsel on the importance of frequent unilateral and non granulomatous. In mild cases where the eyes are white, Avoid allergens Cold water compresses for 10 minutes four times a day Pharmacological Treatment Adults and children > 6 years of age: C: Oxymetazoline 0. Referral Refer to eye specialist for further specialized care in case of the following: Moderate to severe allergic conjunctivitis No response Persons wearing contact lenses Children <2 years of age At the specialized centre, the following treatment may be added depending on the patients presentation: Short term steroid eye drops (in severe cases with involvement of the cornea, apart from mast cell stabilizers, give D: Dexamethasone 0. Treatment of allergic conjunctivitis depends on the severity of the condition and age of the patient. It may be unilateral but usually If no response within 7 days, use mast cell stabilizers such as: bilateral C: Sodium chromoglycate 2% eye drops, instill 6 hourly per day (Doctor initiated) Diagnostic Criteria Use may be seasonal (1–3 months) or long term. Pharmacological Treatment A: Chloramphenicol 1%, ophthalmic ointment, applied 8 hourly for 5 days. It is characterized by inflammation of the conjunctivae, sticky eyes to abundant purulent discharge and eyelids oedema. Causative organisms are Neisseria gonorrhoea, Chlamydia spp and Staphylococcus spp. Diagnostic Criteria Patients present with massive edema and redness of eyelids and with purulent and copious discharge from the eyes, clinical presentation ranges 204 Standard Treatment Guidelines Note: Viral conjunctivitis is very contagious so patients and members of the family from mild (small amount of sticky exudates) to severe form (profuse pus should be alerted and swollen eye lids) depending on the causative organism There is usually rapid ulceration and perforation of corneal which 14. Purulent discharge Pharmacological Treatment Mild discharge without swollen eyelids and no corneal haziness: A: Chloramphenicol 1%, ophthalmic ointment, applied 8 hourly for 5 days. It is characterized by inflammation of the conjunctivae, sticky eyes to abundant purulent Note: discharge and eyelids oedema. Causative organisms are Neisseria gonorrhoea, Chlamydia Ceftriaxone should not be used in neonates that are seriously ill or are spp and Staphylococcus spp. Refer urgently all children who present with squint to Paediatric Eye Tertiary Centre (Muhimbili National Hospital, Kilimanjaro Christian Medical Centre And Mbeya Zonal Referral Hospital. Note: Close follow up is very important due to the following: There is a chance of developing retinoblastoma in the fellow eye 14. Refer urgently all children who Refer all children presenting with a white pupillary reflex, squint and acute painful red present with squint to Paediatric Eye Tertiary Centre (Muhimbili National eye to a qualified eye care personnel/ophthalmologist Hospital, Kilimanjaro Christian Medical Centre And Mbeya Zonal Referral Hospital. The tumour typically occurs on the bulbar conjunctiva, originating pterygium and Squamous cell carcinoma of the conjunctiva.
Subcutaneous immunoglobulin replacement therapy for push vs infusion pump: a retrospective analysis purchase motrin 600mg free shipping pain solutions treatment center ga. Ann Allergy Asthma Immunol primary antibody deﬁciency: advancements into the 21st century discount motrin 400 mg amex knee pain treatment uk. Subcutaneous immunoglobulin replacement in primary immunodeﬁ self-infusions of immunoglobulins as a potential therapeutic regimen in ciencies purchase 600 mg motrin overnight delivery pain treatment center of the bluegrass. Schleinitz N buy motrin 400mg without prescription pain treatment center houston texas, Jean E, Benarous L, Mazodier K, Figarella-Branger D, Bernit E, of life, immunoglobulin G levels, and infection rates in patients with primary im et al. Subcutaneous immunoglobulin administration: an alternative to intravenous munodeﬁciency diseases during self-treatment with subcutaneous immunoglob infusion as adjuvant treatment for dermatomyositis? Subcutane globulin dosage and switch from intravenous to subcutaneous immunoglobulin ous immunoglobulin infusion: a new therapeutic option in chronic inﬂammatory replacementtherapyinpatientswithprimaryhypogammaglobulinemia:decreasing demyelinating polyneuropathy. A correct identiﬁcation of the causes of thrombocytopenia is crucial for the appropriate management of these patients. In this review, we present a systematic evaluation of adults with thrombocytopenia. The approach is clearly different between outpatients, who are frequently asymptomatic and in whom we can sometimes indulge in sophisticated and relatively lengthy investigations, and the dramatic presentation of acute thrombocytopenia in the emergency department or in the intensive care unit, which requires immediate intervention and for which only a few diagnostic tests are available. A brief discussion of the most common etiologies seen in both settings is provided. Introduction Mechanisms of thrombocytopenia Thrombocytopenia is deﬁned as a platelet count below the 2. Two less common mechanisms are platelet 100 109/L may be more appropriate to identify a pathologic sequestration and hemodilution. Because plate lets play an essential role in preserving vessel wall integrity, It is now known that in many cases of thrombocytopenia, such as thrombocytopenia is associated with a defect of primary hemostasis. Establishing the cause of thrombocytopenia relapsing); disease history, with particular reference to autoimmune has obvious clinical repercussions, but is sometimes quite disorders, infections, or malignancies; pregnancy status in premeno challenging. This is particularly the case for hospitalized pa pausal woman; recent medications and vaccinations; recent travels tients, in whom thrombocytopenia appears frequently in the (eg, malaria, rickettsiosis, dengue fever); recent transfusions; recent background of a multisystem disorder and may be determined by organ transplantation; ingestion of alcohol and quinine-containing multiple mechanisms. Conversely, in the outpatient setting, beverages; dietary habits; and risk factors for retroviral infections thrombocytopenia is often isolated and asymptomatic, and the and viral hepatitis. A history of recurrent, symptomatic thrombocy diagnosis of the speciﬁc cause is usually straightforward (Table topenia with platelet counts returning to normal within days, even in 1. Thrombocytopenia in pregnancy deserves special consider the absence of speciﬁc treatment, should prompt investigation of a ation because of the possible consequences on the fetus. The bleeding history does not help structured approach to the diagnosis of thrombocytopenia in in diagnosing the nature of the thrombocytopenia, but gives volves an integration of clinical ﬁndings and appropriate support important clues about its duration and deﬁnes its clinical phenotype. Collecting a detailed medical history is not always possible, the Hematology 2012 191 Table 1. There is no single thrombocytopenia is almost always an acute event and the disease hematologic or biochemical test that is conclusive for a given history and exposure to medications (eg, heparin and antibiotics) mechanism of thrombocytopenia. Patients with thrombocytopenia typically Limited evidence suggests that plasma glycocalicin and thrombopoi experience mucocutaneous bleeding. The presence of joint or etin levels can increase the speciﬁcity of reticulated platelets in extensive soft tissue bleeding suggests the presence of coagulation thrombocytopenia due to increased platelet destruction. The presence of an ischemic common speciﬁc etiologies and associated investigations are dis limb of skin necrosis should raise suspicion of heparin-induced cussed in the next sections. In the era of genomic medicine and widespread molecular testing, examination of the peripheral blood ﬁlm still remains the most A low platelet count during a routine evaluation in an otherwise important investigation guiding our diagnostic approach to thrombo asymptomatic person is a relatively common reason for referrals to cytopenia (Figure 1. All 3 blood cell lineages should be assessed hospital outpatient clinics by general practitioners. From a practical perspective, when we are patients with severe thrombocytopenia can present to the emergency investigating thrombocytopenia in a critically ill patient, the imme department with mucocutaneous bleeding or internal hemorrhage. There is no consensus pathogenetic mechanisms that are not mutually exclusive and that, on the set of investigations to perform, and practice varies greatly particularly in the acute care setting, multiple potential causes of not only from country to country, but also from center to center thrombocytopenia can be identiﬁed, a basic laboratory evaluation within the same country. There is little doubt that local resources should include liver and renal function tests, a clotting screen with may play a relevant role in the choice of investigations. Algorithm for workup of thrombocytopenia based on observation of the peripheral blood ﬁlm. I also request an and only an accurate history collection can help in the diagnostic ultrasound of the abdomen (to rule out the occasional initial process. Antiplatelet Ab assays are not very sensitive, challenging because the substance causing the thrombocytopenia is although their speciﬁcity approaches 90%. When the drug is because of its frequency, consideration should always be given to Hematology 2012 193 Table 2. It occurs in about 1 in 1000 normal adults and is not associated with bleeding or thrombosis. Platelet size and granularity Consistently large platelets suggest hereditary macrothrombocytopenia. Large platelets with a gray color on Wright-Giemsa stain deﬁne the gray platelet syndrome, an autosomal-dominant macrothrombocytopenia associated with bleeding tendency due to absent or greatly reduced -granules. In thrombocytopenia due to peripheral destruction, large platelets or giant platelets are often seen in addition to platelets of normal size. When thrombocytopenia is due to reduced platelet production (eg, after chemotherapy), platelets are of normal size. In myelodysplastic syndromes, platelets have variable size (giant platelets may be seen) and are frequently hypogranular.
Preventing Infection • Instruct patient and caregivers to monitor for signs and symptoms of infection generic motrin 600 mg overnight delivery back pain treatment usa. Teach col leagues and other health care workers to apply precautions to blood and all body ﬂuids best 400mg motrin pain sacroiliac joint treatment, secretions buy 600mg motrin fast delivery back pain treatment nhs, and excretions except sweat (eg buy discount motrin 400mg on-line pain treatment and wellness center greensburg, cerebrospinal ﬂuid; synovial, pleural, peritoneal, pericardial, amniotic, and vaginal ﬂuids; semen. Consider all body ﬂuids to be potentially hazardous in emergency circum stances when differentiating between ﬂuid types is difﬁcult. Improving Activity Tolerance • Monitor ability to ambulate and perform daily activities. Improving Airway Clearance • At least daily, assess respiratory status, mental status, and skin color. Coping With Grief • Help patients explore and identify resources for support and mechanisms for coping. Monitoring and Managing Potential Complications • Inform patient that signs and symptoms of opportunistic infections include fever, malaise, difﬁculty breathing, nau sea or vomiting, diarrhea, difﬁculty swallowing, and any occurrences of swelling or discharge. Assist patient and caregivers in ﬁtting the medication reg imen into their lives. In each case, a profound imbalance exists between myocardial oxygen supply and demand. These signs and symp toms, which are caused by stimulation of the sympathetic nerv ous system, may be present for only a short time or may persist. Assessment and Diagnostic Methods • Patient history (description of presenting symptom; history of previous illnesses and family health history, particularly of heart disease. Previous history should also include infor mation about patients risk factors for heart disease. Medical Management the goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complica tions such as lethal dysrhythmias and cardiogenic shock. Acute Coronary Syndrome and Myocardial Infarction 19 A • Reduce myocardial oxygen demand and increase oxygen sup ply with medications, oxygen administration, and bed rest. Include history of chest pain or discomfort, difﬁculty breathing (dyspnea), palpi tations, unusual fatigue, faintness (syncope), or sweating (diaphoresis. Perform a complete physical assessment, which is crucial for detecting complications and any change in status. Nursing Interventions Relieving Pain and Other Signs and Symptoms of Ischemia • Administer oxygen in tandem with medication therapy to assist with relief of symptoms (inhalation of oxygen reduces pain associated with low levels of circulating oxygen. Acute Coronary Syndrome and Myocardial Infarction 21 A • Assess vital signs frequently as long as patient is experiencing pain. Improving Respiratory Function • Assess respiratory function to detect early signs of compli cations. Promoting Adequate Tissue Perfusion • Keep patient on bed or chair rest to reduce myocardial oxygen consumption. Reducing Anxiety • Develop a trusting and caring relationship with patient; provide information to the patient and family in an hon est and supportive manner. Monitoring and Managing Complications Monitor closely for cardinal signs and symptoms that signal onset of complications. Evaluation Expected Patient Outcomes • Experiences relief of angina • Has stable cardiac and respiratory status • Maintains adequate tissue perfusion • Exhibits decreased anxiety • Complies with self-care program • Experiences absence of complications For more information, see Chapter 28 in Smeltzer, S. Nursing Management • Closely monitor the patient; frequently assess effectiveness of treatment (eg, oxygen administration, nebulizer therapy, chest physiotherapy, endotracheal intubation or tracheostomy, mechanical ventilation, suctioning, bronchoscopy. Addisons Disease (Adrenocortical Insufﬁciency) 25 A Addisons Disease (Adrenocortical Insufﬁciency) Addisons disease occurs when the adrenal cortex function is inadequate to meet the patients need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is responsible for the vast majority of cases. Other causes include surgical removal of both adrenal glands or infection (tubercu losis or histoplasmosis) of the adrenal glands. Therapeutic use of corticosteroids is the most common cause of adrenocortical insufﬁciency. Symptoms may also result from sudden cessation of exogenous adrenocortical hormonal ther apy, which interferes with normal feedback mechanisms. Mental changes (depression, emotional lability, apathy, and confusion) are present in 60% to 80% of patients. In severe cases, distur bance of sodium and potassium metabolism may be marked by depletion of sodium and water and severe, chronic dehydration. Signs and symptoms include the following: • Cyanosis and classic signs of circulatory shock: pallor, appre hension, rapid and weak pulse, rapid respirations, and low blood pressure. Medical Management Immediate treatment is directed toward combating circulatory shock: • Restore blood circulation, administer ﬂuids and corticos teroids, monitor vital signs, and place patient in a recum bent position with legs elevated. Nursing Management Assessing the Patient Assessment focuses on ﬂuid imbalance and stress. Monitoring and Managing Addisonian Crisis • Monitor for signs and symptoms indicative of addisonian cri sis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Addisons Disease (Adrenocortical Insufﬁciency) 27 A • Advise patient to avoid physical and psychological stressors such as cold exposure, overexertion, infection, and emo tional distress. Restoring Fluid Balance •Encourage the patient to consume foods and ﬂuids that assist in restoring and maintaining fluid and electrolyte balance. Improving Activity Tolerance • Avoid unnecessary activities and stress that might precipi tate a hypotensive episode. Promoting Home and Community-Based Care Teaching Patients Self-Care • Give patient and family explicit verbal and written instruc tions about the rationale for replacement therapy and proper dosage. Continuing Care • If patient cannot return to work and family responsibilities after hospital discharge, refer to home health care nurse to assess the patients recovery, monitor hormone replacement, and evaluate stress in the home. Clinical Manifestations Symptoms are highly variable; some include the following: • In early disease there is forgetfulness and subtle memory loss, although social skills and behavioral patterns remain intact.
International Normalized Ratio self-management after mechanical heart valve replacement: is an early start advantageous? A structured teaching and self-management program for patients receiving oral anticoagulation generic 600mg motrin mastercard pain treatment center of tempe. A Prospective Controlled Trial Comparing Weekly Self-Testing and Self-dosing with the Standard Management of Patients on Stable Oral Anticoagulation generic motrin 400 mg on-line knee pain treatment options. Back to Top Date Sent: 3/24/2020 513 these criteria do not imply or guarantee approval generic motrin 600 mg amex pain treatment centers of alabama. Self-management of oral anticoagulants with a whole blood prothrombin-time monitor in elderly patients with atrial fibrillation trusted 600mg motrin bone pain treatment guidelines. Clinical endpoints for studies on self-management of anticoagulation therapy would be bleeding and thromboembolic complications. Six hundred patients (50% of the randomized sample) were included in the analysis, dropouts and deaths were not included, and analysis was not based on intention to treat. It also showed that significantly more measurements were in the therapeutic range among patients in the self-management group. It is an ongoing trial and the published articles only present the interim analysis with data on 55% of the total sample size. There was no difference between them the in thromboembolic rates, and the difference in the bleeding rates did not reach statistical difference. Articles: the search yielded 20 newer articles many of which were reviews and editorials. The purpose of this review is to assess the home use of the monitors for patients with mechanical heart valves or atrial fibrillation, and not for evaluating the portable systems that have been in use since 1987 (known as point of service. Low-dose International normalized ratio self-management: A promising tool to achieve low complication rates after mechanical heart valve replacement. All studies were conducted among selected groups of patients and the results might not be generalized to all patients with mechanical heart replacement. Heneghan et al?s recent meta-analysis (2006) assessed the effects of self-monitoring with/ or without or self-management of 2002 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 514 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History anticoagulation compared with standard monitoring. The meta-analysis had valid methodology, was well conducted, and 10 out of the 14 studies it included were judged to be of good quality. The authors also performed a sensitivity analysis by excluding the studies with the lowest quality. However, the control groups in the trials received their routine care in different settings. The results of a recent meta-analysis (van Walraven, 2006) showed that the study setting has a major influence on anticoagulation control. Moreover, the majority of the trials included in Heneghan?s meta-analysis, provided education and training sessions only to the patients randomized to self-testing, not to the entire study population. Education increases awareness, motivation, and may modify the patient?s attitude and behavior. The education and training were given after randomization, and those who could not complete the training sessions or were incapable of self testing and/or self-management either left the study or were transferred to the routine care group. This resulted in a high dropout rate (20% to > 30%) in the intervention groups, and intention to treat analysis was not conducted in all the trials, which could overestimate the observed results. Ideally, training would be performed prior to randomization to eliminate those who are unable to complete it, and/or are incapable of self testing or self-management, from participating in the trial. The results of this meta-analysis indicate that the thromboembolic events, major bleeds, and death rates were significantly lower in the self-monitoring groups versus the controls who were managed by their personal physicians, anticoagulation management clinics, or managed service. Those who both self-tested and self adjusted their therapy dose had significantly lower thromboembolic events and mortality rates but a non significant reduction the rate of hemorrhage. The difference in thromboembolic event rates was not significant between the intervention and control groups in the pooled results of the 3 trials conducted among patients with mechanical heart valves. The authors did not report on the difference in major hemorrhage or death rate among these patients, and no subgroup analysis was provided for patients with atrial fibrillation. Fitzmaurice, et al?s (2005) study was a relatively large, multicenter, randomized, and controlled trial. Less than 25% of the eligible patient agreed to participate in the trial and were actually randomized to the study groups. Training on self-testing was given after randomization and only to the intervention group not to the entire population, which resulted in a higher dropout rate (43%) in the self-management group compared to 11% of those in the routine care group. Those who were considered incapable of self managing withdrew from the trial or were returned to the routine care group. The study population who self-selected to enroll was younger and included more men than the eligible population. Patients in the routine care group were managed in a variety of models including anticoagulation clinics, hospital outpatient clinics, and primary care clinics which may have an influence on their anticoagulation control, and outcomes. The study participants were highly motivated, mainly younger, willing to take and complete a structured training course on self-management, and capable of performing self-testing correctly and reliably. The purpose of this review is to assess the home use of the monitors for patients receiving long-term anticoagulation treatment, and not for evaluating the portable systems that have been in use since 1987 (known as point of service. It will have a minimum of 2 years of follow-up, and the primary outcome is event rates (stroke, bleeding or death. Self-monitoring of oral anticoagulation: a systematic review and 2002 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 515 these criteria do not imply or guarantee approval.
Excess dietary fat generic 400mg motrin overnight delivery pain treatment center orland park, high alcohol consumption motrin 400mg low price pain treatment in multiple myeloma, and smoking all Cancer of the Colon and Rectum (Colorectal Cancer) 153 increase the incidence of colorectal tumors discount motrin 400mg on line groin pain treatment video. C Medical Management Treatment of cancer depends on the stage of disease and related complications order 400mg motrin with visa knee pain treatment options. Supportive therapy and adjuvant therapy (eg, chemotherapy, radiation therapy, immunotherapy) are included. Surgical Management • Surgery is the primary treatment for most colon and rectal cancers; the type of surgery depends on the location and size of tumor, and it may be curative or palliative. Diagnosis Nursing Diagnoses • Imbalanced nutrition: less than body requirements related to nausea and anorexia • Risk for deﬁcient ﬂuid volume related to vomiting and dehydration • Anxiety related to impending surgery and diagnosis of cancer • Risk for ineffective therapeutic regimen management related to deﬁcient knowledge concerning the diagnosis, surgical procedure, and self-care after discharge • Impaired skin integrity related to surgical incisions, stoma, and fecal contamination of peristomal skin • Disturbed body image related to colostomy • Ineffective sexuality patterns related to ostomy and self concept Collaborative Problems/Potential Complications • Intraperitoneal infection • Complete large bowel obstruction • Gastrointestinal bleeding and hemorrhage • Bowel perforation • Peritonitis, abscess, sepsis Planning and Goals the major goals may include attainment of optimal level of nutrition; maintenance of ﬂuid and electrolyte balance; reduc tion of anxiety; learning about the diagnosis, surgical proce dure, and self-care after discharge; maintenance of optimal tis sue healing; protection of peristomal skin; learning how to irrigate the colostomy (sigmoid colostomies) and change the appliance; expressing feelings and concerns about the colostomy and the impact on self; and avoidance of complications. Include information about post operative wound and ostomy care, dietary restrictions, pain control, and medical management. Providing Emotional Support • Assess patients level of anxiety and coping mechanisms and suggest methods for reducing anxiety, such as deep breathing exercises and visualizing a successful recovery from surgery and cancer. Maintaining Optimal Nutrition • Teach about the health beneﬁts of a healthy diet; diet is individualized as long as it is nutritionally sound and does not cause diarrhea or constipation. Maintaining Fluid and Electrolyte Balance • Administer antiemetics and restrict ﬂuids and food to pre vent vomiting; monitor abdomen for distention, loss of bowel sounds, or pain or rigidity (signs of obstruction or perforation. Supporting a Positive Body Image • Encourage patient to verbalize feelings and concerns. Offer support and, if appropriate, refer to an enterostomal therapist, sex counselor or therapist, or advanced practice nurse. Monitoring and Managing Complications • Before and after surgery, observe for symptoms of compli cations; report; and institute necessary care. Evaluation Expected Patient Outcomes • Consumes a healthy diet and maintains ﬂuid balance • Experiences reduced anxiety • Learns about diagnosis, surgical procedure, preoperative preparation, and self-care after discharge • Maintains clean incision, stoma, and perineal wound • Verbalizes feelings and concerns about self • Recovers without complications For more information, see Chapter 38 in Smeltzer, S. Most uterine cancers are endometrioid (ie, originating in the lining of the uterus. Type 1, which accounts for the majority of cases, is estrogen related and occurs in younger, obese, and perimenopausal women. Type 2, which occurs in about 10% of cases, is high grade and usually serous cell or clear cell. Other risk factors include age above 55 years, obesity, early menar che, late menopause, nulliparity, anovulation, infertility, and diabetes, as well as use of tamoxifen. Clinical Manifestations Irregular bleeding and postmenopausal bleeding raise suspicion of endometrial cancer. Medical Management Treatment consists of total or radical hysterectomy and bilat eral salpingo-oophorectomy and node sampling. Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy. Cancer of the Esophagus 159 Nursing Management See Nursing Management under Cancer of the Cervix for additional information. Cancer of the Esophagus Carcinoma of the esophagus is usually of the squamous cell epi dermoid type; the incidence of adenocarcinoma of the esopha gus is increasing in the United States. Tumor cells may involve the esophageal mucosa and muscle layers and can spread to the lymphatics; in later stages, they may obstruct the esophagus, perforate the mediastinum, or erode into the great vessels. Clinical Manifestations • Patient usually presents with an advanced ulcerated lesion of the esophagus. Medical Management Treatment of esophageal cancer is directed toward cure if can cer is in early stage; in late stages, palliation is the goal of therapy. Intervention for esophageal cancer is directed toward improving the patients nutritional and physical status in preparation for surgery, radiation ther apy, or chemotherapy. Eventually, the diet is advanced as tolerated to a soft, mechanical diet; discontinue parenteral ﬂuids when appropriate. Cancer of the Kidneys (Renal Tumors) the most common type of renal carcinoma arises from the renal epithelium and accounts for more than 85% of all kid ney tumors. These tumors may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One quarter of 162 Cancer of the Kidneys (Renal Tumors) patients have metastatic disease at the time of diagnosis. Risk factors include gender (male), tobacco use, occupational expo C sure to industrial chemicals, obesity, and dialysis. Clinical Manifestations • Many tumors are without symptoms and are discovered as a palpable abdominal mass on routine examination. Cancer of the Kidneys (Renal Tumors) 163 • Renal artery embolization may be used in metastasis to occlude the blood supply to the tumor and kill the tumor cells. Nursing Management See Nursing Process: the Patient With Cancer under Can cer for additional information. Refer to home care nurse as needed to monitor and support patient and coordinate services and resources needed. Cancer of the Larynx Cancer of the larynx accounts for approximately half of all head and neck cancers. Almost all malignant tumors of the larynx arise from the surface epithelium and are classiﬁed as squamous cell carcinoma. Risk factors include male gender, age 60 to 70 years, tobacco use (including smokeless), alcohol use, vocal straining, chronic laryngitis, occupational exposure to carcinogens, nutritional deﬁciencies (riboﬂavin), and fam ily predisposition. Clinical Manifestations • Hoarseness, noted early with cancer in glottic area; harsh, raspy, low-pitched voice. Diagnosis Nursing Diagnoses Based on all the assessment data, major nursing diagnoses may include the following: • Deﬁcient knowledge about the surgical procedure and postoperative course • Anxiety and depression related to the diagnosis of cancer and impending surgery • Ineffective airway clearance related to excess mucus pro duction secondary to surgical alterations in the airway • Impaired verbal communication related to anatomic deﬁcit secondary to removal of the larynx and to edema • Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difﬁculties • Disturbed body image and low self-esteem secondary to major neck surgery, change in appearance, and altered structure and function • Self-care deﬁcit related to pain, weakness, and fatigue; musculoskeletal impairment related to surgical procedure and postoperative course Cancer of the Larynx 167 Collaborative Problems/Potential Complications Based on assessment data, potential complications that may develop include the following: C • Respiratory distress (hypoxia, airway obstruction, tracheal edema) • Hemorrhage, infection, wound breakdown • Aspiration • Tracheostomal stenosis Planning and Goals the major goals for the patient may include knowledge about treatment, reduced anxiety, maintenance of a patent airway, effective use of alternative means of communication, optimal levels of nutrition and hydration, improvement in body image and self-esteem, improved self-care management, and absence of complications. Nursing Interventions Teaching the Patient Preoperatively • Clarify any misconceptions, and give patient and family educational materials about surgery (written and audiovi sual) for review and reinforcement.
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