Institut Universitaire et Stratégique de l’Estuaire

Estuary Academic and Strategic Institute(IUEs/Insam)

Sous la tutelle académique des Universités de Dschang et de Buéa

SYSTEMIC PATHOLOGY

NURS II

Mme Armelle.N. Mbende /BSC in Nursing.

1
GENERAL OBJECTIVES

 Students should understand what Systemic pathology is all about.

 Students should be able to understand, be informed and prepared to assume the role of a
medical nurse.
 Students should be able to assist in the management of different medical cases whenever
they are faced with one.

SPECIFIC OBJECTIBVES

 Common pathologies of the cardiovascular system

 Describe the cardiovascular system
 Know the anatomy and physiology of the cardiovascular system
 The anatomy and physiology of the respiratory system
 List common pathologies of the RS

2
 CHAPTER ONE
CARDIOVASCULAR SYSTEM
GENERAL OBJECTIVE

 Students are expected to understand the cardiovascular system and know the different
pathologies that affect them
 How the pathologies of the system can be manage

SPECIFIC OBJECTIVES
At the end of this course, students should be able to;

- Describe the cardiovascular system

- Know the anatomy and physiology of the cardiovascular system
- Common pathologies of the cardiovascular system
- Nursing intervention and nursing Diagnosis of the pathologies

a) Overview of the system

This system is so vital because its activities defines the present of life. It is made up of the heart,
arteries, veins, capillaries and the lymphatic system.it is also called life giving transport system,
this is so because it carries life supporting oxygen and nutrients the cells and removes metabolic
waste products and carries hormones from one part of the body to the other.
This system is divided into two:

 Pulmonary circulation

In which deoxygenated blood carrying waste carbon dioxide (CO2) is pumped to the lung to be
send out. And oxygen (O2) in the lunge is being picked up by blood back to the heart to be
pumped to other parts of the body.

 Systemic circulation

In which blood carries oxygen and nutrients to all active cells while transport wastes products to
the kidneys, liver and skin for excretion

 There are four valves in the heart:

 Two valves separate the upper and lower chambers, on the right (tricuspid valve) and on
the left side of the heart (mitral valve).
 Two valves separate the heart from the blood vessels: one is between the heart and the
lungs (pulmonary valve) and the other is between the heart and the aorta

3
(Aortic valve). These valves consist of flaps called leaflets or cusps that open and close to help
ensure the continued forward flow of blood via the heart.
1) MYOCARDIA INFARCTION (HEART ATTACK)
a) DEFINITION
Heart attack is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of
oxygen supply (ischemia) occurs when blood flow decreases or stops to a part of the heart,
causing damage to the heart muscle.
b) CAUSES
The heart is the main organ in the cardiovascular system, which also include different types of
blood vessels. Some of the most important vessels are the arteries. They take oxygenated blood
(oxygen rich blood) to the body and all of the organs. The coronary arteries take oxygenated
blood specifically to the heart muscle.

 MI is usually caused by reduced blood flow in a coronary artery due to rupture of an

atherosclerosis plaque and subsequent occlusion of the artery by a thrombus.
 When these arteries become blocked or narrowed due to a buildup of plaque, the blood
flow to your heart can decrease significantly or stop completely. This can cause a heart
attack. Several factors can lead to a blockage in the coronary arteries. Usually coronary
arteries disease.
 Vasospasm this is a sudden constriction or narrowing of the coronary artery
 Decreased oxygen supply, due acute blood loss, anemia, or low blood pressure
 Bad cholesterol (low density lipoprotein)

It’s a colorless substance that’s found in the food we eat and the body also makes it naturally.
Not all cholesterol is bad but LDL cholesterol can stick to the walls of the arteries and produce
plaque that blocks blood flow in the arteries.

 Saturated Fat may also contribute to the buildup of plaque in the coronary arteries.
These fats increases the amount of a bad cholesterol in the body system and reducing the
amount of good cholesterol.

c) RISK FACTORS

 High blood pressure

 High cholesterol levels
 High triglyceride levels these are a type of fat that clog up the arteries. Triglyceride from
the food we eat travel via the body until they’re stored in the body, typically in the fat
cells. However some may remain in the arteries and contribute to the buildup of plaque.

4
  Diabetes
 Obesity because it is associated with the 4 conditions that increase the risk of heart attack
 Smoking
 Age
 Genetic (family history)
 Other factors that can increase the risk of heart attack include:
 Stress
 Lack of exercise
 The use of certain illegal drugs including cocaine and acetamines.
 A history of preeclampsia

d) SIGNS/SYMTOPMS
While the classic symptoms of the heart attack are chest pain and shortness of breath, the
symptoms can be varied. The most common include:

 Pressure or tightness in the chest

 Pain in the chest, back, jaw, and other areas of the upper body that lasts more than a few
minutes or that goes away and comes back (angina pectoris)
 Dyspnea, tachypnea, and crackles if IM has caused pulmonary congestion
 Pulmonary edema
 Shortness of breath
 Cold clammy diaphoretic and pale appearance on skin
 Nausea
 Vomiting
 Anxiety
 A cough
 Dizziness
 Decreased urinary output may indicate cariogenic shock

e) DIAGNOSTIC METHOD
To determine whether you’ve had a heart attack, the doctor will listen to the heart to check for

 Irregularities in the heartbeat

 Measuring the patient blood pressure
 An electrocardiogram (ECG) to measure the heart’s electricity activity ie identifying
areas that aren’t working properly
 Blood tests to check for proteins that are associated with heart damage, such as troponin.
 A stress test to see how the heart responds to certain situations, such as exercise

5
 A coronary angiogram with coronary catherization to look for areas of blockage in the
arteries

f) TREATMENT
 Blood thinners; such as aspirin are often used to break up blood clots and improve blood
flow through narrowed arteries
 Thrombolytic are often used to dissolve clots
 Antiplatelet drugs such as clopidogrel can be used to prevent new clots from forming and
existing clots from growing
 Nitroglycerin can be used to widen the blood vessels
 Beta blockers lower the blood pressure and relax the heart muscle. This can help limit the
severity of damage to the heart.
 ACE Inhibitors can also be used to lower blood pressure and decrease stress on the heart
 Pain relievers may be used to reduce any discomfort that may be felt eg sublingual
nitroglycerin

g) NURSING DIAGNOSIS
 Ineffective cardiac tissue perfusion related to reduced coronary blood flow as evident by
thrombus and plaque
 Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from
left ventricular dysfunction
 Risk of anxiety
 Deficient knowledge about disease self-care

h) NURSING PROIRITIES
 Relieve pain, anxiety
 Reduce myocardial workload
 Prevent/ detect and assist in treatment of life threatening dysrhythmias or complications
 Promote cardiac health, self-care

i) NURSING INTERVENTION
 Administer oxygen along with medication therapy to assist with relief of symptoms
 Encourage bed rest with the back rest elevated to help decrease chest discomfort and
dyspnea
 Encourage changing positions frequently to help keep fluid from pooling in the bases of
the lungs
 Check skin temperature and peripheral pulses frequently to monitor tissue perfusion
 Provide information in an honest and supportive manner

6
  Monitor patient closely for changes in cardiac rate and rhythm, heart sounds, blood
pressure, chest pain, respiratory status
 Record patient’s fluid input and urinary output, changes in skin color and laboratory
valves on a chart
 Education on the disease condition and medication side effects etc

j) NURSING ASSESSMENT
 Assess for chest pain not relieved by rest or medication
 Monitor vital signs, especially the blood pressure and pulse rate
 Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles
 Assess iv site frequently
 Assess for history for illness
 Assess for decreased urinary output

k) COMPLICATIONS
 Congestive heart failure
 Arrhythmia
 Pericarditis
 Cardiogenic shock
 Acute pulmonary edema
 Death

2) RHEUMATIC HEART DISEASE

a) DEFINITION
This is a systemic inflammatory disease of childhood where in the acute form results
from upper respiratory tract infection with a streptococci.

 Rheumatic fever can involve the heart, joints, the CNS (chorea) the skin and
subcutaneous tissues. When it involves the heart it is termed rheumatic heart
disease.
 In the acute stage it can affect the endocardium, myocardium or the pericardium.
Later it can affect the heart valves leading to chronic valva.
 RHD results as a hypersensitivity reaction in which antibodies produced to fight
streptococci reacts to produce characteristics lesion at specific tissue site.

7
 b) SIGNS/SYMPTOMS
 The patient reports streptococci infection few days to 6 weeks earlier
 There is recent history of a low grade fever, epistaxis and abdominal pain
 Polyarthritis with swollen redness and signs of effusion within the knees, ankles, elbows
or hips
 In case of pericarditis, the patient complain of angina pain
 Patient with severe heart failure will present in pain in the right upper quadrant with a
hacking and non-productive cough.
 There is the presence of subcutaneous noddles that are firm, movable, and non-tender and
about 3mm-2cm in diameter. This occurs around the elbows, wrist and knees.
 If left ventricular failure develops edema and tachypnea are noticed
 Auscultation reveals pericardial friction rub which is a grating sound as a heart (moves
heart murmurs which are abnormal heart sounds) gallops and crackles
 Rapid pulse rate

c) DIAGNOSIS
There is no specific lab test to determine the presence of rheumatic fever but throat culture may
ensure the presence of A- streptococci.
d) TREATMENT
 The drug of choice is penicillin and for one is allergic takes erythromycin
 When effective treatment is carried out the organism is eradicated, symptoms are relieved
reoccurrence is prevented and as such reduced the chances of permanent cardiac damage.
 Salicylates (aspirin) for pain, to reduce fever and minimize the joint pain and swelling
 Corticosteroids if salicylates fails or if fever and inflammation are severe.

e) NURSING INTERVENTION INCLUDE:

 Strict bed rest for up to 5 weeks during the acute stage
 Progressive increase in physical activity is instituted
 After the acute phase have subsided a monthly injection of benzathine penicillin G maybe
given to prevent reoccurrence
 In case of heart failure, continues bed rest is required
 Corrective surgery for severe mitral or aortic valvular dysfunction.

f) NURSING MANAGEMENT
 Check the patient if sensitive before administering penicillin and warn the patient about a
hypersensitivity reaction.
 Antibiotics should be administered on time to maintain a consistent antibiotics levels

8
  Stress on the important of bed rest and assist with bathing if necessary. A bedside
commode is provided because it puts less stress on the heart than using a bed pan.
 Offer diversional activities that are physically undemanding
 The patient is placed in an upright position to relieve tissue hypoxia
 If the patient is unstable because of chorea, clear of surrounding of objects that could be
harmful
 Explain all the test and treatments to the patient
 In case of hemoptysis, bed rest is required, salt restriction is done and diuretics are
administered to decrease pulmonary venous pressure
 Open heart surgery in severe case
 In case of heart failure, bed rest, digoxin, diuretics, sodium diets are instituted and O2 in
acute cases.

g) COMPLICATION
 Destruction of the mitral and aortic valves
 Pericardial effusion
 Heart failure that is fatal

3) MITRAL STENOSIS
Mitral valve stenosis or mitral stenosis is a narrowing of the heart’s mitral valve. This abnormal
valve doesn’t open properly, blocking blood flow to the main pumping chamber of the heart (left
ventricle)
a) CAUSES
 The main cause of MVS is an infection called rheumatic fever which is related to
strep infections which can scar mitral valve. Left untreated, MVS can lead to serious
heart complications.
 Calcium buildup on valves, tumors, radiation treatment, blood clots and congestive
heart disease.

b) SIGNS/SYMPTOMS
You may feel fine with MVS, or you may have minimal symptoms for decades. However mild
problems can suddenly worsen. The patient should see the doctor if the patient develops;

 Shortness of breath, especially with exertion or when you lie down

 Fatigue, especially during increased physically activity
 Swollen feet or legs
 Heart palpitations- sensation of a rapid, fluttering heartbeat
 Dizziness or fainting

9
  Heavy coughing, sometimes with blood- tinged sputum
 Chest discomfort or chest pain
 Severe headache, trouble speaking or other symptoms of stroke
 MVS symptoms may appear or worsen anytime your heart rate increases such as
during exercise: or they may be triggered by pregnancy or other body stress, such
as an infection
 In MS, pressure that builds up in the heart is then sent back to the lungs, resulting
in fluid buildup (congestion) shortness of breath
 Signs that the doctor will find
 Heart murmur
 Fluid build -up in the lungs
 Irregular heart rhythms (arrhymia)

c) DIAGNOSIS

 Physical Exam using a stethoscope: Heart produces sounds such as rumbling and
snapping
 Echocardiogram: An image of the heart’s structure and function produced by
ultrasound waves
 X –rays of heart and lungs (looking at the size of left atrium and whether lungs
are congested)
 Trans esophageal: An image of the heart produce when a device that emits
ultrasound waves is threaded into the esophagus, these picture creates a more
detailed picture than a traditional echo because the esophagus is right behind the
heart
 Stress test: The doctor may have the pt work out, and then monitor the pt while
exercising to determine how the pt heart responds to physical stress.

d) TREATMENT
 Mild MVS doesn’t need any treatment. If MVS is causing symptoms, the Dr
might prescribe medications. Although these do not actually fix the problem with
MVS.
 Anti-coagulants (blood thinners)
 Diuretics (to reduce fluid buildup via increased urine output)
 Anti-arrhythmic (medications to treat abnormal heart rhythms)
 Beta-blockers (medications to slow the heart rate)

10
  Surgery by surgically repairing the existing MV to make it function properly. By
replacing them with a new one either (from a cow, pig or human cadaver).

e) COMPLICATIONS
 Pulmonary hypertension
 Heart failure
 Heart enlargement
 Atrial fibrillation
 Blood clots
 Lung congestion (pulmonary edema)

4) MYOCARDITIS

a) DEFINITION
This is the inflammation of the myocardium that maybe acute or chronic and occurs at
any age. Recovery is usually fast, without any defect.

b) CAUSES
c) Viruses eg HIV, influenza, coxsakie virus A and B
d) Bacteria eg diphtheria, Tb, and tetanus
e) Radiation therapy
f) Chemical poisons eg chronic alcoholism
g) Parasitic infections eg toxoplasmosis, chargarc disease (South American
typanomosis)
h) Helminthic fever eg trichinosis
i) Rheumatic fever

b) SIGNS/SYMPTOMS

 Usually history of recent upper respiratory tract infection without fever, viral
pharyngitis, tonsillitis.
 Nonspecific symptoms such as symptoms which are not peculiar to the heart such
as;
 Fatigue
 Dyspnea
 Persistent tachycardia and fever

11
  Occasionally pt may compliant of mild continuous pressure of soreness in the
chest
 Angina pain that radiates to the shoulders and the back due to the inflammation
 Presence of heart murmurs due to over load working of the heart.
 In case of ventricular failure, pt will present with pulmonary congestion, dyspnea
and tachycardia because there will be backward flow of blood due to failure of the
valves to open and also the failure of the ventricles to contract leading to dyspnea

c) DIAGNOSIS
 Biopsy of the myocardium confirms diagnosis
 Culture of stool or pharyngeal washing or other body fluid may identify the
organism
d) TREATMENTS
 Anti-infective for underlying causative organisms
 Bed rest to decrease the work load of the heart
 Restriction of activity in cases of left ventricular failure, to minimize myocardial
oxygen consumption
 Supplemental O2 therapy if need be
 Sodium restriction
 Administration of anti-arrhythmias drugs (Quinidine) to decrease or to regulate
the cardiac contractivity
 Anti-coagulants for thrombo embolism

e) NURSING INTERVENTION

 Emphasis the importance of bed rest and assist the patient with bedding or
activities that are physically in demanding
 Reduce anxiety by allowing the pt to express his concerns, about the effects of
activity on his responsibilities and reassure him that this is temporary
 Watch of signs of ventricular failure
 Observe for signs of toxicity of digitalis such as anorexia, nausea, vomiting,
blurred vision and cardiac arrhythmias
 Administer parental infective medication as ordered
 Teach the pat taking digitalis at home to check his pulse for1 minute before taking
it and to stop taking if the heart rate falls below 60b/m

f) COMPLICATIONS

 Left ventricular failure

12
  Cardio myopathy
 Chronic valvutitis (inflammation of the valves or heart valves)
 Arrhythmias
 Thrombo embolism

5) CONGESTIVE HEART FAILURE

a) OVERVIEW

With a healthy heart, oxygen-rich blood from the left ventricle is pumped through the body to the
organs to provide them with oxygen and nutrients. After supplying the organs, the oxygen-poor
blood flows back from the body to the right side of the heart, from where it is transported to the
lungs. In the lungs, the blood is enriched with oxygen so that it can once again be pumped
throughout the body via the left ventricle.

b) DEFINITION

Heart failure is a weakening of the heart’s pumping function. Ie a chronic condition in which the
heart doesn’t pump blood as well as it should. It typically affects either the right side of the heart
(right-sided heart failure) or the left side of the heart (left-sided heart failure). In advanced heart
failure, both sides of the heart can be affected (global heart failure). Heart failure can either be
chronic or acute in nature. Chronic heart failure is an advance disease that has been present for
weeks, months or years and is more common than acute heart failure, which occurs suddenly and
unexpectedly. Acute heart failure can suddenly stem from chronic heart failure.

13
c) CAUSES HEART FAILURE?
 Heart failure is caused by diseases that affect or damage the heart muscle. The most
common cause of chronic heart failure is coronary artery disease, particularly after a heart
attack.
 Coronary artery disease (CAD) is triggered by the narrowing of the coronary blood
vessels (coronary arteries), most commonly due to atherosclerosis. The coronary arteries
are the vessels that provide the heart with oxygen and other important nutrients.
Progressive narrowing (also called stenosis) of the arteries leads to circulation
disturbances of the heart muscle. CAD is often first recognized when angina pectoris
(chest pain and tightness) is present, but otherwise it remains unnoticed.
 A heart attack is due to a decrease in circulation of oxygen-rich blood to the heart muscle,
causing the tissue to irreversibly die. This damage affects the pump function of the heart,
leading to heart failure. A large portion of those affected also suffer from high blood
pressure, which additionally intensifies the situation.
 High blood pressure (hypertension) is the sole reason for heart failure in up to 20% of
individuals, making it the second most common cause of this disease. High blood
pressure causes an increased resistance, thereby making the heart continuously pump
harder. The heart is unable to perform under this additional stress over a long period of
time, and therefore loses some of its capacity.
14
  A similar effect can be caused by a heart valve problem. Through narrowed or leaky
aortic valves, the heart must pump stronger or beat more frequently, which also leads to a
chronic increased burden.
 Heart rhythm disorders such as a heart rate that is too low (bradycardia), can also be the
trigger of heart failure, as too little blood is circulated. A heart rate that is too rapid
(tachycardia) is associated with decreased stroke volume and can therefore also lead to
heart failure.
 Hereditary diseases can be the cause of heart failure. Pregnancy, autoimmune disorders,
alcohol, drugs, or misuse of medications, heart rhythm disorders and an overactive
thyroid, as well as metabolic disorders (diabetes mellitus) can all be causes of heart
failure.

d) SYMPTOMS

- Congested lung: Fluid backup in the lungs can cause shortness of breath with exercise
or difficulty breathing at rest or when lying flat in bed. Lung congestion can also
cause dry, hacking cough or wheezing
- Fluid and water retention: less blood to the kidneys causes fluid and water retention,
resulting in swollen ankles, legs, abdomen and weight gain. Bloating in the stomach
may cause loss of appetite or nausea.
- Dizziness, fatigue and weakness
- Rapid or irregular heartbeats

e)TPYES OF HEART FAILURE

Heart failure is divided into the following types:

 Left-sided heart failure

 Right-sided heart failure
 Global heart failure
 Systolic heart failure
 Diastolic heart failure
 Chronic heart failure
 Acute heart failure

Each type of heart failure has different symptoms, and the symptoms can vary in intensity.
However, the main symptom of heart failure is difficulty breathing with physical activity.
Warning signs may include sweating with mild physical activity, the inability to lie flat, chest
tightness or presence of leg swelling.

 Left-sided heart failure

15
The left side of the heart is responsible for pumping oxygen-rich blood throughout the body to
the organs. In left-sided heart failure, the pump function of the left ventricle is restricted, causing
not enough oxygen-rich blood to be pumped throughout the body. The blood instead backs up
just beyond the right ventricle in the pulmonary circulation which can lead to fluid in the lungs
(pulmonary edema), difficulty breathing, throat irritation, a “rattling” sound when breathing,
weakness, or dizziness

It is most often caused by coronary artery disease (CAD), high blood pressure, or heart attack,
and less frequently by a disorder of the heart muscle or heart valves.

Left-sided heart failure can present acutely or may develop over time. When developing over
time, it is usually first noticed when physical activity causes shortness of breath. When severe, it
may even lead to shortness of breath and hypotension (low blood pressure) when at rest.

 Right-sided heart failure

The right side of the heart is responsible for returning oxygen-poor blood back to the lungs so
that gas exchange can occur. In right-sided heart failure, the right ventricle does not work
properly, causing blood that is flowing back to the heart from the body to back up in front of the
heart. This causes an increased pressure in the veins, forcing fluid into the surrounding tissue.
This leads to water retention, or so-called edema, particularly in the feet, toes, ankles and shins.
People often notice edema when taking off tight socks and seeing the imprint still visible on their
skin. It can also lead to a severe need to urinate at night when fluids return to normal circulation
and the kidneys receive better circulation.

The cause is most often an acute or chronic increase in resistance of the pulmonary circulation.
This resistance stems from pulmonary diseases such as pulmonary emboli, asthma, pronounced
emphysema, chronic obstructive pulmonary disorder (COPD, most often due to tobacco use) or
from left-sided heart failure. Rare causes include heart valve problems or heart muscle diseases.

 Global heart failure

When both the left and right sides of the heart are affected, this is known as global heart failure.
Symptoms of both left- and right-sided heart failure are present.

 Systolic and diastolic heart failure

Systolic heart failure deals with an impaired pump or ejection performance (ejection fraction) of
one or both ventricles. This occurs due to the loss of normal functioning heart muscle cells or

16
external disturbances of the pump function. Blood backs up in the lungs and the organs do not
receive an adequate amount of oxygen.

In diastolic heart failure, the heart’s ability to pump is not impacted, but the elasticity of the
ventricle is impaired, causing it to not relax and refill appropriately. One of the most common
causes of diastolic dysfunction is high blood pressure. Through the increased resistance in the
arteries, the heart must pump harder, thereby making the heart muscle thicker and harder. The
elasticity of the heart muscle is reduced, and less blood can be pumped between contractions
from the ventricles into the body. This causes the body to not receive enough blood and
nutrients. A heart valve disease can also lead to thickening of the heart muscle. The heart
musculature becomes stiffer and less elastic due to storage of proteins. The symptoms of
diastolic heart failure may be as simple as coughing, and as severe as difficulty breathing
(dyspnea).

 Chronic and acute heart failure

Chronic heart failure is a progressive disease that has been present for weeks, months or years,
and occurs more often than acute heart failure. In chronic heart failure, the symptoms are often
not taken seriously, as the body has been able to compensate over a long period of time, or the
symptoms are attributed to increasing age. The symptoms reflect either left or right-sided heart
failure.

 Acute heart failure occurs suddenly, within minutes or hours, after a heart attack or a
chronic period of heart failure, when the body can no longer compensate. Some
symptoms include:

 Strong difficulty breathing and/or coughing

 Bubbling sound when breathing
 Rapid heart rate
 Pallor
 Breaking out in cold sweats 

Heart failure significantly decreases quality of life. Those affected often experience a lot of
frustration stemming from physical limitations and tend to withdraw from social life. For this
reason, psychological disorders such as depression are often present in addition to the expected
physical symptoms.

f)  DIAGNOSIS

17
Diagnosis begins with a comprehensive evaluation of the individual’s medical history paying
particular attention to symptoms (beginning, duration, manifestation). This helps to classify the
symptom’s severity. The heart and lungs are examined. If there is suspicion of a heart attack
(acute or old) or rhythm disorder, ECG is performed. Furthermore, an echocardiograph and
general blood tests are performed. The necessity for catheterization is decided on an individual
basis

 An electrocardiogram
 An echocardiogram uses sound waves to record the heart’s structure and motion
 MRI takes pictures of the heart
 Stress tests
 Blood tests
 Cardiac catheterization can show blockages of the coronary arteries

g) TREATMENT
 With chronic heart failure, medications (such as ACE Inhibitors, Beta Blockers and
Diuretics) are implemented. Medications are used to prevent complications and improve
quality of life. ACE Inhibitors and Beta Blockers can be life prolonging, but must be
taken regularly and chronically to have this effect.
 Additionally, rhythm therapies (for treatment of heart rhythm disorders) or three-chamber
pacemakers are also used. The latter provides for timely activation of the atria and both
ventricles. A defibrillator is also often implanted as part of the pacemaker to counteract
dangerous heart rhythm disorders in the setting of severe heart failure. This treatment is
also known as resynchronization therapy. Physical therapy is also an important part of
successful treatment.
h) CONGESTIVE HEART FAILURE STAGES

STAGE MAIN SYMPTOMS OUTLOOK

CLASS I You don’t experience any
symptoms during typical
physical activity
CLASS II You are likely comfortable at
rest, but normal physical
activity may cause fatigue,
palpitations and shortness of
breath
CLASS III You’re likely comfortable at
rest, but there’s a noticeable
CHF at this stage can be
managed through lifestyle
changes, heart medications
and monitoring
CHF at this stage can be
managed via lifestyle
changes, heart meds and
careful monitoring
Treatment can be
complicated. Talk with the

18
 limitation of physical activity.
Even mild exercise may
cause fatigue, palpitations, or
shortness of breath
CLASS IV You’re likely unable to carry
on any amount of physical
activity without symptoms,
which are present even at rest
doctor about what heart
failure at this stage may mean
to the patient
There’s no cure for CHF at
this stage, but there are still
quality of life and palliative
care options. You’ll want to
discuss the potential benefits
and risks of each with your
doctor

I) TREATMENTS
 ACE Inhibitors open up narrowed blood vessels to improve blood flow. Vasodilators are
another option if the pat cannot tolerate ACE Inhibitors eg captopril
 Beta blockers eg atenolol, propranolol
 Diuretic
 surgeries

6) HYPERTENSION
Hypertension is another name for high blood pressure

Blood pressure is the force exerted by the blood against the walls of the blood vessels. The
pressure depends on the work being done by the heart and the resistance of the blood vessels.

a) DEFINITION

Hypertension can also be defined as blood pressure higher than 130 over 80 millimeters of
mercury (mmHg).

b) CAUSES

The cause of hypertension is often not known.

Around 1 in every 20 cases of hypertension is the effect of an underlying condition or

medication.

19
Chronic kidney disease (CKD) is a common cause of high blood pressure because the kidneys do
not filter out fluid. This fluid excess leads to hypertension.

c) RISK FACTORS

A number of risk factors increase the chances of having hypertension.

 Age: Hypertension is more common in people aged over 60 years. With age, blood
pressure can increase steadily as the arteries become stiffer and narrower due to plaque
build-up.
 Ethnicity: Some ethnic groups are more prone to hypertension.
 Size and weight: Being overweight or obese is a key risk factor.
 Alcohol and tobacco use: Consuming large amounts of alcohol regularly can increase a
person's blood pressure, as can smoking tobacco.
 Sex: The lifetime risk is the same for males and females, but men are more prone to
hypertension at a younger age. The prevalence tends to be higher in older women.
 Existing health conditions: Cardiovascular disease, diabetes, chronic kidney disease,
and high cholesterol levels can lead to hypertension, especially as people get older.

Other contributing factors include:

 physical inactivity
 a salt-rich diet associated with processed and fatty foods
 low potassium in the diet
 alcohol and tobacco use
 certain diseases and medications

A family history of high blood pressure and poorly managed stress can also contribute.

Below is a 3-D model of hypertension, which is fully interactive.

Explore the model using your mouse pad or touchscreen to understand more about hypertension.

d) SIGNSAND SYMPTOMS

Blood pressure can be measured by a sphygmomanometer, or blood pressure monitor.

 Having high blood pressure for a short time can be a normal response to many situations.
Acute stress and intense exercise, for example, can briefly elevate blood pressure in a
healthy person.

20
  For this reason, a diagnosis of hypertension normally requires several readings that show
high blood pressure over time.
 The systolic reading of 130 mmHg refers to the pressure as the heart pumps blood around
the body. The diastolic reading of 80 mmHg refers to the pressure as the heart relaxes and
refills with blood.

The AHA 2017 guidelines define the following ranges of blood pressure:

Systolic (mmHg) Diastolic (mmHg)

Normal blood pressure Less than 120 Less than 80
Elevated Between 120 and 129 Less than 80
Stage 1 hypertension Between 130 and 139 Between 80 and 89
Stage 2 hypertension At least 140 At least 90
Hypertensive crisis Over 180 Over 120

If the reading shows a hypertensive crisis when taking blood pressure, wait 2 or 3 minutes and
then repeat the test.

If the reading is the same or higher, this is a medical emergency.

The person should seek immediate attention at the nearest hospital.

 Symptoms

A person with hypertension may not notice any symptoms, and it is often called the "silent
killer." While undetected, it can cause damage to the cardiovascular system and internal organs,
such as the kidneys.

 Regularly checking your blood pressure is vital, as there will usually be no

symptoms to make you aware of the condition.
 It is maintained that high blood pressure causes sweating, anxiety, sleeping problems, and
blushing. However, in most cases, there will be no symptoms at all.
 If blood pressure reaches the level of a hypertensive crisis, a person may experience
headaches and nosebleeds.

e) TYPES OF HYPERTENTION

High blood pressure that is not caused by another condition or disease is called primary or
essential hypertension. If it occurs as a result of another condition, it is called secondary
hypertension.

21
 1) Primary hypertension can result from multiple factors, including blood plasma
volume and activity of the hormones that regulate of blood volume and pressure.
It is also influenced by environmental factors, such as stress and lack of exercise.
2) Secondary hypertension has specific causes and is a complication of another
problem.

f) TREATMENT

Medications
 People with blood pressure higher than 130 over 80 may use medication to treat
hypertension.
 Drugs are usually started one at a time at a low dose. Side effects associated with
antihypertensive drugs are usually minor.
 Eventually, a combination of at least two antihypertensive drugs is usually required.
 A range of drug types are available to help lower blood pressure, including:

 diuretics, including thiazides, chlorthalidone, and indapamide

 beta-blockers and alpha-blockers
 calcium-channel blockers
 central agonists
 peripheral adrenergic inhibitor
 vasodilators
 angiotensin-converting enzyme (ACE) inhibitors
 angiotensin receptor blockers

The choice of drug depends on the individual and any other conditions they may have.

Anyone taking antihypertensive medications should be sure to carefully read labels, especially
before taking any over-the-counter (OTC) medications, such as decongestants. These may
interact with medications used to lower blood pressure.

 NURSING INTERVENTION

Regular health checks are the best way to monitor your blood pressure.

While blood pressure is best regulated through the diet before it reaches the stage of
hypertension, there is a range of treatment options.

22
  Lifestyle adjustments are the standard first-line treatment for hypertension.
Regular physical exercise
 Doctors recommend that patients with hypertension engage in 30 minutes of moderate-
intensity, dynamic, aerobic exercise. This can include walking, jogging, cycling, or
swimming on 5 to 7 days of the week.
Stress reduction
 Avoiding stress, or developing strategies for managing unavoidable stress, can help with
blood pressure control.
 Using alcohol, drugs, smoking, and unhealthy eating to cope with stress will add to
hypertensive problems. These should be avoided.
 Smoking can raise blood pressure. Giving up smoking reduces the risk of hypertension,
heart conditions, and other health issues.
g) COMPLICATIONS

Long-term hypertension can cause complications through atherosclerosis, where the formation of
plaque results in the narrowing of blood vessels. This makes hypertension worse, as the heart
must pump harder to deliver blood to the body.

High blood pressure raises the risk of a number of health problems, including a heart attack.

Hypertension-related atherosclerosis can lead to:

 heart failure and heart attacks

 an aneurysm, or an abnormal bulge in the wall of an artery that can burst, causing severe
bleeding and, in some cases, death
 kidney failure
 stroke
 amputation
 hypertensive retinopathies in the eye, which can lead to blindness

h) PREVENTION

Regular blood pressure testing can help people avoid the more severe complications.

 Diet

Some types of hypertension can be managed through lifestyle and dietary choices, such as
engaging in physical activity, reducing alcohol and tobacco use, and avoiding a high-sodium
diet.

23
  Reducing the amount of salt

Average salt intake is between 9 grams (g) and 12 g per day in most countries around the world.

The WHO recommends reducing intake to under 5 g a day, to help decrease the risk of
hypertension and related health problems.

This can benefit people both with and without hypertension, but those with high blood pressure
will benefit the most.

 Moderating alcohol consumption

Moderate to excessive alcohol consumption is linked to raised blood pressure and an increased
risk of stroke.

The American Heart Association (AHA) recommend a maximum of two drinks a day for men,
and one for women.

 Eating more fruit and vegetables and less fat

People who have or who are at risk of high blood pressure are advised to eat as little saturated
and total fat as possible. Recommended instead are:

 whole-grain, high-fiber foods

 a variety of fruit and vegetables
 beans, pulses, and nuts
 omega-3-rich fish twice a week
 non-tropical vegetable oils, for example, olive oil
 skinless poultry and fish
 low-fat dairy products

It is important to avoid trans-fats, hydrogenated vegetable oils, and animal fats, and to eat
portions of moderate size.

 Managing body weight

Hypertension is closely related to excess body weight, and weight reduction is normally followed
by a fall in blood pressure. A healthy, balanced diet with a calorie intake that matches the
individual's size, sex, and activity level will help.

24
It can result from:

 diabetes, due to both kidney problems and nerve damage

 kidney disease
 pheochromocytoma, a rare cancer of an adrenal gland
 Cushing syndrome, which can be caused by corticosteroid drugs
 congenital adrenal hyperplasia, a disorder of the cortisol-secreting adrenal glands
 hyperthyroidism, or an overactive thyroid gland
 hyperparathyroidism, which affects calcium and phosphorous levels
 pregnancy
 sleep apnea
 obesity

Treating the underlying condition should see an improvement in blood pressure.

QUESTIONS

1)
Explain how the cardiovascular system works

 Define CHF
 What can be the causes of CHF
 What are the clinical manifestations
 Give the investigations carried out
2) What do you understand by
 Rheumatic fever
 The signs/symptoms associated with the disease
 How it can be diagnosed
 Give the medical and nursing management

ANSWERS

1)
a) This system is so vital because its activities defines the present of life. It is
made up of the heart, arteries, veins, capillaries and the lymphatic
system.it is also called life giving transport system, this is so because it
carries life supporting oxygen and nutrients the cells and removes
metabolic waste products and carries hormones from one part of the body
to the other.
This system is divided into two:

25
  Pulmonary circulation

In which deoxygenated blood carrying waste carbon dioxide (CO2) is pumped to the lung to be
send out. And oxygen (O2) in the lunge is being picked up by blood back to the heart to be
pumped to other parts of the body.

 Systemic circulation

In which blood carries oxygen and nutrients to all active cells while transport wastes products to
the kidneys, liver and skin for excretion

 There are four valves in the heart:

 Two valves separate the upper and lower chambers, on the right (tricuspid valve) and on
the left side of the heart (mitral valve).
 Two valves separate the heart from the blood vessels: one is between the heart and the
lungs (pulmonary valve) and the other is between the heart and the aorta
(Aortic valve). These valves consist of flaps called leaflets or cusps that open and close to help
ensure the continued forward flow of blood via the heart.

b)Heart failure is a weakening of the heart’s pumping function. Ie a chronic condition in which
the heart doesn’t pump blood as well as it should. It typically affects either the right side of the
heart (right-sided heart failure) or the left side of the heart (left-sided heart failure). In advanced
heart failure, both sides of the heart can be affected (global heart failure)

c)Heart failure is caused by diseases that affect or damage the heart muscle. The most common
cause of chronic heart failure is coronary artery disease, particularly after a heart attack.

 Coronary artery disease (CAD) is triggered by the narrowing of the coronary blood
vessels (coronary arteries), most commonly due to atherosclerosis. The coronary arteries
are the vessels that provide the heart with oxygen and other important nutrients.
Progressive narrowing (also called stenosis) of the arteries leads to circulation
disturbances of the heart muscle. CAD is often first recognized when angina pectoris
(chest pain and tightness) is present, but otherwise it remains unnoticed.
 A heart attack is due to a decrease in circulation of oxygen-rich blood to the heart muscle,
causing the tissue to irreversibly die. This damage affects the pump function of the heart,
leading to heart failure. A large portion of those affected also suffer from high blood
pressure, which additionally intensifies the situation

26
 CHAPTER TWO

PATHOLOGIES OF THE RESPIRATORY SYSTEM

GENERAL OBJECTIVES

 Students are expected to know the respiratory system and be able to identify when it has
being affected by a pathology

SPECIFIC OBJECTIVES
At the end of the course, students describe:

 The anatomy and physiology of the respiratory system

 List common pathologies of the RS
 State causes of these pathologies
 Give possible nursing interventions of stated pathologies
 Common treatment of the pathologies

a) INTRODUCTION

The respiratory system provides vital gas exchange by distributing air to the alveolar.
Here, pulmonary capillary blood, takes on O2 and gives off CO2.
The respiratory system is divided into the upper respiratory tract (URT) and the lower
respiratory tract (LRT). The conducting passages of the upper respiratory (URT) include:
the nose, with associated structures such as the pharynx and larynx which continues with
the trachea.
The LRT include the trachea, bronchi and the bronchioles.

b) ASSESSMENT OF THE RESPIRATORY

 The patients appearance may provide a due if he looks frail (looking weak) he may have
a chronic disease that impairs appetite.
 If he is diaphoresis, restless, irritable or protective of a painful body part he may be in
acute distress
 Also assess behavior changes that may indicate hypoxia, hypercapnia (the presence in the
blood of an abnormally high concentration of CO2), confusion, lethargy (mental and

27
 physical sluggishness or degree of inactivity), and bizarre behavior, or quite sleep from
which the patients can’t be arouse may signal hypercapnia
 Watch out for marked cyanosis indicated by bluish coloration which may come from
hypoxemia or poor tissue perfusion (poor blood supply to the tissues)
 You also need to check the chest configuration at rest during ventilation.
 You may notice the following deviations
 Pigeon chest: anteriorly display sternum
 Barrel chest: increased anterior display sternum
 Kyphosclosis: it is raised shoulder and scapular, thoracic convexity and altered chest
configuration (which in-turns restrict breathe)
 Observe the patient breathing rate and pattern, certain disorders produces a characteristics
change in breathing pattern.
 An acute respiratory disorder for example can produce

c) COMMON RESPIRATORY PATTERNS

 Tachypnea (rapid breathing)
 Hypopnea (shallow breathing)
 Hyperpnoea (deep breathing)
 Intra cranial lesions can produce cheyne stroke or Boits respiration
 Eupnoea normal respiratory rate and rhythm 12b/m-20b/m for adult and teenagers
 For children ages 2-12yrs is about 20-30b/m
 For neonates 30-50b/m
 Bradypnea slower but irregular respiration but normal during sleep
 Apnea arrested breathing may be periodic
 Cheyne stroke respiration: Respiration gradually becoming faster and deeper than normal
and then slower over 30-170secs
 Biots respiration: Faster and deeper respiration than normal with abrupt pauses each
breath has the same depth. May occur with spinal meningitis or other CNS abnormalities.
 Kuss maul’s respiration: deeper and faster breathing without pauses. In adults more than
20b/m, breathing usually sounds labored (deep breathing resemble sighs) can occur with
a result from renal failure or metabolic acidosis.
 Apneustic breathing: Prolong, grasping inspiration followed by extremely short
inefficient expiration can occur with a result from lesions in the brain respiratory control
center.

28
 d) GENERAL INTERVENTION WITH RESPECT TO THE RESPIRATORY
SYSTEM

1) Position and Posture

Clients with respiratory problem can usually breath more comfortably if they are
positioned so that the head and chest are elevated. Elevating the head and chest
promotes expansion of the lungs and increases the efficiency of respiratory muscles.
A semi fowler’s position may be suited for clients with moderate respiratory distress.
A client who is weak or severely dyspneic is often most comfortable sitting upright,
leaning on a padded over bed table, by resting the arm on the table, the client will
increase the effectiveness of the secondary inspiratory muscles.
2) Environmental Control
The single most important cause of respiratory irritation is cigarette smoke, chronic
pulmonary emphysema as well as lung-cancer are measured problems that are
adversely affecting air pollution and cigarette smoking.
3) Activity and Rest
Some respiratory problem force clients to alter their normal activities of daily living.
Certain acute disorder (eg influenza) require for several days before normal activity is
resumed.
4) Oral Hygiene
Most clients with breathing difficulty breath via the mouth which dries oral mucosa
as the dry mucosa increases the risk of stomatitis and sputum production may also dry
the mouth for this reason oral hygiene is important.
5) Hydration
6) Infection ,Prevention and Control
7) Psychosocial support
8) Respiratory therapy
Oxygen administration is done when ever hypoxia occur or is expected to occur.
There are 3 major indicated for O2 administration.
- Reduce arterial blood O2
- Increase work of breathing
- The need for decreased myocardial work load

1) PLEURISY
a) DEFINTION
It is inflammation of the visceral and parietal pleurae that line the inside of the thoracic cage and
envelope the lungs. It is called pleuritis. This order causes the pleurae to become swollen and

29
congested, hampering pleural fluid transport and increasing friction between the pleural surfaces.
This inflamed membrane can rub together during respiration (particularly inspiration). This result
is severe sharp knife-like pain.
b) CAUSES
It can result from pneumonia, tuberculosis, viruses, rheumatoid arteritis, uremia, Dressler’s
syndrome, pulmonary infarction and chest trauma, as well as systemic lupus erythematosis.

c) CLINICAL MANIFESTATION/ ASSESSMENT FINDINGS

- Patient report with sudden sharp pain that worsens on inspiration. This is due to
the inflammation or irritation of the sensory nerve endings on the parietal pleura
that rub against one another during respiration. Pain may also be so severe that it
limits the person’s movement on the affected site during breathing.
- He may also have dyspnea
- When you auscultate the chest you may hear a characteristic pleural friction rub, a
course creaky sound heard during late inspiration and early expiration.

d) DIAGNOSTIC TEST
- DT rest on patient’s history and the respiratory assessment. DT helps rule out causes and
pinpoint the underlying disorders.
- Electrocardiography rules out CAD
- Chest X-ray can help identify pneumonia
e) TREATMENTS
Symptomatic treatment include:

- Anti-inflammatory agents
- Analgesics and bed rest
- Severe pain may require an intercostal nerve block of two more intercostal nerves
(narcotics can also be given for pain).
- Pleurisy with pleural effusion calls for thoracenthesis which is both a diagnostic
and therapeutic procedure.
f) NURSING INTERVENTION
- Assess the patient for pain every 3 hours and administer anti-tussives and pain
medications. Pain relieve allows for maximum chest expansion.
- Encourage the patient to take deep breaths and 2 cough
- To minimize pain apply firm pressure on the sites of the pain
- Assess respiratory status at least every 4hrs, monitor for complications as fever
increased dyspnea and changes in breath sound
- Allow the pat to have an uninterrupted rest as much as possible

30
 - Pain may impair pt mobility, so help pt perform a range of motion exercise
- If the pt needs thoracenthesis teach him to breath normally and avoid sudden
moving such as coughing or sighing during the procedure
- Monitor his vital signs and watch out for syncope. Also watch out for
bradycardia, hypotension, pain, pulmonary edema being removed so quickly.
- Reassure the pt via out the procedure. After thoracenthesis watch respiratory
distress and signs of pneumothorax (air in the pleura).
- Listen to pt fears and concerns, answer the questions the pt has and remain with
him in period of extreme stress.
- Whenever possible include the pt in the care decision.

2) PNEUMONIAS
a) Definition: Pneumonia is defined as acute inflammation of the lung parenchyma distal to
the terminal bronchioles (consisting of the respiratory bronchiole, alveolar ducts, alveolar
sacs and alveoli). The terms ‘pneumonia’ and ‘pneumonitis’ are often used
synonymously for inflammation of the lungs, while ‘consolidation’ (meaning
solidification) is the term used for gross and radiologic appearance of the lungs in
pneumonia.
b) Pathogenesis:The microorganisms gain entry into the lungs by one of the following four
routes:
 Inhalation of the microbes present in the air.
 Aspiration of organisms from the nasopharynx or oropharynx.
 Haematogenous spread from a distant focus of infection.
 Direct spread from an adjoining site of infection
The normal lung is free of bacteria because of the presence of a number of lung defense
mechanisms at different levels such as nasopharyngeal filtering action, mucociliary action of the
lower respiratory airways, the presence of phagocytosing alveolar macrophages and
immunoglobulins. Failure of these defense mechanisms and presence of certain predisposing
factors result in pneumonias. These conditions are as under:
a. Altered consciousness. The oropharyngeal contents may be aspirated in states causing
unconsciousness e.g. in coma, cranial trauma, seizures, cerebrovascular accidents, drug
overdose, alcoholism etc.
b. Depressed cough and glottic reflexes. Depression of effective cough may allow
aspiration of gastric contents e.g. in old age, pain from trauma or thoracoabdominal
surgery, neuromuscular disease, weakness due to malnutrition, kyphoscoliosis, severe
obstructive pulmonary diseases, endotracheal intubation and tracheostomy.
c. Impaired mucociliary transport. The normal protection offered by mucus-covered
ciliated epithelium in the airways from the larynx to the terminal bronchioles is impaired
or destroyed in many conditions favouring passage of bacteria into the lung parenchyma.

31
 These conditions are cigarette smoking, viral respiratory infections, immotile cilia,
syndrome, inhalation of hot or corrosive gases and old age.
d. Impaired alveolar macrophage function. Pneumonias may occur when alveolar
macrophage function is impaired e.g. by cigarette smoke, hypoxia, starvation, anaemia,
pulmonary oedema and viral respiratory infections.
e. Endobronchial obstruction. The effective clearance mechanism is interfered in
endobronchial obstruction from tumour, foreign body, cystic fibrosis and chronic
bronchitis

3) BACTERIAL PNEUMONIA( BRONCHO PNEUMONIA)

a) DEFINITION
Bacterial infection of the lung parenchyma is the most common cause of pneumonia or
consolidation of one or both the lungs. Two types of acute bacterial pneumonias are
distinguished—lobar pneumonia and broncho-(lobular-) pneumonia, each with distinct etiologic
agent and morphologic changes. Another type distinguished by some workers separately is
confluent pneumonia which combines the features of both lobar and bronchopneumonia and
involves larger (confluent) areas in both the lungs irregularly, while others consider this as a
variant of bronchopneumonia. Lobar pneumonia is an acute bacterial infection of a part of
alobe, the entire lobe, or even two lobes of one or both the lungs. Bronchopneumonia or lobular
pneumonia is infection of the terminal bronchioles that extends into the surrounding alveoli
resulting in patchy consolidation of the lung. The condition is particularly frequent at the
extremes of life (i.e. in infancy and old age), as a terminal event in chronic debilitating diseases
and as a secondary infection following viral respiratory infections such as influenza, measles
etc.

b) Clinical features:
Classically, the onset of lobar pneumonia is sudden. The major symptoms are:
o shaking chills, fever, malaise with pleuritic chest pain, dyspnoea and cough with
expectoration which may be mucoid, purulent or even bloody.

32
 o The common physical findings are fever, tachycardia, and tachypnoea, and sometimes
cyanosis if the patient is severely hypoxaemic.
o There is generally a marked neutrophilic leucocytosis. Blood cultures are positive in
about 30% of cases.
o Chest radiograph may reveal consolidation.
e) Complications. Since the advent of antibiotics, serious complications of lobar
pneumonia are uncommon. However, they may develop in neglected cases and in
patients with impaired immunologic defenses. These are as under:
 There is ingrowth of fibroblasts from the alveolar septa resulting in fibrosed, tough,
airless leathery lung tissue.
 About 5% of treated cases of lobar pneumonia develop inflammation of the pleura with
effusion.
 Less than 1% of treated cases of lobar pneumonia develop encysted pus in the pleural
cavity termed empyema.
 A rare complication of lobar pneumonia is formation of lung abscess, especially when
there is secondary infection by other organisms.
 Occasionally, infection in the lungs and pleural cavity in lobar pneumonia may extend
into the pericardium and the heart causing purulent pericarditis, bacterial endocarditis and
myocarditis.
4) CHRONIC OBSTRUCTIVE PULMONARY DISEASE
a) Definition: Chronic obstructive pulmonary disease (COPD) or chronic obstructive airway
disease (COAD) are commonly used clinical terms for a group of pathological conditions in
which there is chronic, partial or complete, obstruction to the airflow at any level from trachea to
the smallest airways resulting in functional disability of the lungs i.e. they are diffuse lung
diseases. The following 4 entities are included in COPD:
a. Chronic bronchitis
b. Emphysema
c. Bronchial asthma
d. Bronchiectasis
Chronic bronchitis and emphysema are quite common and often occur together in COPD.

 CHRONIC BRONCHITIS

a)Definition: Chronic bronchitis is a common condition defined clinically as persistent cough

with expectoration on most days for at least three months of the year for two or more consecutive
years. The cough is caused by oversecretion of mucus. In spite of its name, chronic inflammation
of the bronchi is not a prominent feature. The condition is more common in middle-aged males
than females; approximately 20% of adult men and 5% of adult women have chronic bronchitis,
but only a minority of them develop serious disabling COPD or cor pulmonale. Quite frequently,
chronic bronchitis is associated with emphysema.

33
b) Etiopathogenesis. The two most important etiologic factors responsible for majority of cases
of chronic bronchitis are: cigarette smoking and atmospheric pollution. Other
contributory factors are occupation, infection, familial and genetic factors.

Figure: Diagrammatic representation of chronic bronchitis.

c) Clinical Features: Some important features of are as under:
Persistent cough with copious expectoration of long duration; initially beginning in a
heavy smoker with ‘morning catarrh’ or ‘throat clearing’ which worsens in winter.
Recurrent respiratory infections are common.
Dyspnoea is generally not prominent at rest but is more on exertion.
Patients are called ‘blue bloaters’ due to cyanosis and oedema.
Features of right heart failure (cor pulmonale) are common.
Chest X-ray shows enlarged heart with prominent

 EMPHYSEMA
a) DEFINTION

The WHO has defined pulmonary emphysema as combination of permanent dilatation of air
spaces distal to the terminal bronchioles and the destruction of the walls of dilated air spaces.
Thus, emphysema is defined morphologically, while chronic bronchitis is defined clinically. The
two conditions coexist frequently and show considerable overlap in their clinical features.
b)Etiology: The association of two conditions is principally linked to the common etiologic
factors— most importantly tobacco smoke and air pollutants. Other less significant contributory
factors are occupational exposure, infection and somewhat poorly-understood familial and
genetic influences. However, pathogenesis of the most significant event in
emphysema is the destruction of the alveolar walls.
c)Clinical features.

34
  There is long history of slowly increasing severe exertional dyspnoea.
 Patient is quite distressed with obvious use of accessory muscles of respiration.
 Chest is barrel-shaped and hyperresonant.
 Cough occurs late after dyspnoea starts and is associated with scanty mucoid sputum.
 Recurrent respiratory infections are not frequent.
 Patients are called ‘pink puffers’ as they remain well oxygenated and have tachypnoea.
 Weight loss is common.
 Chest X-ray shows small heart with hyperinflated lungs.

Figure: The anatomic regions involve in major forms of emphysema

d) NURSING INTERVENTION
- If ordered, perform chest physiotherapy, including postural drainage and chest
percussion and vibration several times daily
- Schedule respiratory treatments at least 1 hour before and after meals
- Provide high calorie-protein rich diet to promote health and healing.
- Make sure the patient receives adequate fluids at least 3 litters per day to loosen
secretions
- Encourage daily activity
- Administer medications as ordered and record the pt response
- Watch for complications, such as respiratory tract infection, spontaneous
pneumothorax, respiratory distress.
- Provide supportive care, and help the patient adjust to lifestyle, changes imposed
by a chronic illness

 BRONCHIAL ASTHMA
a) Definition: Asthma is a disease of airways that is characterised by increased
responsiveness of the tracheobronchial tree to a variety of stimuli resulting in widespread
spasmodic narrowing of the air passages which may be relieved spontaneously or by

35
 therapy. Asthma is an episodic disease manifested clinically by paroxysms of dyspnoea,
cough and wheezing. However, a severe and unremitting form of the disease termed
status asthmaticus may prove fatal.
b) Etiology, Pathogenesis and Types. Based on the stimuli initiating bronchial asthma, two
broad etiologic types are traditionally described: extrinsic (allergic, atopic) and intrinsic
(idiosyncratic, non-atopic) asthma.
Extrinsic (atopic, allergic) asthma. This is the most common type of asthma. It usually
begins in childhood or in early adult life. Most patients of this type of asthma have
personal and/or family history of preceding allergic diseases such as rhinitis, urticaria or
infantile eczema. Hypersensitivity to various extrinsic antigenic substances or ‘allergens’
is usually present in these cases. Most of these allergens cause ill-effects by inhalation
e.g. house dust, pollens, animal danders, moulds etc. Occupational asthma stimulated by
fumes, gases and organic and chemical dusts is a variant of extrinsic asthma.
Intrinsic (idiosyncratic, non-atopic) asthma. This type of asthma develops later in
adult life with negative personal or family history of allergy, negative skin test and
normal serum levels of IgE. Most of these patients develop typical symptom-complex
after an upper respiratory tract infection by viruses. Associated nasal polypi and chronic
bronchitis are commonly present. There are no recognizable allergens but about 10% of
patients become hypersensitive to drugs, most notably to small doses of aspirin (aspirin-
sensitive asthma).
c) Clinical features. Asthmatic patients suffer from episodes of acute exacerbations
interspersed with symptom free periods. Characteristic clinical features are paroxysms of
dyspnoea, cough and wheezing, airflow obstruction, shortness of breath. Most attacks
typically last for a few minutes to hours. When attacks occur continuously it may result in
more serious condition called status asthmaticus.
d) TREATMENTS
Pharmaceutical drugs are selected based on, among other things, the severity of illness and the
frequency of symptoms. Specific medications are based on fast-acting and longing categories.
Bronchodilators are recommended for short term relief of syptoms
Lifestyle modification
Medications are divided in to two general classes: quick relief medications used to treat acute
symptoms; and long term control medication used to prevent further exacerbation

 BRONCHIECTASIS
a) Definition: Bronchiectasis is defined as abnormal and irreversible dilatation of the bronchi
and bronchioles (greater than 2 mm in diameter) developing secondary to inflammatory
weakening of the bronchial walls. The most characteristic clinical manifestation of
bronchiectasis is persistent cough with expectoration of copious amounts of foul-smelling,

36
 purulent sputum. Post-infectious cases commonly develop in childhood and in early adult
life.
b) Etiopathogenesis. The origin of inflammatory destructive process of bronchial walls is
nearly always a result of two basic mechanisms: endobronchial obstruction and infection.
Endobronchial obstruction by foreign body, neoplastic growth or enlarged lymph nodes causes
resorption of air distal to the obstruction with consequent atelectasis and retention of secretions.
Infection may be secondary to local obstruction and impaired systemic defense mechanism
promoting bacterial growth, or infection may be a primary event i.e. bronchiectasis developing
in suppurative necrotizing pneumonia.

Figure. Types of bronchial dilatations in bronchiectasis

c) Clinical features. The clinical manifestations of bronchiectasis typically consist of chronic
cough with foulsmelling sputum production, haemoptysis and recurrent pneumonia. Sinusitis is a
common accompaniment of diffuse bronchiectasis. Late complications occurring in cases
uncontrolled for years include development of clubbing of the fingers, metastatic abscesses
(often to the brain).
5) PNEUMOTHORAX
An accumulation of air in the pleural cavity is called pneumothorax. It may occur in one of the
three circumstances: spontaneous, traumatic and therapeutic.
i) Spontaneous pneumothorax occurs due to spontaneous rupture of alveoli in any form of
pulmonary disease. Most commonly, spontaneous pneumothorax occurs in association with
emphysema, asthma and tuberculosis. Other causes include chronic bronchitis in an old patient,
bronchiectasis, pulmonary infarction and bronchial cancer. In young patients, recurrent
spontaneous rupture of peripheral subpleural blebs may occur without any cause resulting in
disabling condition termed spontaneous idiopathic pneumothorax.

37
ii) Traumatic pneumothorax is caused by trauma to the chest wall or lungs, ruptured
oesophagus or stomach, and surgical operations of the thorax.
iii) Therapeutic (artificial) pneumothorax used to be employed formerly in the treatment of
chronic pulmonary tuberculosis in which air was introduced into the pleural sac so as to collapse
the lung and limit its respiratory movements. The effects of pneumothorax due to any cause
depend upon the amount of air collected in the pleural cavity. If the quantity of air in the pleura
is small, it is resorbed. Larger volume of air collection in the pleural cavity causes dyspnoea and
pain in the chest. Pneumothorax causes lung collapse and pulls the mediastinum to the
unaffected side. Occasionally, the defect in the lungs is such that it acts as flap-valve and allows
entry of air during inspiration but does not permit its escape during expiration, creating tension
pneumothorax which requires urgent relief of pressure so as to relieve severe dyspnoea and
circulatory failure.

 NURSING INTERVENTION

-Listen to the patient’s fear and concerns.

- keep the pt as comfortable as possible
- Administer analgesics as necessary
- Assess the patient’s respiratory status
- watched for complications signaled by pallor, grasping respirations, and sudden chest pain
- Encourage the patient to perform deep breathing exercise every hour when awake
- Carefully monitor vital signs at least every hour of indicated of sock
- Prepare the patient for thoracotomy as indicated

QUESTIONS
2)
a) what is pleurisy
b) what are some its cause
c) how can it be identified with it clinical features
d) what are some the diagnostic measures
e) how can it be treated
f) list some nursing interventions

ANSWERS
1) PLEURISY
a) DEFINTION
It is inflammation of the visceral and parietal pleurae that line the inside of the thoracic cage and
envelope the lungs. It is called pleuritis. This order causes the pleurae to become swollen and

38
congested, hampering pleural fluid transport and increasing friction between the pleural surfaces.
This inflamed membrane can rub together during respiration (particularly inspiration). This result
is severe sharp knife-like pain.

b) CAUSES
It can result from pneumonia, tuberculosis, viruses, rheumatoid arteritis, uremia, Dressler’s
syndrome, pulmonary infarction and chest trauma, as well as systemic lupus erythematosis.
c) CLINICAL MANIFESTATION/ ASSESSMENT FINDINGS
- Patient report with sudden sharp pain that worsens on inspiration. This is due to
the inflammation or irritation of the sensory nerve endings on the parietal pleura
that rub against one another during respiration. Pain may also be so severe that it
limits the person’s movement on the affected site during breathing.
- He may also have dyspnea
- When you auscultate the chest you may hear a characteristic pleural friction rub, a
course creaky sound heard during late inspiration and early expiration.
d) DIAGNOSTIC TEST
- DT rest on patient’s history and the respiratory assessment. DT helps rule out causes and
pinpoint the underlying disorders.
- Electrocardiography rules out CAD
- Chest X-ray can help identify pneumonia
e) TREATMENTS
Symptomatic treatment include:

- Anti-inflammatory agents
- Analgesics and bed rest
- Severe pain may require an intercostal nerve block of two more intercostal nerves
(narcotics can also be given for pain).
- Pleurisy with pleural effusion calls for thoracenthesis which is both a diagnostic
and therapeutic procedure.
3) NURSING INTERVENTION
- Assess the patient for pain every 3 hours and administer anti-tussives and pain
medications. Pain relieve allows for maximum chest expansion.
- Encourage the patient to take deep breaths and 2 cough
- To minimize pain apply firm pressure on the sites of the pain

39
 CHAPTER THREE

PATHOLOGIES OF THE CENTRAL NERVOUS SYSTEM

GENERAL OBJECTIVES

 What do students know about the central nervous system and what are the various
pathologies that affect it

SPECIFIC OBJECTIVE

At the end of this chapter, the students should be able to

Give an over view of the central nervous system
Able to review the functions of the CNS
Be able to know the causes and how to manage a patient suffering from neuritis
Be able to handle an epileptic case with he/she harming themselves
To manage an epileptic case
Be able to draw nursing care plans and nursing teaching to the patient

2)EPILEPSY

a) Definition

Epilepsy is a chronic disorder that causes unprovoked, recurrent seizures. A seizure is a sudden
rush of electrical activity in the brain.

There are two main types of seizures. Generalized seizures affect the whole brain. Focal, or
partial seizures, affect just one part of the brain.

A mild seizure may be difficult to recognize. It can last a few seconds during which you lack
awareness.

40
Stronger seizures can cause spasms and uncontrollable muscle twitches, and can last a few
seconds to several minutes. During a stronger seizure, some people become confused or lose
consciousness. Afterward you may have no memory of it happening.

There are several reasons you might have a seizure. These include:

 high fever
 head trauma
 very low blood sugar
 alcohol withdrawal

There’s no cure for epilepsy, but the disorder can be managed with medications and other
strategies.

b) CAUSES

For 6 out of 10 people with epilepsy, the cause can’t be determined. A variety of things can lead
to seizures.

Possible causes include:

 traumatic brain injury

 scarring on the brain after a brain injury (post-traumatic epilepsy)
 serious illness or very high fever
 stroke, which is a leading cause of epilepsy in people over age 35
 other vascular diseases
 lack of oxygen to the brain
 brain tumor or cyst
 dementia or Alzheimer’s disease
 maternal drug use, prenatal injury, brain malformation, or lack of oxygen at birth
 infectious diseases such as AIDS and meningitis
 genetic or developmental disorders or neurological diseases

Heredity plays a role in some types of epilepsy. In the general population, there’s a 1 percent
chance of developing epilepsy before 20 years of age. If you have a parent whose epilepsy is
linked to genetics, that increases your risk to 2 to 5 percent.

Genetics may also make some people more susceptible to seizures from environmental triggers.

Epilepsy can develop at any age. Diagnosis usually occurs in early childhood or after age 60

41
c) SYMPTOMS

Seizures are the main symptom of epilepsy. Symptoms differ from person to person and
according to the type of seizure.

1) Focal (partial) seizures

A simple partial seizure doesn’t involve loss of consciousness. Symptoms include:

 alterations to sense of taste, smell, sight, hearing, or touch

 dizziness
 tingling and twitching of limbs

2) Complex partial seizures involve loss of awareness or consciousness. Other

symptoms include:

 staring blankly
 unresponsiveness
 performing repetitive movements

3) Generalized seizures
 Generalized seizures involve the whole brain. There are six types:
 Absence seizures, which used to be called “petit mal seizures,” cause a blank stare. This
type of seizure may also cause repetitive movements like lip smacking or blinking.
There’s also usually a short loss of awareness.
 Tonic seizures cause muscle stiffness.
 Atonic seizures lead to loss of muscle control and can make you fall down suddenly.
 Clonic seizures are characterized by repeated, jerky muscle movements of the face, neck,
and arms.
 Myoclonic seizures cause spontaneous quick twitching of the arms and legs.
 Tonic-clonic seizures used to be called “grand mal seizures.” Symptoms include:

 stiffening of the body

 shaking
 loss of bladder or bowel control
 biting of the tongue
 loss of consciousness

42
Following a seizure, you may not remember having one, or you might feel slightly ill for a few
hours.

.e) DIAGNOSIS

 Your medical history and symptoms will help your doctor decide which tests will be
helpful. You’ll probably have a neurological examination to test your motor abilities and
mental functioning.
 In order to diagnose epilepsy, other conditions that cause seizures should be ruled out.
Your doctor will probably order a complete blood count and chemistry of the blood.

Blood tests may be used to look for:

 signs of infectious diseases

 liver and kidney function
 blood glucose levels
 Electroencephalogram (EEG) is the most common test used in diagnosing epilepsy. First,
electrodes are attached to your scalp with a paste. It’s a noninvasive, painless test. You
may be asked to perform a specific task. In some cases, the test is performed during
sleep. The electrodes will record the electrical activity of your brain. Whether you’re
having a seizure or not, changes in normal brain wave patterns are common in epilepsy.

Imaging tests can reveal tumors and other abnormalities that can cause seizures. These tests
might include:

 CT scan
 MRI
 positron emission tomography (PET)
 single-photon emission computerized tomography

Epilepsy is usually diagnosed if you have seizures for no apparent or reversible reason.

d) TREATMENT

Most people can manage epilepsy. Your treatment plan will be based on severity of symptoms,
your health, and how well you respond to therapy.Some treatment options include:

 Anti-epileptic (anticonvulsant, antiseizure) drugs: These medications can reduce the

number of seizures you have. In some people, they eliminate seizures. To be effective,
the medication must be taken exactly as prescribed.

43
  Vagus nerve stimulator: This device is surgically placed under the skin on the chest and
electrically stimulates the nerve that runs through your neck. This can help prevent
seizures.
 Ketogenic diet: More than half of people who don’t respond to medication benefit from
this high fat, low carbohydrate diet.

Brain surgery: The area of the brain that causes seizure activity can be removed or
altered.
 Research into new treatments is ongoing. One treatment that may be available in the
future is deep brain stimulation. It’s a procedure in which electrodes are implanted into
your brain. Then a generator is implanted in your chest. The generator sends electrical
impulses to the brain to help decrease seizures.
 Another avenue of research involves a pacemaker-like device. It would check the pattern
of brain activity and send an electrical charge or drug to stop a seizure.
 Minimally invasive surgeries and radiosurgery are also being investigated.
e) Medications for epilepsy
 The first-line treatment for epilepsy is antiseizure medication. These drugs help reduce
the frequency and severity of seizures. They can’t stop a seizure that’s already in
progress, nor is it a cure for epilepsy.
 The medication is absorbed by the stomach, Then it travels the bloodstream to the brain.
It affects neurotransmitters in a way that reduces the electrical activity that leads to
seizures.
 Antiseizure medications pass through the digestive tract and leave the body through
urine.
 There are many antiseizure drugs on the market. Your doctor can prescribe a single drug
or a combination of drugs, depending on the type of seizures you have.

These medications are generally available in tablet, liquid, or injectable forms and are taken once
or twice a day. You’ll start with the lowest possible dose, which can be adjusted until it starts to
work. These medications must be taken consistently and as prescribed.

Some potential side effects may include:

 fatigue
 dizziness
 skin rash
 poor coordination
 memory problems

Rare, but serious side effects include depression and inflammation of the liver or other organs.

44
Epilepsy is different for everybody, but most people improve with antiseizure medication. Some
children with epilepsy stop having seizures and can stop taking medication.

Is surgery an option for epilepsy management?

 If medication can’t decrease the number of seizures, another option is surgery.

 The most common surgery is a resection. This involves removing the part of the brain
where the seizures start. Most often, the temporal lobe is removed in a procedure known
as temporal lobectomy. In some cases, this can stop seizure activity.
 In some cases, you’ll be kept awake during this surgery. That’s so doctors can talk to you
and avoid removing part of the brain that controls important functions such as vision,
hearing, speech, or movement.
 If the area of the brain is too big or important to remove, there’s another procedure called
multiple subpial transection, or disconnection. The surgeon makes cuts in the brain to
interrupt the nerve pathway. That keeps seizures from spreading to other areas of the
brain.
 After surgery, some people are able to cut down on antiseizure medications or even stop
taking them.
 There are risks to any surgery, including a bad reaction to anesthesia, bleeding, and
infection. Surgery of the brain can sometimes result in cognitive changes. Discuss the
pros and cons of the different procedures with your surgeon and seek a second opinion
before making a final decision.

Dietary recommendations for people with epilepsy

The ketogenic diet is often recommended for children with epilepsy. This diet is low in
carbohydrates and high in fats. The diet forces the body to use fat for energy instead of glucose, a
process called ketosis.

 The diet requires a strict balance between fats, carbohydrates, and protein. That’s why it’s
best to work with a nutritionist or dietitian. Children on this diet must be carefully
monitored by a doctor.
 The ketogenic diet doesn’t benefit everybody. But when followed properly, it’s often
successful in reducing the frequency of seizures. It works better for some types of
epilepsy than others.
 For adolescents and adults with epilepsy, a modified Atkins diet may be recommended.
This diet is also high in fat and involves a controlled carb intake. Because these diets tend
to be low in fiber and high in fat, constipation is a common side effect.Talk to your
doctor before starting a new diet and make sure you’re getting vital nutrients. In any case,
not eating processed foods can help improve your health.

45
 QUESTIONS
1) What is epilepsy
2) List the different types
3) List the various Causes of epilepsy
4) Diagnostic test

ANSWERS
1) Epilepsy is a chronic disorder that causes unprovoked, recurrent seizures. A
seizure is a sudden rush of electrical activity in the brain.
2) There are two main types of seizures. Generalized seizures affect the whole brain.
Focal, or partial seizures, affect just one part of the brain.
 A mild seizure may be difficult to recognize. It can last a few seconds during which you
lack awareness.
 Stronger seizures can cause spasms and uncontrollable muscle twitches, and can last a
few seconds to several minutes. During a stronger seizure, some people become confused
or lose consciousness. Afterward you may have no memory of it happening.

3)Possible causes include:

 traumatic brain injury

 scarring on the brain after a brain injury (post-traumatic epilepsy)
 serious illness or very high fever
 stroke, which is a leading cause of epilepsy in people over age 35
 other vascular diseases
 lack of oxygen to the brain

46
 4)

 CT scan
 MRI
 positron emission tomography (PET)
 single-photon emission computerized tomography

CHAPTER FOUR
PATHOLOGIES OF THE URINARY SYSTEM
GENERAL OBJECTIVE

 Students are to know the urinary system, their functions and the different pathologies
affecting the system and how they can be managed
SPECIFIC OBJECTIVE
At the end of the course, students should be able to:

- State some pathologies of the urinary system

- Be able to know their causes and signs/symptoms
- Give possible nursing intervention/management of the pathologies
- Being able to draw nursing care plans for patients suffering from urinary system
disorders

1) ACUTE RENAL FAILURE (CHRONIC KIDNEY DISEASE)

KIDNEY FAILURE

a) Definition
Kidney failure, also called end-stage renal disease (ESRD), is the last stage of chronic
kidney disease. This is a medical condition that occurs when the kidneys lose the ability to
remove waste and balance fluids. When the kidney fail, it means they have stopped working well
enough for the patient to survive without dialysis or a kidney transplant.

47
 b) Causes
In most cases, KF is caused by other health problem that have done permanent damage to the
kidneys little by little, over time.

 Diabetes is the most common cause of ESRD

 Autoimmune disease such as lupus and IgA nephropathy
 Genetic diseases such as polycystic kidney disease
 Nephrotic syndrome
 Urinary tract problems

Sometimes the kidneys can stop working very suddenly (within 2 days) this type is called acute
kidney failure or acute renal failure(ARF)
Common causes of ARF

 Direct damage to the kidneys

 Ureters become blocked
 Infection
 Severe dehydration
 Blood clot
 Heart attack
 Illegal drugs and drug abuse
 Not enough blood flowing to the kidneys
 Urinary tract problems

This type of kidney failure is not always permanent and the kidney may go back to normal or
almost normal with treatment and if the patient doesn’t have serious health problems
c) Symptoms
CKD usually gets worse slowly, and symptoms may not appear until the kidneys are badly
damaged

 Muscle cramps
 Persistent Nausea/vomiting
 Not feeling hungry
 Fluid retention causing Swelling in the feet and ankles
 Too much urine or not enough urine
 Shortness of breath
 Pain in the chest
 confusion

If the kidneys stop working suddenly (acute kidney failure) it present with

48
 Fluid retention
 Decrease urine output
 Abdominal pain
 Back pain
 Fatigue
 Weakness
 Irregular heartbeat
 Diarrhea
 Fever
 Nosebleeds
 Rash
 Vomiting
Having one or more of the symptoms above may be sign os serious kidney problem
d) Diagnosis
 urine output measurement
 urine test
 Blood test which may reveal rapidly rising levels of urea and creatine. These 2
substances are used to measure kidney function
 Imaging tests; such as ultra sound, CT scan
 Kidney biopsy can be done

e) Treatment
 To balance the amount of fluids in the blood either taking in fluid via IV or sending out
fluid by the help of diuretics
 Medications to control blood potassium. Because if the kidneys aren’t properly filtering
potassium from the blood, the Dr will prescribe calcium, glucose or sodium polystyrene
sulfonate to prevent the accumulation of high potassium in the blood. Too much
potassium cause dangerous irregular heartbeats(arrhythmias) and muscle weakness.
 Medications to restore blood calcium levels. If the levels of calcium in your blood drop
too low the Dr may recommend an infusion of calcium.
 There is no cure for ESRD, but many people live long while on Dialysis or a kidney
transplant. The kidney do many jobs to keep you healthy. Which are
 cleaning the blood
 they also control chemicals and fluid in the body
 help control blood pressure
 help make RBCs. Dialysis can do only some, not all, f the job that a healthy kidney do
f) Complications
 gout
 anemia

49
  bone disease and high phosphorus(hyperphosphatemia)
 heart disease
 hyperkalemia (high potassium)
 fluid build up
 coma
 death

ASSIGMENT CHECK THE STAGES OF CKD AND GENERAL NURSING

INTERVENTION
2) KIDNEY STONE
a) Definition
Your kidneys remove waste and fluid from your blood to make urine. Sometimes, when you
have too much of certain wastes and not enough fluid in your blood, these wastes can build up
and stick together in your kidneys. These clumps of waste are called kidney stones.
b) Causes and risk factors of kidney stones
Anyone can get a kidney stone, but some people are more likely than others to have them. Men
get kidney stones more often than women do

 You may also be more likely to have kidney stones if:

 You have had kidney stones before.
 Someone in your family has had kidney stones.
 You don’t drink enough water.
 You follow a diet high in protein, sodium and/or sugar.
 You are overweight or obese.
 You have had gastric bypass surgery or another intestinal surgery.
 You have polycystic kidney disease or another cystic kidney disease.
 You have a certain condition that causes your urine to contain high levels of cystine,
oxalate, uric acid or calcium.
 You have a condition that causes swelling or irritation in your bowel or your joints.
 You take certain medicines, such as diuretics (water pills) or calcium-based antacids.

c) Symptoms Of Kidney Stones

If you have a very small kidney stone that moves easily through your urinary tract, you may not
have any symptoms, and may never know that you had a kidney stone.
If you have a larger kidney stone, you may notice any of the following symptoms:

50
  Pain while urinating
 Blood in your urine
 Sharp pain in your back or lower abdomen
 Nausea and vomiting

If you are having any of these symptoms, contact your health care provider.
d) Diagnosis/Treatments for kidney stones
 The treatment for a kidney stone depends on the size of the stone, what it is made of,
whether it is causing pain and whether it is blocking your urinary tract. To answer these
questions and to figure out the right treatment for you, your doctor might ask you to have
a urine test, blood test, x-ray and/or CT scan.
 A CT scan sometimes uses contrast dye. If you have ever had a problem with contrast
dye, be sure to tell your doctor about it before you have your CT scan.
 If your test results show that your kidney stone is small, your doctor may tell you to take
pain medicine and drink plenty of fluids to help push the stone through your urinary tract.
If your kidney stone is large, or if it is blocking your urinary tract, additional treatment
may be necessary.
 One treatment option is shock wave lithotripsy. This treatment uses shock waves to break
up the kidney stones into small pieces. After the treatment, the small pieces of the kidney
stone will pass through your urinary tract and out of your body with your urine. This
treatment usually takes 45 minutes to one hour and may be done under general
anesthesia, which means you will be asleep and unable to feel pain.
 Another treatment option is ureteroscopy. This treatment is also done under general
anesthesia. The doctor uses a long tool shaped like a tube to find and remove the stone or
to find and break the stone into small pieces. If the stone is small, the doctor may be able
to remove it. If it is large, it may need to be broken into pieces. In this case, a laser will
be used to break the stone into pieces that are small enough to pass through your urinary
tract.
 In rare cases, a surgery called percutaneous nephrolithotomy is needed to remove a
kidney stone. During the surgery, a tube will be inserted directly into your kidney to
remove the stone. You will need to be in the hospital for two to three days to have and
recover from this treatment.
e) Prevention
The best way to prevent most kidney stones is to drink enough fluids every day. Most people
should drink eight to 12 cups of fluid per day. If you have kidney disease and need to limit
fluids, ask your doctor how much fluid you should have each day. Limiting sodium and animal
protein (meat, eggs) in your diet may also help to prevent kidney stones. If your doctor can find
out what your kidney stone is made of, he or she may be able to give you specific diet
recommendations to help prevent future kidney stones.

51
If you have a health condition that makes you more likely to have kidney stones, your doctor
might tell you to take medicine to treat this condition.
Never start or stop any treatment or diet without talking to your doctor first!
f) Types of kidney stones

 Calcium stones are the most common type of kidney stones. They are usually made of
calcium and oxalate (a natural chemical found in most foods), but are sometimes made of
calcium and phosphate.
 Uric acid stones form when your urine is often too acidic. Uric acid can form stones by
itself or with calcium.
 Struvite stones can happen when you have certain types of urinary tract infections in
which bacteria make ammonia that builds up in your urine. Struvite stones are made of
magnesium, ammonium and phosphate.
 Cystine stones are made of a chemical that your body makes naturally, called cystine.
Cystine stones are very rare, and happen in people who have a genetic disorder that
causes cystine to leak from the kidneys into the urine.
 Kidney stones can be as small as a grain of sand or as large–sometimes larger than–a
pearl. They can stay in your kidneys or travel through your ureters (the tubes that go from
your kidneys to your bladder), and out of your body with your urine. When a kidney
stone moves through your ureters and out your urethra with your urine, it is called
passing a kidney stone. A kidney stone can also get stuck in your urinary tract and block
urine from getting through. When you pass a kidney stone or a large kidney stone blocks
the flow of your urine, it can be very painful.

QUESTIONS

52
 1) What is kidney failure
2) What are the causes
3) List 4 signs and symptoms
4) Treatment plan

1) Definition
Kidney failure, also called end-stage renal disease (ESRD), is the last stage of chronic
kidney disease. This is a medical condition that occurs when the kidneys lose the ability to
remove waste and balance fluids. When the kidney fail, it means they have stopped working well
enough for the patient to survive without dialysis or a kidney transplant.
2) Causes
In most cases, KF is caused by other health problem that have done permanent damage to the
kidneys little by little, over time.

 Diabetes is the most common cause of ESRD

 Autoimmune disease such as lupus and IgA nephropathy
 Genetic diseases such as polycystic kidney disease
 Nephrotic syndrome
 Urinary tract problems
3) Symptoms
CKD usually gets worse slowly, and symptoms may not appear until the kidneys are badly
damaged

 Muscle cramps
 Persistent Nausea/vomiting
 Not feeling hungry
 Fluid retention causing Swelling in the feet and ankles
 Too much urine or not enough urine
4) Treatment
 To balance the amount of fluids in the blood either taking in fluid via IV or sending out
fluid by the help of diuretics
 Medications to control blood potassium. Because if the kidneys aren’t properly filtering
potassium from the blood, the Dr will prescribe calcium, glucose or sodium polystyrene
sulfonate to prevent the accumulation of high potassium in the blood. Too much
potassium cause dangerous irregular heartbeats(arrhythmias) and muscle weakness.
 Medications to restore blood calcium levels. If the levels of calcium in your blood drop
too low the Dr may recommend an infusion of calcium.
 There is no cure for ESRD, but many people live long while on Dialysis or a kidney
transplant. The kidney do many jobs to keep you healthy. Which are

53
  cleaning the blood
 they also control chemicals and fluid in the body

CHAPTER FIVE

PATHOLOGIES OF THE FEMALE/ MALE REPRODUCTIVE SYSTEM

GENERAL OBJECTIVES

 Students are to be able to identify reproductive disease and their management

SPECIFIC OBJECTIVES
Students should be able to

- Define BPH and its out come

- Signs/symptoms of BPH
- Possible causes and treatments

5) BENIGN PROSTATIC HYPERPLASIA

This is a condition that affects the prostate gland in men. ‘Hyperplasia’ means enlargement.
‘Benign’ means the enlargement isn’t caused by cancer or infection.
The prostate helps make semen. It is found between bladder and the urethra. As men ages, the
prostate gland slowly grows bigger. As it gets bigger, it may press on the urethra. This can cause
the flow of urine to be slower and less forceful.
a) CAUSES
The exact cause of BPH isn’t well understood. It appears to be related to aging.
About 50% of men over age 50 have BPH. Up to 90% of men older than 80 have it.
The following factors could increase your risk of BPH.

- Age 40 or older
- Family history
- Being obese
- Heart and circulatory disease
- Type 2 diabetes
- Erectile dysfunction
b) SYMPTOMS
- The need to get up more often at night to urinate
54
 - The need to empty the bladder often during the day
- Difficulty in starting the urine flow
- Dribbling after urination ends
- Decrease in the size and strength of the urine stream
- Incontinence, or lack of control over urination

These symptoms can be caused by other things besides BPH. They may be signs of
more serious diseases, such as a bladder infection or bladder cancer.
c) DIAGNOSIS
 The Doctor will take a complete history of your syptoms.
 He will do a rectal exam to check the prostate
 They will put a gloved, lubricated finger into your rectum to feel size of the prostate
gland
 To make sure that the prostate problem is benign, the doctor may do other tests. He will
test the urine for signs of infection.
 They may do a blood test
 An ultrasound exam or a biopsy of the prostate may also help them make a diagnosis
 There is nothing you can do to prevent or avoid BPH. Recent studies have shown that
increasing physical activity may help. It can lower the frequently of BPH symptoms

d) TREATMENTS
 Treatment for BPH depends on what symptoms you have and how severe they are.
Options include lifestyle changes, medicine, minimally invasive procedures and surgery.
 LIFESTYLE CHANGES
 Reducing liquid intake, especially before going to bed or going out in public
 Avoiding caffeine, alcohol, and over the counter medicines that make the person urinate
more
 Training your bladder to hold urine longer
 Exercising your pelvic floor muscles
 Preventing constipation
 Medicine
 The doctor can prescribe different medicines to treat BPH. Some of these reduce the
symptoms by improving urine flow or reducing blockages in the bladder. Others stop the
growth of or shrink the prostate. Sometimes a combination of different medicines is used.
The Dr will recommend medicine based on the symptoms and condition
 Minimally invasive procedures
 This treatment does not involve surgery. Most of these treatments use heat to destroy
prostate tissue that is pressing on the urethra. They can usually be done by the Dr in his

55
 office. Most are done by inserting a catheter via the urethra to reach the prostate. These
treatment may require local, regional, or general anesthesia. These treatment relieve
symptoms of BPH. They do not cure it.
Surgery which is the most effective it is used in men who have strong symptoms that persist after
trying other treatments. Surgery has risk such as bleeding, infection, or impotence
6) BREAST CANCER

a) DEFINITION
Cancer is a disease in which cells in the body grow, change and multiply out of control. Usually
cancer is named after the body part in which it originated, thus breast cancer refers to the erratic
growth and proliferation of cells that originate in the breast tissue. Breast cancer develops in the
breast tissue, primarily in the milk ducts (ductal carcinoma) or glands (lobular carcinoma). The
cancer is still called and treated as breast cancer even if it is first discovered after the cells have
travelled to other sites (areas) of the body. In those cases, the cancer is referred to as metastases
or advanced breast cancer. The exact cause of breast cancer is not known but the number of risk
factors are sex, age, breastfeeding, bacteria, injury of the breast, high hormone levels, races,
being overweight ,economic status also dietary deficiency and alcohol intake

STAGES OF BREAST CANCER

Cancer stage is based on four characteristics

 The size of the lymph node

 Whether the cancer is invasive or non-invasive
 Whether cancer is in the lymph nodes
 Whether the cancer has spread to the other parts of the body beyond the breast

RISK FACTORS
(a) Risk factors you cannot change
 Gender
Simply being a woman is the main risk factor for developing breast cancer. Men can
develop breast cancer, but this disease is about 100 times more common among women
than men. This is probably because men have less of the female hormones estrogen and
progesterone. This can promote breast cancer growth
Age
The risk of developing breast cancer increases as you get older. About 1 out of 8 invasive
breast cancers are found in women younger than 45,While about 2 to 3 invasive breast
cancers are found in women age 55 or older.
 Genetic risk factors
About 5% to 10% of breast cancer cases are thought to be hereditary, meaning that they
result directly from gene defects (called mutations) inherited from a parent BRCA 1 and

56
 BRCA2 genes. In normal cells these genes help prevent cancer by making protein that
keep the cells from growing abnormally
 Family history of breast cancer
Women whose close blood relatives have this disease are prion to it. Having one first-
degree relative (mother, sister or daughter) with breast cancer approximately doubles a
woman’s risk
 Personal history of breast cancer
A woman with breast cancer in one breast has an increased risk of developing a new
cancer in the other breast or in another part of the same
breast.

 Race and ethnicity

Overall, white women are slightly more likely to develop breast cancer than are African-
American women. Women who are more likely to die of this cancer are African-
American women .
 Dense breast tissue
Breasts are made up of fatty tissue, fibrous tissue and glandular tissue. Someone is said
to have dense breast tissue, when they have more glandular and fibrous tissue and less
fatty tissue. Dense tissue can also make mammogram less accurate .
 Certain benign breast conditions
Women diagnosed with certain benign breast condition might have an increased risk of
breast cancers. Some of these conditions are more closely linked to breast cancer risk
than others.
 Menstrual periods
Women who have had more menstrual cycles because they started menstruating
early(before age 12) and or went through menopause later (after age 55)have a slightly
higher risk of breast cancer
Breast feeding
Some studies suggest that breast feeding may slightly lower breast cancer risk, especially if it
is continued for 1 year and a half to 2years.But this has been a difficult area of study
especially in countries such as the United States, where breast feeding for this long is
common. One explanation for this possible effect may be that breastfeeding reduces a
woman’s total number of life time menstrual cycles .
 Drinking alcohol
The use of alcohol is clearly linked to an increased risk of developing breast cancer. The
risk increases with the amount of alcohol consumed. Excessive alcohol consumption is
also known to increase the risk of developing several other types of cancer
 Being overweight or obese
Being overweight or obese after menopause increase breast cancer risk. Before
menopause, your ovaries produced most of your estrogen and fat tissue produces a small
57
 amount of estrogen. After menopause, most of a woman’s estrogen comes from fat tissue.
Also women who are overweight tend to have higher blood insulin levels. Higher insulin
levels have also been linked to some cancers, including breast cancer
 Physical activity
Evidence is growing that physical activity in the form of exercise reduces breast cancer
risk. The main question is how much exercise is needed. In one study from the women’s
Health Initiative, as little as 1-2 hours per week of walking reduced a woman’s risk by
18% and walking 10 hours a week reduces the risk a little more

2.7 Signs and symptoms of breast cancer

Wide spread use of screening mammogram has increased the number of breast cancers found
before they cause any symptoms. Still, some breast cancers are not found by mammogram, either
because the test was not done or because, even under ideal condition, mammogram does not find
every breast cancer.
Most common symptoms include:

 A new lump or mass that is painless that has irregular edges is more likely to be
cancerous.
 Lump can be tender, soft or rounded.
 The lump can even be painful.

Other possible symptoms of breast cancer include:

 Swelling of all or part of a breast (even if no distinct lump is felt).

 Skin irritation or dimpling.
 Breast or nipple pain.
 Nipple inverted (turning inward)
 Redness scariness or thickening of the of the nipple or breast or breast skin
 Nipple discharge (other than breast milk)
 Sometimes a breast cancer can spread to lymph nodes under the arm or around the
collarbone and cause lymph or swelling there, even before the original tumor in the breast
tissue is large enough to be felt

2.8 DIAGNOSIS OF BREAST CANCER

These tests used to diagnose and monitor patients with breast cancer may include:

 Breast Ultrasound to show whether the lump patients with breast cancer may include
 CT (computerized tomography) Scan to see if the cancer has spread.
 Ductogram; This test, also called a galactogram, helps determine the cause of nipple
discharge

58
  Mammography to screen for breast cancer or help identify the breast lump size
 Breast biopsy, using methods such as needle, aspiration, ultrasound-guided.
 Staging which helps guide future treatment and follow up and gives idea of what to
expect in the future

2.9 NURSING DIAGNOSING OF BREAST CANCER

 Discomfort as evidence of pain
 Weight loss related to altered nutrition
 Altered nutrition less than body requirements related to altered oral mucosal
membrane
 Loss of self esteem related to disease condition
 Anxiety related to fear of unknown
 Knowledge deficit related to lack of education on breast cancer

2.10 NURSING I NTERVENTION OF BREAST CANER

 Describe surgical procedure to alleviate fear.

 Monitor for adverse effects of chemotherapy: bone marrow suppression, nausea and
vomiting, alopecia, weight gain or loss, fatigue , stomatitis, anxiety and depression
 Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough,
nausea, anorexia
 Provide psychological support to the patient throughout the diagnostic and treatment
process
 Involve the patient in planning and treatment
 Describe surgical procedure to alleviate fear
 Prepare the patient for the effects of chemotherapy and plan ahead for alopecia, fatigue.
 Administer antiemetic, prophylactic, as directed for patients receiving chemotherapy.
 Help patient identify and support persons as family or community.
 Suggest to the patient that psychological intervention maybe necessary for anxiety,
depression and sexual problems.
 Teach all women they recommend cancer-screening procedure

In case of surgical intervention the following is done;

PRE-OPERATIVE CARE

 Explain surgical procedure to patient giving importance and disadvantages of procedure

 Sign a consent form
 Prepare patient psychologically and physically for procedure
 Administer pre-operative medications as ordered
 Setup an 1V line
59
  Accompany patient to theatre

POST-OPERATIVE CARE

 Check vital signs immediately as you receive patient from the theatre and every 15-30
minute until patient is fully conscious.
 Check operation side for any bleeding.
 Position patient on a supine position with head turned to one side.
 Raise the side rails of the bed.
 Stay with patient until he is fully is fully conscious.
 Administer medication as ordered.
 Do dressing

2.11 TREATMENT OF BREAST CANCER

Treatment Involve the following:

 Chemotherapy given every 3-4 weeks for 6-9months which usually begins 4 weeks after
surgery. Drugs differ in their mechanisms of action: various combinations are used
example cyclosphosphamid, methotrexate,fluorouracil, doxorubicin, mitoxana etc.
 Hormonal agents may be used in advanced disease to induce remission that last for
months to several years example tamoxifen.

Surgically treatment will involve the following:

 Surgeries include lumpectomy(breast preventing procedure)

 Mastectomy(breast removal) and mammoplasty (reconstructive surgery)
 Endocrine related surgeries to reduce endogenous estrogen as a palliative measure.
 Bone marrow transplantation may be combined with chemotherapy
 Radiation therapy to destroy cancerous tissue
 Biologic therapy, it is also called targeted therapy. Anti-cancer drugs are used to target
certain changes in the cell that can lead to cancer example trastuzumab(herceptine).side
effects of treatments may range from nausea and vomiting to lose of hair especially on
the head.
The various stages can be treated thus:

60
 Table 2: Stages and treatment of breast cancer

STAGES AND TREATMENTS

TYPES

Stage O and DCIS Lumpectomy plus radiation or mastectomy. There is some controversy
on how best to treat DCIS

Stage I and II Lumpectomy plus radiation or mastectomy with some sort of lymph
node removal.
Hormone therapy, chemotherapy and recommended following surgery

Stage III Surgery, possibly followed by chemotherapy, hormone therapy and

biological therapy

Stage IV Surgery, radiation, chemotherapy or a combination of these treatments

2.12 COMPLICATION
 Lymph edema (temporary swelling of the breast), and pains around the area.
 Amputation of one or both breasts
 Hair loss
 Metastasis and Death

61
 INFECTIOUS PATHOLOGY
GAS GANGRENE
DEFINITION
GAS GANGRENE (also known as clostridial myonecrosis and myonecrosis) is a bacterial
infection that produces tissue gas in gangrene. Gangrene is a death body tissue. Clostridial
myonecrosis, a type of gas gangrene, is a fast spreading and potentially life-threatening form of
gangrene caused by a bacterial infection from clostridium bacteria.
CAUSES
 Clostridium perfringens bacterium is the most commonly caused bacteria. In some
cases , it may be caused by group A streptococcus bacteria. The infection occurs
suddenly and spreads quickly.
 They can also develop at a recent surgical or injured site.
 Certain injuries have a higher risk of causing gas gangrene for example, muscle injuries,
wounds that are very deep, wounds that are contaminated with stool or dirt
 These bacteria are soil borne anaerobic bacteria by specific exotoxins. These
microorganisms are opportunistic and in general enter the body through significant skin
breakage.
RISK FACTORS
 Diabetes type ii causing vascular blockage
 Open fracture
 Arterial disease (atherosclerosis)
 Ischemic/thomboses necrosis
 Tumors that block or hoard blood supply

SIGNS/SYMPTOMS
 Fever
 Air under the skin
 Pain in the area around the wound
 Swelling
 Pale skin that quickly turns gray, dark red, purple, or black
 Blisters with foul-smelling discharge
 Excessive sweating

62
  Increased heart rate
 vomiting

DIAGNOSIS
Firstly, the doctor can diagnose gas gangrene by performing physical examination and ordering
various tests
 Skin culture to test the presence of clostridium perfringens and other bacteria
 Blood test to check for abnormally high white blood cell count which indicate an
infection
 Imaging tests, such as X-ray to visualized tissues and check for the presence of gas or
MRI or Arteriogram
 Surgery to evaluate the spread of gas gangrene within the body
TREATMENT
Treatment begins immediately once diagnosis is made;
 High doses of antibiotics will be administered intravenously
 Dead or infected tissues will need to be surgically removed right away
 Dr may also try to repair damaged blood vessels to boost blood flow to the affected area.
 Damaged tissues can also be treated with a type of constructive surgery called skin graft.
 Amputation of a limb may be necessary to prevent infection from spreading to the rest of
the body and a prosthetic limb can be fitted once healing is established.
 Some Dr might use Hyperbaric oxygen therapy to treat gangrene. This type of
therapy involves breathing pure oxygen in a pressurized chamber for about 90
minutes. This therapy is given 2-3 times per day.
 This therapy steadily increases the amount of oxygen in the blood, helping infected
wounds to heal faster.

COMPLICATIONS
Gas gangrene is a very serious condition that often begins unexpectedly and progresses rapidly
 Permanent tissue damage
 Jaundice
 Liver damage
 Kidney failure
 Shock
 Widespread infection
 death

63
 QUESTIONS
Write short notes on the following
1) definition of breast cancer
2) signs/symptoms
3) what is gas gangrene and it cause

ANSWERS
1)Cancer is a disease in which cells in the body grow, change and multiply out of control.
Usually cancer is named after the body part in which it originated, thus breast cancer refers to the
erratic growth and proliferation of cells that originate in the breast tissue. Breast cancer develops
in the breast tissue, primarily in the milk ducts (ductal carcinoma) or glands (lobular carcinoma).
2)

 Gender
Simply being a woman is the main risk factor for developing breast cancer. Men can
develop breast cancer, but this disease is about 100 times more common among women
than men. This is probably because men have less of the female hormones estrogen and
progesterone. This can promote breast cancer growth
Age
The risk of developing breast cancer increases as you get older. About 1 out of 8 invasive
breast cancers are found in women younger than 45,While about 2 to 3 invasive breast
cancers are found in women age 55 or older.
 Genetic risk factors

64
 About 5% to 10% of breast cancer cases are thought to be hereditary, meaning that they
result directly from gene defects (called mutations) inherited from a parent BRCA 1 and
BRCA2 genes. In normal cells these genes help prevent cancer by making protein that
keep the cells from growing abnormally
1) GAS GANGRENE (also known as clostridial myonecrosis and myonecrosis) is a
bacterial infection that produces tissue gas in gangrene. Gangrene is a death body tissue.
Clostridial myonecrosis, a type of gas gangrene, is a fast spreading and potentially life-
threatening form of gangrene caused by a bacterial infection from clostridium bacteria.
3)CAUSES
 Clostridium perfringens bacterium is the most commonly caused bacteria. In some
cases , it may be caused by group A streptococcus bacteria. The infection occurs
suddenly and spreads quickly.

65