MS REVIEWER FINALS Pathophysiology

 Precipitating factors
 Viruses
HEPATITIS
 IV Drug use
Viral Hepatitis  Contaminated blood
 Water or Blood
 Viral hepatitis is liver inflammation caused by
 Alcohol
a viral infection and it can either be acute or
 Inflammation of liver
chronic, and five important causes are
hepatitis A, B, C, D and E.  Liver cell destruction/hepatocyte damage
 Liver enlargement
 Necrosis of liver acini cells
Types of Hepatitis (Hepatitis A, B, C, D and E)  Monunuclear infiltrates
 Autolysis
 Hepatitis A is always an acute, short-term  Anorexia, nausea, vomiting,
disease, while hepatitis B, C, and D are urticarial, rashes, arthralgias
most likely to become ongoing and  Decreased ability to remove toxins from
chronic.  Increased bilirubin levels
 Hepatitis E is usually acute but can be  Darkened urine, jaundice
particularly dangerous in pregnant women.  Scarring of liver
 The hepatitis A and E viruses typically  Continued hepatic failure
cause only acute, or short-term,  Encephalopathy
infections.  Coma
Types Transmission Prevention  Death
Hepatitis A Oral/fecal Hand washing
(HAV) contaminated HAV vaccine
food or water HEPATITIS A
Hepatitis B Infected blood, Hand washing
(HBV) sex, and HBV vaccine  Hepatitis A, formerly called infectious
needles. hepatitis, is caused by an RNA virus of the
Infected enterovirus family.
mother to  HAV is transmitted primarily through the
newborn fecal–oral route, by the ingestion of food or
Hepatitis C Infected blood Hand washing liquids infected with the virus. It is more
(HCV) and needles No vaccine prevalent in countries with overcrowding and
Hepatitis D Infected blood, Hand washing poor sanitation.
(HDV) sex, and No vaccine
 The virus has been found in the stool of
needles.
Infected infected patients before the onset of
mother to symptoms and during the first few days of
newborn illness.
Hepatitis E Contaminated Hand washing
Transmission
(HEV) water No vaccine
 Hepatitis A can be spread from close,
Acute Hepatitis personal contact with an infected person,
such as through certain types of sexual
 Acute viral hepatitis lasts for less than six contact (like oral-anal sex), caring for
months and the individual has nausea, someone who is ill, or using drugs with
vomiting, and right upper quadrant pain. others.
 Sometimes if there’s a high total bilirubin, it  Hepatitis A is very contagious, and people
can lead to jaundice, pruritus, dark urine, and can even spread the virus before they feel
clay- colored stools. sick.

Chronic Viral Hepatitis Clinical manifestations

 Chronic viral hepatitis lasts for more than six
months and the individual can sometimes be
asymptomatic.
 Other times, chronic viral hepatitis can cause
fever, fatigue, and loss of appetite, as well as
extrahepatic symptoms like arthralgias and
skin rashes.
 Many patients are anicteric (without
jaundice) and symptomless.
 When symptoms appear, they resemble
those of a mild, flu-like upper respiratory tract
infection, with low-grade fever.
 Anorexia, an early symptom, is often severe.
It is thought to result from release of a toxin
by the damaged liver or from failure of the
 damaged liver cells to detoxify an abnormal
product.
 Later, jaundice and dark urine may become
apparent.
 Indigestion is present in varying degrees,
marked by vague epigastric distress,
nausea, heartburn, and flatulence.
Assessment and Diagnostic Findings
 Stool analysis for hepatitis A antigen
 Serum hepatitis A virus antibodies;
immunoglobulin
Prevention of Hepatitis A
 Encourage conscientious individual hygiene.
Encourage proper community and home
sanitation.
 Hepatitis Vaccine
 Administration of immune globulin
 Immune globulin vaccination recommended
for household members and for those in
sexual contact with people with Hepatitis A.
 Educate patients regarding safe practices for
preparing and dispensing food.
 Facilitate mandatory reporting of viral
hepatitis to local health departments.
 Promote community health education
programs.
 Promote vaccination to interrupt community-
wide outbreaks.
 Recommend pre-exposure vaccination for all
children 12– 23 months of age. Continue
existing immunization programs for children
1–18 years of age.
Nursing Management
 Encourage a nutritious diet, as well as bed
rest during the acute stage.
 Provide small, frequent feedings
supplemented by IV glucose if necessary
during period of anorexia.
 Promote gradual but progressive ambulation
to hasten recovery. Patient is usually
managed at home unless symptoms severe.
 Assist patient and family to cope with
temporary disability and fatigue, both
common problems associated with hepatitis.
 Educate patient and family about seeking
additional health care if the symptoms persist
or worsen.
 Instruct patient and family regarding diet,
rest, follow-up blood work, avoidance of
alcohol, and sanitation and hygiene
measures to prevent the spread of disease.
 Educate patient and family about reducing
risk for contracting hepatitis A.
Medical Management
 Bed rest during the acute stage and a
nutritious diet are important aspects of
treatment.
 During the period of anorexia, the patient
should receive frequent small feedings,
supplemented if necessary by IV fluids with
glucose.
 The patient’s sense of well-being and
laboratory test results are generally
appropriate guides to bed rest and restriction
of physical activity.
 Gradual but progressive ambulation hastens
recovery, provided the patient rests after
activity and does not participate in activities
to the point of fatigue
HEPATITIS B (HBV)
 Hepatitis B is a systemic, viral infection in
which necrosis and inflammation of liver cells
produce a characteristic cluster of clinical,
biochemical, and cellular changes.
 It is caused by a double- stranded DNA virus
called, the hepatitis B virus (HBV).
Transmission
 Hepatitis B Virus unlike HAV, the HBV is
transmitted primarily through blood
(percutaneous and permucosal routes).
 HBV can be found in blood, saliva, semen,
and vaginal secretions and can be
transmitted through mucous membranes and
breaks in the skin.
 HBV is also transferred from carrier mothers
to their infants, especially in areas with a high
incidence (e.g., Southeast Asia).
 The infection usually is not transmitted via
the umbilical vein but from the mother at the
time of birth and during close contact
afterward.
Clinical Manifestations
 Abdominal pain
 Dark urine
 Fever
 Joint pain
 Loss of appetite
 Nausea and vomiting
 Weakness and fatigue
 Yellowing of your skin and the whites of your
eyes (jaundice)
Diagnostic Procedures
Your doctor will examine you and look for signs of
liver damage, such as yellowing skin or belly pain.
Tests that can help diagnose hepatitis B or its
complications are:
 Blood tests. Blood tests can detect signs of
the hepatitis B virus in your body and tell your
doctor whether it's acute or chronic.
 Liver ultrasound. A special ultrasound
called transient elastography can show the
amount of liver damage.
  Liver biopsy. Your doctor might remove a
small sample of your liver for testing (liver
biopsy) to check for liver damage.
 Complete Blood Count. RBCs are
decreased because of shortened life span of
RBCs. WBCs may be abnormally low
(leukopenia) or high (leukocytosis);
monocytes may be increased (monocytosis),
and lymphocytes may be increased and
atypical in appearance.
 Urinalysis. Checks the urine for bilirubin for
the nonjaundiced client. Elevated bilirubin
levels and proteinuria and hematuria may
occur.
 Stool analysis. Clay-colored stools indicate
lack of normal bile excretion into the
intestine.
 Prothrombin Time (PT). Evaluates the
body’s ability to produce a clot in a
reasonable amount of time.
 Serum bilirubin high level. Indicates the
liver is incapable of adequately removing
bilirubin in a timely manner due to blockage
of bile ducts or liver disease, such as acute
hepatitis.
 Liver Scan. May be indicated for differential
diagnosis, to identify underlying chronic liver
disease, or for evaluating organ function.
Helps estimate the severity of parenchymal
damage.
 Screening for HBV. Screening tests attempt
to find a disease before a person develops
symptoms. Many people with hepatitis B
have no symptoms, so screening for this
disease enables early detection so that
patients can receive treatment and avoid
unknowingly spreading the virus to others.
Initial Tests for HBV
Initial tests for hepatitis B measure antibodies and
antigens related to HBV including:
 Hepatitis B surface antigen (HBsAg)
 Hepatitis B surface antibody (anti-HBs)
 Total hepatitis B core antibody (anti-HBc)
 IgM Hepatitis B core antibody (IgM antiHBc)
If a patient is diagnosed with hepatitis B based on
these initial tests, additional hepatitis B testing may
be used to monitor the disease, guide treatment, and
determine if a person can spread hepatitis B to
others. These additional tests may include:
 Hepatitis B e antigen (HBeAg)
 Hepatitis B e antibody (anti-HBe)
 Hepatitis B viral DNA
Nursing Management
 The nurse educates family members and
friends who have had intimate contact with
the patient about the risks of contracting HBV
and makes arrangements for them to receive
hepatitis B vaccine or HBIG as prescribed.
 Encourage those at risk must be made aware
of the early signs of HBV and of ways to
reduce risk by avoiding all modes of
transmission.
 Advice patients with all forms of hepatitis
should avoid drinking alcohol
Nursing Management (Continuing and Transitional
Care)
 During a home visit, the nurse assesses the
patient’s physical and psychological status
and confirms that the patient and family
understand the importance of adequate rest
and nutrition.
 The nurse also reinforces previous
education. Because of the risk of
transmission through sexual intercourse,
strategies to prevent exchange of body fluids
are recommended, such as abstinence or
the use of condoms.
 The nurse emphasizes the importance of
keeping follow-up appointments and
participating in other health promotion
activities and recommended health
screenings.
Gerontologic Considerations
 The immune system is altered in the aged. A
less responsive immune system may be
responsible for the increased incidence and
severity of HBV among older adults and the
increased incidence of liver abscesses
secondary to decreased phagocytosis by the
Kupffer cells.
 The older patient with HBV has a serious risk
of severe liver cell necrosis or fulminant
hepatic failure, particularly if other illnesses
are present. With the advent of an HBV
vaccine as the standard for prevention, the
incidence of hepatic diseases may decrease
in the future.
Medical Management
 Alpha-interferon
- is the single modality of therapy that offers
the most promise of all agents that has been
used to treat chronic hepatitis B.
 Lamivudine (Epivir)
- an antiviral agent. -have revealed improved
seroconversion rates, loss of detectable
virus, improved liver function, and reduced
progression to cirrhosis
 Adefovir (Hepsera)
- an antiviral agent
- may be effective in people who are resistant
to lamivudine.
 Antacids and Antiemetics
- measures to control the dyspeptic
symptoms and general malaise.
HEPATITIS C
 Hepatitis C which is caused by hepatitis C
virus and can cause acute or chronic
hepatitis.
 It’s caused by contact with blood - like
sharing needles or syringes, and contact with
body fluids - like unprotected sex and during
passing from mother to child during labor and
delivery.
 Hepatitis C can cause extrahepatic
manifestations like cryoglobulinemia -
which is where the blood viscosity is high and
causes headaches and confusion,
membrano proliferative glomerulonephritis
and dermatologic conditions, such as
porphyria cutanea tarda which can cause
erosions and blisters.
Transmission
The hepatitis C virus is a blood borne virus. It is most
commonly transmitted through:
 the reuse or inadequate sterilization of
medical equipment, especially syringes and
needles in healthcare settings;
 the transfusion of unscreened blood and
blood products; and
 injecting drug use through the sharing of
injection equipment.
HCV can be passed from an infected mother to her
baby and via sexual practices that lead to exposure
to blood (for example, people with multiple sexual
partners and among men who have sex with men);
however, these modes of transmission are less
common. Hepatitis C is not spread through breast
milk, food, water or casual contact such as hugging,
kissing and sharing food or drinks with an infected
person.
Clinical Manifestations
The disease is called acute hepatitis C when you first
get it. The symptoms are similar to those of the flu,
but you might not have symptoms at all. If you do,
they may include:
 Belly pain
 Clay-colored poop
 Dark urine
 Fatigue
 Fever
 Jaundice (yellow tint to your skin or eyes)
 Joint pain
 Poor appetite
 Nausea
 Vomiting
Symptoms usually show up between 2 and 12
weeks
Chronic hepatitis C is often difficult to diagnose
because most people have no early symptoms.
Early symptoms can include:
 Fatigue
 Muscle aches
 Loss of appetite
Most symptoms of chronic hepatitis C don’t appear
until cirrhosis (severe scarring of the liver) develops
and the liver begins to fail. These symptoms can
include:
 Weakness
 Weight loss
 Blood clotting problems
Assessment and Diagnostic Findings
 This blood test is the first - and sometimes
only - one you may get. Also called the
ELISA screen, it checks for antibodies that
your body releases to fight the virus. These
are proteins your body makes when it finds
the hep C virus in your blood.
What does it mean?
Negative (non-reactive)
 This is when your blood shows no signs of
HCV antibodies. Most of the time, that’s
because you never came in contact with the
virus and you do not have hep C.
Sometimes, your negative result can be false,
meaning you have HCV. That may happen if you:
 Took the test too soon after your exposure.
This test checks for only HCV antibodies,
which can take several months to appear.
 Have HIV, a donated organ, or other
conditions that weaken your immune system,
which can suppress your antibodies.
 Get hemodialysis for kidney problems
If you’ve been exposed in the last 6 months, you’ll
need to be retested.
Positive (reactive)
This means you’ve been infected with HCV. But
false positives are surprisingly common.
More than 1 in 5 people who test positive don’t
actually have hepatitis C. Possible reasons include:
 In as many as 1 in 4 people, the HCV goes
away without treatment. But even after this
“natural clearance,” the HCV antibodies will
always be in your blood.
 The test may mistake HCV antibodies for
those for lupus, rheumatoid arthritis, and
other conditions.
 Babies born to mothers with hep C probably
have HCV antibodies. But most newborns
aren’t actually infected.
No test is foolproof. False positive errors happen
more often in groups of people -- like medical
workers stuck with tainted needles -- who have low
odds of having HCV.
If your antibody test is positive, you’ll need to have a
different kind of test:
 RNA. This test measures the number of viral
RNA (genetic material from the hepatitis
virus) particles in your blood, also called the
“viral load.” The RNA test is almost 100%
accurate and can detect an infection within a
couple of weeks after exposure.
Tests after the Diagnosis
Once the doctor knows you have hep C, they’ll do
tests to find out more about your condition. This will
help determine your treatment. They could include:
 Genotype tests to find out which of the six
kinds (genotypes) of hepatitis C you have.
 Liver function tests. They measure
proteins and enzymes levels, which usually
rise 7 to 8 weeks after you’re infected. As
your liver gets damaged, enzymes leak into
your bloodstream. But you can have normal
enzyme levels and still have hepatitis C.
Tests to check for liver damage. You might get:
 Elastography. Doctors use a special
ultrasound machine to feel how stiff your liver
is.
 Liver biopsy. The doctor inserts a needle
into your liver to take a tiny piece to examine
in the lab.
 Imaging tests. These use various methods
to take pictures or show images of your
insides. They include:
 CT scan
 Magnetic resonance imaging (MRI)
 Magnetic resonance elastography (MRE)
 Ultrasound
Prevention
 Advise avoidance of high-risk behaviors
such as IV drug use. Avoid multi-dose vials
in patient care settings.
 Monitor cleaning, disinfection, and
sterilization of reusable devices in patient
care settings.
 Use barrier precautions in situations of
contact with blood or body fluids.
 Use needleless IV and injection systems in
health care. Use standard precautions in
clinical care.
Risk Factors
 Hepatitis C Children born to women infected
with hepatitis C virus.
 Health care and public safety workers after
needlestick injuries or mucosal exposure to
blood.
 Multiple contacts with a hepatitis C virus–
infected person Multiple sex partners, history
of sexually transmitted infection, unprotected
sex.
 Past/current illicit IV/injection drug use
Nursing Management
 Inform the patient and family members about
the nature of the disease if the patient is
taken care at home.
 Assist is paracentesis if indicated.
 Patients with cirrhosis could be in deep pain
and discomfort, use of analgesics should be
administered with great caution since it can
worsen the liver damage.
 Diversionary therapy and non-
pharmacological approach should be applied
in managing pain.
 Ongoing monitoring of vital signs, abdominal
girth and reminding for the routine check-up
must be emphasized for effective
management.
 Educate patient and family about reducing
risk for contracting hepatitis C.
Medical Management
 A combination of two antiviral agents,
Peginterferon and Ribavirin (Rebetol),
was effective in producing improvement in
patients with hepatitis C and intreating
relapses
 Daclatasvir (Daklinza):
Approval of this drug meant no more shots
for the 1 in 10 people infected with hepatitis
C virus (HCV) types 1 and 3. You take this
pill once a day with sofosbuvir (Sovaldi). You
might get a headache or feel a little tired. Tell
your doctor if you feel super-sluggish.
 Elbasvir and grazoprevir (Zepatier):
This once-a-day pill treats HCV types 1 and
4. It may also offer new hope for people with
hep C who also have cirrhosis, HIV, late-
stage kidney disease, and other hard-totreat
conditions. Like the other antivirals, the side
effects are mild. You might have a slight
headache or bellyache, or you might feel
tired.
 Glecaprevir and pibrentasvir (Mavyret):
Three pills daily can treat all types of hep C.
Side effects are mild and can include
headache, fatigue, diarrhea, and nausea.
 Ledipasvir and sofosbuvir (Harvoni):
This once-a-day pill launched a revolution in
hep C treatment. It was the first interferon-
free med for people with type 1. A year later,
the FDA also gave the thumbs up for people
with HCV types 4, 5, and 6 to use it. Side
effects are mild. You might feel tired or have
a slight headache. Some people have a
bellyache, diarrhea, and trouble sleeping.
 Ombitasvir, paritaprevir, and ritonavir,
with dasabuvir (Viekira Pak):
Doctors say this treatment works well for
people with HCV type 1. You can even take
it if you have some liver scarring, as long as
your liver still can do its job. Your doctor
might call this compensated cirrhosis. You
 take two pills once a day and another pill
twice a day.
 Simeprevir (Olysio)and sofosbuvir
(Sovaldi):
The FDA said these two drugs could be given
together to treat people with HCV type 1.
Before that, you had to take the pills with
interferon or ribavirin. Sofosbuvir can cause
fatigue, headache, and tummy troubles and
make it hard for you to sleep. Simeprevir may
cause dry skin and a rash and make you
more sensitive to sunlight.
 Sofosbuvir and velpatasvir (Epclusa):
This can treat all types of hep C with a single
tablet. Common side effects are headache
and fatigue. There are certain drugs that
shouldn't be taken with it, as the combination
can slow your heartbeat. As always, check
with your doctor.
 Sofosbuvir, velpatasvir, and voxilaprevir
(Vosevi):
This can also treat all types of hep C with one
tablet that you take each day. Typically, your
doctor will only prescribe this if you don't
have cirrhosis and after other treatments
have not worked. The most common side
effects are headache, tiredness, diarrhea,
and nausea
DELTA HEPATITIS
 Hepatitis D which can cause acute or chronic
hepatitis, is caused by hepatitis D virus- or
HDV- which is a defective virus that needs
HBV to cause an infection, because HBsAg
makes up the outer envelope within which
the HDV genome resides.
 Hepatitis D virus (HDV) infections occur only
in those who are infected with HBV. The dual
infection of HDV and HBV can result in a
more serious disease and worse outcome.
Hepatitis B vaccines provide protection from
HDV infection.
Transmission
 The routes of HDV transmission, like HBV,
occur through broken skin (via injection,
tattooing etc.) or through contact with
infected blood or blood products.
 Transmission from mother to child is possible
but rare. Vaccination against HBV prevents
HDV coinfection and hence expansion of
childhood HBV immunization programmes
has resulted in a decline in hepatitis D
incidence worldwide.
Clinical Manifestations
The symptoms of hepatitis B and hepatitis D are
similar, so it can be difficult to determine which
disease is causing your symptoms. In some cases,
hepatitis D can make the symptoms of hepatitis B
worse. It can also cause symptoms in people who
have hepatitis B but who never had symptoms.
 Yellow skin and eyes (jaundice)
 Stomach upset
 Pain in your belly
 Throwing up Fatigue
 Not feeling hungry
 Joint pain
 Dark urine
 Light-colored stool
Early Signs and Symptoms of Acute Hepatitis D
People with acute hepatitis D may have the following
symptoms:
 fatigue
 loss of appetite
 pain in the upper right abdomen, over the
liver dark urine
 lighter stools
 nausea vomiting
 yellowing of the skin and whites of the eyes
(jaundice)
Chronic Hepatitis D Symptoms
People with chronic hepatitis D may not notice any
symptoms even after years of living with the virus.
Over time, however, they may notice symptoms from
complications of the infection, such as severe
damage to the liver. Signs and symptoms of liver
damage include:
 fatigue
 unexplained weight loss
 weakness
 itchy skin
 a swollen abdomen
 swollen ankles
 yellowing of the skin and whites of the eyes
Assessment and Diagnostic Findings
 Anti-delta antibodies in the presence of
HBAg on testing confirm the diagnosis.
 Because cases of hepatitis D are not
clinically distinguishable from other types of
acute viral hepatitis, diagnosis can be
confirmed only by testing for the presence of
antibodies against HDV and/or HDV RNA.
HDV infection should be considered in any
person with a positive hepatitis B surface
antigen (HBsAg) who has severe symptoms
of hepatitis or acute exacerbations.
Prevention
While there are no vaccines available for this virus,
getting vaccinated against hepatitis B will protect
you against hepatitis D. If you have not been
vaccinated against hepatitis B, you can reduce the
risk of hepatitis D infection by taking the following
precautions.
 Avoid sharing drug equipment, such as
needles, spoons, filters, cookers, pipes, and
straws.
  Practice safe sex. Use condoms and dental
dams to reduce the risk of getting a sexually
transmitted infection, including Hepatitis B.
 Avoid dental, medical or cosmetic
procedures that penetrate the skin with
unsterilized equipment. Procedures can
include: blood transfusions, acupuncture,
piercings, and tattoos.
 Wear latex gloves if you are likely to be in
contact with someone else's blood or bodily
fluids.
 Avoid sharing personal items with infected
persons, such as razors, scissors, nail
clippers, and toothbrushes.
Be especially careful to follow these precautions
when travelling abroad in countries where hepatitis
B is widespread. Also know that cleaning shared
items with bleach may not kill hepatitis B.
Risk Factors
Since HDV requires the support of hepatitis B virus
for its own replication, inoculation with HDV in the
absence of HBV will not cause hepatitis D. Alone,
the viral genome replicates in a helperindependent
manner, but the viral particles do not exit the cell.
When in the presence of hepatitis B virus, risk
factors for hepatitis D include:
 Using intravenous (IV) or injection drugs
 Being infected while pregnant (the mother
can pass the virus to the baby)
 Carrying the hepatitis B virus
 Men having sexual intercourse with other
men
 Sexual intercourse with HDV infected
persons
 Receiving many blood transfusions
 People exposed to unscreened blood or
blood products
 Haemophiliacs
 Hemodialysis patients
 Health care and public safety workers
 Individuals who are not infected with HBV,
and have not been immunized against HBV,
are at risk of infection with HBV with
simultaneous or subsequent infection with
HDV.
Nursing Management
1. Inform the patient and family members about
the nature of the disease if the patient is
taken care at home.
2. Assist is paracentesis if indicated.
3. Patients with cirrhosis could be in deep pain
and discomfort, use of analgesics should be
administered with great caution since it can
worsen the liver damage.
4. Diversionary therapy and non-
pharmacological approach should be applied
in managing pain.
5. Ongoing monitoring of vital signs, abdominal
girth and reminding for the routine check-up
must be emphasized for effective
management.
Medical Management
 Currently, interferon alfa is the only licensed
drug available in the treatment for HDV
infection. The rate of recurrence is high, and
the efficacy of interferon is related to the
dose and duration of treatment. High-dose,
long-duration therapy for at least a year is
recommended.
HEPATITIS E VIRUS
 Hepatitis E is inflammation of the liver
caused by the hepatitis E virus (HEV). The
virus has at least 4 different types: genotypes
1, 2, 3 and 4. Genotypes 1 and 2 have been
found only in humans. Genotypes 3 and 4
circulate in several animals including pigs,
wild boars and deer without causing any
disease, and occasionally infect humans.
 It is believed that HEV is transmitted by the
fecal-oral route, principally through
contaminated water in areas with poor
sanitation. The incubation period is variable,
estimated to range between 15 and 65 days.
 The virus is shed in the stools of infected
persons and enters the human body through
the intestine. It is transmitted mainly through
contaminated drinking water. The infection is
usually self-limiting and resolves within 2–6
weeks.
Transmission
Hepatitis E infection is found worldwide and is
common in low- and middle-income countries with
limited access to essential water, sanitation, hygiene
and health services. In general, hepatitis E
resembles hepatitis A. It has a self-limited course
with an abrupt onset. Jaundice is always present.
Chronic forms do not develop.
 Foodborne transmission from ingestion of
products derived from infected animals;
 Zoonotic transmisison from animals to
humans;
 Transfusion of infected blood products;
 Vertical transmission from a pregnant
woman to her fetus.
 In areas with better sanitation and water
supply, hepatitis E infection is infrequent,
with only occasional sporadic cases. Most of
these cases are caused by genotype 3 virus
and are triggered by infection with virus
originating in animals.
Clinical Manifestations
Typical signs and symptoms of hepatitis include:
  an initial phase of mild fever, reduced
appetite (anorexia), nausea and vomiting
lasting for a few days;
 abdominal pain, itching, skin rash, or joint
pain;
 jaundice (yellow colour of the skin), dark
urine and pale stools; and
 a slightly enlarged, tender liver
(hepatomegaly).
 Pregnant women with hepatitis E, particularly
those in the second or third trimester, are at
increased risk of acute liver failure, fetal loss
and mortality. Up to 20–25% of pregnant
women can die if they get hepatitis E in third
trimester.
Hepatitis E Virus and Pregnancy
 In rare cases, acute Hepatitis E can result in
fulminant hepatitis (acute liver failure) and
death. Overall population mortality rates from
hepatitis E range from 0.5% to 4.0%.
Fulminant hepatitis occurs more frequently
during pregnancy. Pregnant women are at
greater risk of obstetrical complications and
mortality from Hepatitis E, which can induce
a mortality rate of 20% among pregnant
women in their third trimester.
 Cases of chronic hepatitis E infection have
been reported in immunosuppressed people,
particularly organ transplant recipients on
immunosuppressive drugs, with genotype 3
or 4 HEV infection. These remain
uncommon.
Diagnostic Procedures
 Definitive diagnosis of hepatitis E infection is
usually based on the detection of specific
anti-HEV immunoglobulin M (IgM) antibodies
to the virus in a person’s blood.
 Blood tests are obtained in order to detect
elevation of antibody levels of specific
antibodies
 Reverse transcriptase polymerase chain
reaction (RT-PCR) to detect the hepatitis E
virus RNA in blood and stool.
 Immune Electron Microscopy to detect the
hepatitis E virus.
 Enzyme immunoassay which is practical,
highly sensitive and inexpensive detection of
Anti-HEV antibody.
Treatment
 There is no specific treatment capable of
altering the course of acute hepatitis E. As
the disease is usually self-limiting,
hospitalization is generally not required.
Most important is the avoidance of
unnecessary medications. Acetaminophen,
paracetamol and medication against
vomiting should be used sparingly or
avoided.
 Hospitalization is required for people with
fulminant hepatitis and should also be
considered for symptomatic pregnant
women.
 Immunosuppressed people with chronic
hepatitis E benefit from specific treatment
using ribavirin, an antiviral drug. In some
specific situations, interferon has also been
used successfully.
Prevention
Prevention is the most effective approach against
the infection. At the population level, transmission of
HEV and hepatitis E infection can be reduced by:
 maintaining quality standards for public
water supplies; and
 establishing proper disposal systems for
human faeces.
On an individual level, infection risk can be reduced
by:
 maintaining hygienic practices; and
 avoiding consumption of water and ice of
unknown purity
Nursing Management
 Proper surveillance of the community and
the source of water should be emphasized to
the community leaders.
 Teach the children as well as the adults of
proper hand washing and good hygiene.
 Evaluate the source of water supply in the
community and refer to the leaders of the
community if the source of drinking water is
at danger of making the transmission of
Hepatits E possible.
 Emphasize to the leaders of the community
the political will to provide hygienic sanitation
to each of the houses in the community.
Medical Management
 The goal of management is to prevent the
spread through fecaloral route.
 Always observe good hygiene.
 Proper and regular water analysis must be
made for public water supplies. HEV
infections is limiting and hospitalization is not
done. Vaccines are not yet developed so
focus in management is more on preventive
measures.
HEPATITIS G VIRUS
 In the United States ,about 5% of chronic
liver disease remains cryptogenic (i.e., does
not appear to be autoimmune or viral in
origin), and 50% of these patients have
received blood transfusions before
developing disease. Therefore, another form
of hepatitis, referred to as hepatitis G virus
 (HGV) or GB virus-C (GBV-C), has been Prevention
described; these are thought to be two
different isolates of the same virus, which are  Persons who are regularly exposed to blood
percutaneously transmitted. Autoantibodies or blood products from others should protect
are absent. themselves with gloves to reduce the risk of
 The clinical significance of this virus remains the spread of viruses.
uncertain. Risk factors are similar to those for  Those who inject drugs should ensure they
hepatitis C. There is no clear relationship use clean, sterile needles and avoid sharing
between HGV/GBV-C infection and needles, syringes or other druguse
progressive liver disease. Persistent equipment.
infection does occur but does not affect the Transmission
clinical course.
 Often found in co-infections with other  Hepatitis G virus is spread by infected blood
viruses, such as hepatitis C virus (HCV)- or blood products. It can be transmitted by
common, hepatitis B virus (HBV) , and a sharing personal items contaminated with
Human Immunodeficiency Virus (HIV). the virus, and other similar behaviors
 Also known as human pegivirus – HPgV is a including from mother-tonewborn child at
virus in the family Flaviviridae and a member birth or by various sexual activities.
of the Pegivirus, is known to infect humans,
but is not known to cause human disease.
 Reportedly, HIV patients co-infected with
GBV-C can survive longer than those without
GBV-C, but the patients may be different in
other ways. Research is active into the virus'
effects on the immune system in patients
coinfected with GBV-C and HIV
 GBV-C infection has been found worldwide
and currently infects around a sixth of the
world's population. High prevalence is
observed among subjects with the risk of
parenteral exposures, including those with
exposure to blood and blood products, those
on hemodialysis, and intravenous drug
users. Sexual contact and vertical
transmission may occur. About 10–25% of
hepatitis C-infected patients and 14–36% of
drug users who are seropositive for HIV-1
show the evidence of GBV-C infection.
Clinical Manifestations

 Almost no cases have symptoms like the

other hepatitis viruses (A, B, C and E).
Hepatitis G virus has a carrier rate of
between 2 and 5 percent in the general
population. It causes persistent infection for
up to 9 years in 15 to 30 percent of adults.
Risk Factors
Certain groups are at risk of being infected with
hepatitis G. Those at high risk are:

 injecting drug users;

 recipients of infected blood or blood
 products; and hemodialysis patients.
Those at medium risk are people:

 getting tattoos, acupuncture or body

piercings with tools that are not sterile;
 with impaired immune response;
 who engage in prostitution; and
 who are homosexuals.
GUILLAIN-BARRÉ SYNDROME 3. Signs of respiratory compromise.
4. Paresthesias - creeping/crawling sensations
What is GBS?
across skin
 acute destruction of myelin sheaths due to 5. Cranial nerve symptoms - facial weakness,
an autoimmune disorder that results in dysphagia, diplopia, dysarthria
varying degrees of muscle weakness and 6. Autonomic manifestations - fluctuating blood
paralysis. pressure, dysrhythmias
 Cranial and motor nerves are affected Assess/Monitor
more often resulting in altered sensory
perception.  Airway patency
 aggregates lymphocytes which delay  Respiratory status
recovery or result in permanent deficits.  Vital signs
 Chronic inflammatory demyelinating  Heart Rhythm
polyneuropathy (CIPD) - a different type of  Cranial Nerve Function
GBS that progresses over a long period, and  Pain Level
recovery is rare.  Skin Integrity
3 STAGES OF GBS Diagnostic Procedures
Initial Period Plateau Recovery 1. Electromyography (EMG) and Nerve
Period Period Conduction Velocity (NCV)
1-4 weeks several days to 4 to 6 months  Electromyography and Nerve
2 weeks and up to 2 Conduction Velocity are
years
electrodiagnostic tests that measure
onset of no demyelination
the electrical activity of muscles and
symptoms until deterioration, and return of
no further no muscle nerves.
deterioration is improvement strength  These tests shows evidence of
noted. denervation after 4+ weeks
2. White Blood Cell Count
 The tests shows leukocytosis
Pathophysiology Diagnostic criteria for Guillain -Barré
syndrome (GBS) frequently require a
pleocytosis of <50 white cell count
(WBC)/mm3.
3. Lumbar Puncture (LP)
 A lumbar puncture (spinal tap) is
performed in your lower back, in the
lumbar region. During a lumbar
puncture, a needle is inserted
between two lumbar bones
(vertebrae) to remove a sample of
cerebrospinal fluid.
 Shows the distinguishing
characteristic GBS finding of an
increase in protein within the CSF
without an increase in cell count
Medical Management
Intravenous Immunoglobulin Therapy (IVIG)

 an infusion of antibodies (the proteins that

Assessment
Signs and Symptoms:
1. Acute progressing muscle weakness to
muscle flaccidity without muscle atrophy.
Plasma Exchange (plasmapheresis)
 Ascending - bilateral lower extremity
muscles initially then progresses
upward
 Descending - face muscles initially
then progresses downward
2. Decreased/absent deep tendon reflexes
body uses to fight foreign invaders) that has
been collected from tens of thousands of
other people. This infusion helps calm down
your body’s immune system attack on your
nerves.
 This is a procedure that involves filtering the
liquid part of the blood (known as plasma).
During this filtering process, the body’s
antibodies which are attacking the nerves
are removed and cleaned the plasma is
 returned back to the body. This helps stop
the body’s immune system from continuing
to attack the nerves.
Nursing Management

 Maintain a patent airway: suction and/or

intubate as needed.
 Monitor ABGs: administer oxygen or
mechanical ventilation as needed.
 Keep the head of the bed at 45 degrees; turn,
cough, deep breathe every 2hr; conduct
incentive spirometry/chest physiotherapy
 Monitor blood pressure and respond to
fluctuations as needed (betablocker
administration for hypertension. IV fluids for
hypotension)
 Continuously monitor heart rhythm and
intervene as indicated (e..g., atropine for
bradycardia
 Provide comfort measures. (frequent
repositioning, ice, heat, massage,
distraction)
 Monitor cranial nerve function and
intervene to maintain safety accordingly
(e.g., risk for aspiration, risk for injury)
 Facilitate effective communication. (Use
of a communication board to help clients with
dysarthria)
 Assess coping and depression.
 Administer medications as prescribed.
 Analgesia (PCA Morphine) - Monitor for
respiratory depression and constipation.
 IV Immunoglobulin (IVIg) - Monitor side
effects such as chills, fever, and myalgia,
and for possible complications including
anaphylaxis or renal failure.
SEXUALLY TRANSMITTED DISEASES
CHLAMYDIA
 Chlamydia is a sexually transmitted infection
(STI) caused by a bacteria called chlamydia
trachomatis.
 It is one of the most common causes of
endocervicitis, although Mycoplasma may
also be involved.
Statistics
 2.86 million infections every year in the
United States
 Most commonly found in young people who
are sexually active with more than one
partner and is transmitted through sexual
contact.
 1 in 20 sexually active young women aged
14-24 years has chlamydia.
Pathophysiology
 Bacterial Factors
 Pathogen load
 Serovars and polymorphisms
 Virulence factors
 Host Factors
 Genetic predisposition
 Age
 Hormonal Status
 Immunological response
 Sexual behavior
 Microbiome and coinfections,
Environmental factors and prevalence,
Failure in diagnoses and treatment
 Repeat and persistent chlamydial
infections
 Damage of genital tract and reproductive
system
Pelvic inflammatory disease, tubal
obstruction and adverse pregnancy
outcomes
 Female infertility
Complications
Untreated Chlamydia infections can spread to the
fallopian tube and uterus leading to serious
complications including:
 Pelvic Inflammatory Disease (PID)
 an infection of one or more of the upper
reproductive organs, including the
uterus, fallopian tubes and ovaries.
 Increased risk of ectopic pregnancy
 an ectopic pregnancy is when a fertilized
egg implants itself outside of the womb,
usually in one of the fallopian tubes.
 Infertility
 Infertility is a disease of the male or
female reproductive system defined by
the failure to achieve a pregnancy after
12 months or more of regular
unprotected sexual intercourse.
Chlamydia Symptoms
Chlamydia infections of the cervix often produce NO
SYMPTOMS, but the following may occur:
 cervical discharge
 dysuria
 dyspareunia
 bleeding
Signs of chlamydia in men include:
 white, cloudy or watery discharge from the
penis
 pain or burning when urinating
 pain and/or swelling in the testicles
You can also get chlamydia infection in your anus,
eyes and throat. For both men and women, this can
cause pain, discharge or bleeding in the anus, or
inflammation (redness) of the eye (called
conjunctivitis). Chlamydia in the throat does not
usually have any symptoms.
How do you get chlamydia?
 Unprotected Vaginal Sex
 Unprotected Anal Sex Unprotected
 Oral Sex
 Chlamydia can be passed on through genital
contact. This means you can get chlamydia
from someone who has the infection if your
genitals touch, even if you don’t have sex or
ejaculate (cum).
 You can also get chlamydia if you come into
contact with infected semen (cum) or vaginal
fluid, or get them in your eye.
 Chlamydia can’t be passed on through
kissing, hugging, sharing towels or using the
same toilet as someone with the infection.
GONORRHEA
Gonorrhea is a sexually transmitted infection (STI).
It’s caused by the bacterium Neisseria gonorrhoeae.
It tends to target warm, moist areas of the body,
including the:
 urethra (the tube that drains urine from the
bladder)
 eyes
 throat
 vagina
 anus
 female reproductive tract (the fallopian
tubes, cervix, and uterus)
Statistics
 According to CDC (2015), Gonorrhea is the
second most commonly reported STI with an
estimated 820,000 new infections each year.
How do you get gonorrhea?  CAUTION: Pregnant women are not
allowed to take Tetracycline because of
 Unprotected vaginal sex
potential adverse effects on the fetus.
 Unprotected anal sex In these cases, erythromycin may be
 Unprotected oral sex prescribed.
Complications  CULTURES OF CHLAMYDIA AND OTHER
STIs should be obtained from all patients
The inflamed cervix that results from infection may who have been sexually assaulted when
leave a woman more vulnerable to HIV transmission they first seek medical attention; patients are
from an infected partner. It is often asymptomatic treated prophylactically.
and major cause of PID.  Cultures should then be repeated 2 weeks.
 Tubal Infertility  Annual screening for chlamydia is
 Ectopic Pregnancy recommended for all young women who are
sexually active and older women with new
 Chronic Pelvic Pain
sex partners or multiple partners.
Symptoms
Diagnostic Procedures
(men)
 SAMPLES FROM FEMALE: obtained from
 burning or painful sensation during urination the endocervix, anal canal, and pharynx.
 greater frequency or urgency of urination  SAMPLES FROM MALE: specimens are
 a pus-like discharge obtained from the urethra, anal canal, and
 (or drip) from the penis (white, yellow, beige, pharynx.
or greenish)  Serologic testing for syphilis and HIV should
 swelling or redness at the opening of the be offered to patients with gonorrhea or
penis chlamydia because any STI increases the
 swelling or pain in the testicles risk of other STIs.
 a persistent sore throat  CHLAMYDIA (C. TRACHOMATIS)
 Gram stain and direct fluorescent
(women) antibody test
 discharge from the vagina (watery, creamy,  nucleic acid amplification test (NAATs)
or slightly green) but demand strict attention to laboratory
 pain or burning sensation while urinating procedures to ensure test reliability.
 urge to urinate more frequently  GONORRHEA (N. GONORRHOEAE)
 heavier periods or spotting  Gram stain (appropriately for male
urethral samples)
 sorethroat
 culture
 pain during sexual intercourse
 nucleic acid amplification test (NAATs)
 sharp pain in the lower abdomen
 N. Gonorrhoeae organisms are susceptible
 fever
to environmental changes, specimens for
Pathophysiology culture must be delivered to the laboratory
immediately after they are obtained.
 Bacteria Neisseria gonorrhoeae
 Replicate and grow at site of infection Assessment
 Inflammatory Reaction
 The patient should be asked to describe the
 Fibrosis (Fibrotic reaction)
onset and progresion of symptoms and to
 Gonorrheal Complication charcterize any lesions by location and by
Medical Management describing drainage, if present.
 Brief explanation of why the information is
 FIRST LINE TREATMENT FOR needed are often helpful.
GONORRHEA INFECTION:  Clarification of terms may be necessary if
Dual therapy with AZITHROMYCIN & either the patient or nurse words that are
CEFTRIAZONE given simultaneously on unfamiliar to the other.
the same day.  Protecting confidentiality is important when
 ANTIBIOTIC: discussing sexual issues.
DOXYCYCLINE (Vibramycin) for 1  When a detailed sexual history is necessary,
week or it is important to respect the patient's right to
AZITHROMYCIN (Zithromax) - single privacy.
dose  When obtaining a sexual history, the CDC
 CEPHALOSPORINS - recommend recommends the following systematic
treatment for antimicrobial resistance to interview of key areas, the "five Ps":
fluoroquinolones in the treatment of PARTNERS, PREVENTION OF
gonorrhea
 PREGNANCY, PROTECTION FROM STIs,
PRACTICES, PAST HEALTH HISTORY.
 Asking specific information about sexual
contacts usually should be done only when
the nurse is part of a team that will conduct
partner notification.
 The nurse should describe to the patient the
public health notification process and
resources that are available to assist sexual
partners or infants and children.
 During physical examination, the examiner
looks for rashes, lesions, drainage,
discharge, or swelling. Inguinal nodes are
palpated to elicit tenderness and to assess
swelling.
 Women are examined for abdominal or
uterine tenderness. The mouth and throat
are examined for signs of inflammation or
exudate.
 The nurse wear gloves while examining the
mucuos membranes, and gloves are
changed and replaced after vaginal or rectal
examination.
Nursing Management
 Assist patients in assessing their own risk.
Recognition of risk is a first step before
changes in behavior occur.
 Nurses play a major role in counselling
patients about safer sex practices such as
the use of condoms and spermicides, and
careful choice of partners.
 Exploring options with patients, addressing
knowledge deficits, and correcting
misinformation may reduce morbidity and
mortality.
 Advise the patient to refer their partner for
evaluation and treatment.
 Advise all woman aged 25 and younger who
are sexually active to undergo annual
screening.
 Those older than 25 years should be
screened if risk factors are present. Repeat
testing should occur 3 months after
treatment.
 Educate women and help them improve
communication skills and initiate discussions
about sex with their partners.
Communicating with partners about sex, risk,
postponing intercourse, and using safer sex
behaviors, including the use of condoms,
may be lifesaving.
 Nurses can help women to advocate for their
own health by discussing safety with
partners prior to sexual activity.
 Instruct the patient to abstain from sexual
intercourse until all of her sex partner are
treated.
 Place a mechanism to ensure that all
patients who are diagnosed are reported to
the local public health department to ensure
follow-up of the patient.
 The target group for preventive patient
education about gonorrhea and chlamydia is
the adolescent and young adults population.
 Reinforce the importance of abstinence,
when, appropriate, education should
address the postponing the age of initial sex
exposure, limiting the number of sexual
partners, and using condoms for barrier
protection.
 Young women and those who are pregnant
should also be instructed about the
importance of routine screening for
chlamydia.
HERPES SIMPLES VIRUS 2
 A recurrent, lifelong viral infection that
causes herpetic lesions (blisters) on the
external genitalia and occasionally on the
vagina and cervix.
 Peak incidence is among adolescents and
young adults;
 It is a sexually transmitted infection but may
also be transmitted asexually from wet
surface or by self-transmission (i.e. touching
a cold sore and then touching the genital
area). It is also possible by fomites such as
towels used by an infected person.
 HSV organism is present in the exudates of
the lesion. Herpes can be transmitted while
a lesion is present and for 10 days after a
lesion has healed.
 Newborns can be infected during vaginal
delivery when active genital lesions are
present. Caesarean section prevents this
transmission.
 The initial infection is usually very painful and
blisters might take 2 to 4 weeks to heal, but
it can also be asymptomatic.
 Over 87% of infected individuals are
unaware of their infection; most HSV
transmissions occur from asymptomatic viral
shedding
 Recurrences are less painful, self-limited and
usually produce less severe symptoms.
Recurrences can be associated with stress,
sunburn, dental work, or inadequate rest or
poor nutrition, or any situations that tax the
immune system.
 Herpes can be transmitted by contact with
skin that is not covered with a condom.
 Vaccines for herpes genitalis are in clinical
trials; however, at this time, there is no
commercially available vaccine.
Pathophysiology
 Establishes the primary infection within the
host
 Enters sensory nerve terminals at peripheral
sites
Retrogade axonal transport
  Enters the trigeminal nerve ganglion
 Establishes latency
Triggering factors
 Reactivation of virus
Travels from dorsal root ganglion along
the sensory nerves
 Reaches the epidermis and at the epidermal-
dermal junction
 Results In recurrent infection
Assessment and Diagnosis
 Health History is taken
 Physical and pelvic examination is
performed.
 Assessment for risk of STIs (i.e. occupation,
vices)
 Perineum is inspected for painful lesions.
 Inguinal nodes are often enlarged and tender
during an occurrence of genital herpes.
 Diagnosis is confirmed by viral culture, Pap
smear.
Clinical Manifestations
 Itching and pain as the infected area
becomes red and edematous.
 Macules and papules progress to vesicles
and ulcers.
 Vesicular state often appears as a blister,
ehich later coalesces, ulcerates, and
encrusts.
 Labia are the usual primary site, although the
cervix, vagina, and perianal skin may be
affected.
 Glans penis, foreskin, and penile shaft are
typically affected in men.
 Influenza like symptoms may occur 3 to 4
days after the lesions appear.
 Enlarged lymph nodes in the groin, minor
temperature elevation, malaise, headache,
aching muscles, and dysuria are often noted.
 Pain is evident during the first week and then
decreases.
 The lesions last 2 to 12 days before crusting
over.
 Complications may arise from extragenital
spread, such as buttocks, upper thighs, or
even the eyes, as a result of touching lesions
and then touching other areas.
 Patients should be advised to wash their
hands after contact with lesions.
 Other potential problems are aseptic
meningitis, neonatal transmission, and
severe emotional stress related to the
diagnosis.
Medical Management
 Currently, there is no cure for genital herpes
infection, but treatment is aimed at relieving
the symptoms.
 Three oral antiviral agents can suppress
symptoms and shorten the course of
infection. These are effective at reducing the
duration of lesions and preventing
recurrences.
 acyclovir (Zorivax)
 valacyclovir (Valtrex)
 famciclovir (Famvir)
 Analgesics and saline compress can provide
additional relief symptoms.
 Prophylactic vaccine and topical gel
development for genital herpes continues to
investigated in clinical trials.
Nursing Management
RELIEVING PAIN
 Lesions should be kept clean, and proper
hygiene practices are advocated.
 Sitz bath ease discomfort.
 Aspirin and otehrs analgesic agents control
pain during outbreaks.
 Wearing of loose, comfortable clothing to
prevent constriction.
 Abstinence from sexual intercourse during
treatment for active disease.
 Increased fluid intake in encouraged.
 Patient is alerted for bladder diestention, pt.
is instructed to contact her primary provider
if she cannot void due to discomfort.
 Painful voiding happens when urine comes
in contact with herpes lesions. This can be
reduced by pouring warm water over the
vulva during voiding.
 Oral antiviral agents can also be prescribed
and the patient is instructed when to take it
and the possible side effects
PREVENTING INFECTION AND ITS SPREAD
 Proper hand hygiene
 barrier methods with sexual contact
 adherence to prescribed medication
regimens
RELIEVING ANXIETY
 listening to patients concern
 providing information and instruction
 assist in discussing the infection and its
implications with her current sexual partner
 refer to support groups
HEALTH EDUCATION
 Adequate explanation about the infection
and how it is transmitted, management and
treatment strategies
 Educate on how to protect himself from
exposure from HIV and other STIs.
SYPHILIS
 A bacterial infection usually transmitted
through sexual intecourse. It is caused by the
spirochete Treponema pallidum.
 Early manifestations can be as a painless
sore found on the genitals, rectum or mouth.
Syphilis spreads from person to person via
skin or mucous membrane contact with
these sores.
Stages
Primary Syphilis
 Occurs 2 to 3 weeks after initial inoculation
with the organism. The first sign of syphilis is
a small sore, called a chancre. It usually
appears at the spot where the bacteria
entered the body. With or without treatment,
the lesions typically resolve within 3 to 12
weeks.
Secondary Syphilis
 Occurs when the hematogenous spread of
organisms from the original chancre leads to
generalized infection.
 Some individuals may experience hair loss,
muscle aches, a fever, a sore throat and
swollen lymph nodes.
 Transmission can occur by contact with the
lesions formed.
Latent
 After the secondary stage, a period called
Latent, occurs when the disease is not
treated promptly.
 This stage is characterized by absence of
signs and symptoms. Signs and symptoms
may never return, or the disease may
progress to the third (tertiary) stage.
Tertiary Syphilis
 The final stage of the disease. The stage
presents as slow progression of the
inflammation that eventually leads to the
damage of the brain, nerves, eyes, heart,
blood vessels, liver, bones and joints, and
other organs.
 Aortitis, neurosyphilis, that may come with
dementia, psychosis, paresis, stroke, or
meningitis.
Diagnosis
 Physical examination
 Blood tests
Treatment/Nursing Management
 Primary and secondary Syphilis are easy to
treat with a penicillin injection.
 People who are allergic to penicillin will likely
be treated with a different antibiotic, such as
doxycycline, azithromycin, and ceftriaxone.
 Educate patient on safe sex practice
 Encourage the use of condoms
 Educate patient on avoiding sex with an
infected partner
Prevention
 Use condoms during any type of sexual
contact
 Screening for STIs before engaging in any
sexual activity
TRICHOMONIASIS
 Trichomoniasis is a very common sexually
transmitted disease. It is caused by infection
with a protozoan parasite called
Trichomonas vaginalis.
 Although symptoms of the disease vary,
most people who have the parasite cannot
tell they are infected.
 Trichomoniasis is the most common curable
STD. Infection is more common in women
than in men. Older women are more likely
than younger women to have been infected
with trichomoniasis.
Pathophysiology
 Trophozoite in vaginal and prostatic
secretions and urine
 Multiplies by longitudinal binary fission
 Trophozoite in vagina or orofice of urethra
 Sexual Intercourse
 Infected men/women
Assessment and Diagnostic Findings
 The area is observed for erythema, edema,
excoriation and discharge. Each of the
infection-producing organisms produces its
own characteristics discharge and effect.
The patient is asked to describe any
discharge and other symptoms, such as
odor, itching, or burning.
 Dysuria often occurs as a result of local
irritation of the urinary meatus. A urinary tract
infection may need to be ruled out by
obtaining a urine specimen for culture and
sensitivity testing.
 The patient is also asked about other factors
that could contribute to infection, including
hygiene practices, use or nonuse of
condoms, and use of chemicals such as
nonoxynol-9 with barrier methods of birth
control.
The patient is asked about the occurrence of factors
that may contribute to the infection:
 Physical and chemical factors, such as
constant moisture from tight or synthetic
clothing, perfumes and powders, soaps,
 bubble bath, poor hygiene, and use of 3. Preventing Reinfection or Spread of
feminine hygiene products. Infection- The patient needs to be informed
 Psychogenic factors such as stress, fear of about these risks and the importance of
STDs, and abuse. adequate treatment of herself and her
 Medical conditions or endocrine factors, partner.
such as predisposition to vulvar involvement 4. Promoting Home and Community-Based
in a patient who has diabetes or is elderly. Care- Patient teaching, tact and reassurance
 Use of medications such as antibiotics, are important aspects of nursing care.
which may alter the vaginal flora and allow
an overgrowth of monilial organisms.
 New sex partner, multiple sex partners,
previous vaginal infection.
It is not possible to diagnose trichomoniasis based
on symptoms alone. For both men and women,
physical examination and laboratory tests can be
done to diagnose trichomoniasis.
Based on the nursing assessment and other data,
the patient's major nursing diagnoses may include: -
- Discomfort related to burning, odor, or itching
from the infectious process
- Anxiety related to stressful symptoms
- Risk for infection or spread of infection
- Deficient knowledge about proper hygiene
and preventive measures
Medical Management
Oral anti-infective medications kill trich such as
Metronidazole (Flagyl) or Tinidazole (Tindamax).

Points in mind while undergoing the treatment:

1. A single medication dose cures up to 95% of
infected women. Men and women may need
to take the medication for five to seven days.
2. The patient and their sexual partner must be
treated for trich or they will continuously pass
the infection back and forth.
3. The patient and their sexual partner shouldn't
have sex for one week after finishing the
medication to give the drug time to kill of the
infection and for symptoms to clear up.
Having sex too soon can lead to reinfection.
4. Patient shouldn't drink alcohol for 24-72
hours after taking medications because it
can lead to severe nausea and vomiting.
5. Patient should have a follow up check-up
after three months to ensure that they are no
longer infected.
Nursing Management
1. Relieving Discomfort- Treatment with the
appropriate medication usually relieves
discomfort.
2. Reducing Anxiety- Explaining the cause of
symptoms may reduce anxiety related to fear
of a more serious illness. Discussing ways to
help prevent vulvovaginal infections may
help the patient adopt specific strategies to
decrease infection and the related
symptoms.
APPENDICITIS
It is the inflammation of the appendix.
Roles of the appendix:
 to store good bacteria in the GI tract while the
tract is recovering from a diarrhea illness
 helps in maintaining gut flora
Cause of Appendicitis:
 Obstruction of a fecalith, foreign body,
parasites, worms, enlarged lymph nodes and
trauma and injury
Pathophysiology
 Obstruction lumen of the appendix
 Increased pressure inside the appendix
 Multiplication of bacteria and increase fluid
appeinside the appendix
 Major venous obstruction (occlusion of blood
flow and blood stays stagnant)
 Clot formation
 Ischemia to the appendix wall will weaken
and break down
 Spilled content to the abdominal cavity
Signs and Symptoms
 Abdominal pain
 Poor appetite
 Point of McBurney’s (most intense in the
patient) found one-third distance between
the belly button and anterior superior iliac
spine)
 Elevated temperature
 Nausea and vomiting
 Increased WBC, Inability to pass gas
(constipated or diarrhea)
 Desire to be in a fetal position
 Experience rebound tenderness
abdominal rigidity (putting pressure it hurts,
let go the pain it a lot more intense)
Assessment & Diagnostic Findings
 History & Physical
 Examination
 Complete Blood Count (CBC):
- elevated WBC count; elevation of
neutrophils
 C-reactive Protein (CRP) Test:
- protein levels are elevated
 CT Scan: RLQ density or
- localized distention of the bowel; at least
6 mm appendix
 Pregnancy Testt
- ectopic pregnancy; before radiologic
studies are done
 Transvaginal Ultrasound:
- alternative; to confirm the diagnosis
 Urinalysis
- UTI or renal calculi
 Laparoscopy
- acute appendicitis in equivocal
cases
Medical Management
 If appendicitis is diagnosed, immediate
surgery is usually recommended.
 Antibiotics and intravenous fluids are
administered until surgery is performed.
 Appendectomy (surgery to remove the
appendix) is performed as soon as possible.
 In the case of complicated appendicitis (e.g.,
with gangrene or perforation), the patient is
typically treated postoperatively with a 3- to
5-day course of antibiotics.
 Appendectomy may be postponed in
patients with abscess formation involving the
cecum and/or terminal ileum until the mass
is drained
Nursing Management
1. Place client on bed rest.
2. Prepare the patient for surgery by
administering an IV infusion to replace fluid
loss and promote adequate renal function,
antibiotic therapy to prevent infection, and
analgesic agents to relieve pain.
3. Place the patient in a High-Fowler’s position
after surgery.
4. The patient is taught how to use an incentive
spirometer and encouraged to use it at least
every two hours while awake.
5. To relieve pain, a parenteral opioid (e.g.,
morphine) is typically prescribed; however,
when the patient is able to tolerate oral fluids
and foods, the opioid is switched to an oral
agent.
6. Auscultate for the return of bowel sounds
and inquire about the patient's passing of
flatus.
or 7. Urine output is measured.
8. Encourage the patient to walk on the day of
surgery. The patient may be discharged on
the day of surgery if the temperature is
normal, there is no undue discomfort in the
operative area, and the appendectomy was
performed laparoscopically.
CROHN’S DISEASE (REGIONAL ENTERITIS)
 Crohn's disease is a chronic inflammatory
condition affecting the gastrointestinal tract
at any point from the mouth to the rectum.
Patients may experience diarrhea,
abdominal pain, fever, weight loss,
abdominal masses, and anemia.
Pathophysiology
 Crypt inflammation and abscesses
 Small, focal ulcers
 Longitudinal and transverse ulcers
 Fistulas, fissures, and abscesses
 Granulomas
 Disease advances
- Bowel wall thickens and becomes fibrotic,
and the intestinal lumen narrows.
Clinical Manifestations
Onset Symptoms in Crohn’s disease:
 Prominent right lower quadrant abdominal
pain
 Diarrhea unrelieved by defecation
 Scar tissue and the formation of granulomas
interfere with the ability of the intestine to
transport products of upper intestinal
digestion through the constricted lumen,
resulting in crampy abdominal pain.
 There is abdominal tenderness and spasm.
 Ulcers in the membranous lining of the
intestine
 Disrupted absorption
Chronic symptoms include:
 Diarrhea
 Abdominal pain
 Steatorrhea
 Anorexia
 Weight loss
 Nutritional deficiencies
 Abscesses, fistulas, and fissures
Symptoms beyond the GI tract:
 Joint disorders
 Skin lesions
 Ocular disorders
 Oral ulcers
Assessment & Diagnostic Findings
 For initial assessment, the doctor may ask
about the patient's medical history. They may
also conduct a full physical examination,
order blood tests, and order stool tests.
 To diagnose Crohn’s disease,the doctor will
need to see what’s going on inside the
digestive tract. To do so, they may use
imaging tests that create pictures of the
digestive tract from the outside, such as X-
rays. They may also use an endoscope to
look inside the digestive tract during a
colonoscopy or sigmoidoscopy.
Laboratory Tests
1. Blood test
- Blood tests can help doctors to check
for signs of infection or antibodies in
the blood. If patients have increased
levels of white blood cells or platelets
in the blood, it may be a sign of
infection or inflammation in the body.
The inflammation might be caused by
Crohn’s disease or other
inflammatory conditions.
2. Stool Test
- Blood in stool is a sign of digestive
problems, such as Crohn’s disease.
- Doctors may also order stool tests to
check for disease-causing organisms
in the digestive tract.
3. MRI scans, CT scan, and UGI
- Imaging tests include X-rays, MRI
scans, CT scans, and the UGI series.
They allow your doctor to examine
your digestive tract from the outside.
This helps them assess and
document signs of damage or
inflammation. It can help them
diagnose Crohn’s disease and its
potentially serious complications,
such as fistulas or abscesses.
Medical and Nursing Management
Pharmacologic Interventions
1. Anti-inflammatory drugs
- Mesalamine
- Sulfasalazine
- 5-ASA agents such as Asacol, Dipentum,
or Pentase
2. Cortisone or steroids
3. Immune system suppressors 6-
mercaptopurine/Azathioprine
4. Infliximab (Remicade)
5. Antibiotics
6. Anti-Diarrheals- Diphenoxylate, Loperamide,
Codeine
7. Fluid replacement- treat dehydrated patients
with fluids & electrolytes.
Diet and Nutrition
- High protein, high calorie diet is given by oral
or parenteral route.
- Plasma & blood transfusions are given for
anemia & hypoproteinaemia.
- Low fat diet or milk free diet improves lactose
deficiency or malabsorption.
- Low residue or high fibre diet is also
supplemented to reduce colics.
- Supplementation of iron, folic acid, calcium,
vitamin D, electrolytes whenever deficiency
occurs.
 - Total parenteral nutrition (TPN) has been
demonstrated to be effective in controlling
the disease actively & complications of
Crohn’s disease.
Surgical Procedures
- Colectomy with ileostomy
- Colectomy with ileorectal anastomosis
Nursing Management
1. Provide emotional support to the patient and
his family.
2. Schedule patient care to include rest periods
throughout the day.
3. If the patient is receiving parenteral nutrition,
provide meticulous site care.
4. Give iron supplements and blood transfusion
as ordered.
5. Administer medications as ordered.
6. Provide good patient hygiene and meticulous
oral care if the patient is restricted to nothing
by mouth.
7. Record fluid intake and output, weigh the
patient daily.
8. If the patient is receiving TPN, monitor his
condition closely.
9. Evaluate the effectiveness of medication
administration.
10. Emphasize the importance of adequate rest.
11. Give the patient a list of foods to avoid,
including lactosecontaining milk products,
spicy or fried high-residue foods.
12. Teach the patient about the prescribed
medications, their desires effects and
possible adverse reactions
ULCERATIVE COLITIS
 Inflammatory, usually chronic disease that
affects the mucosa of the colon
 Begins in the rectum and sigmoid a colon
and commonly extends upward into the
entire column, really affecting the small
intestine.
 Produces edema and ulceration
 Ranges from a mild, localized disorder to a
fulminant disease that may cause a
perforated colon, progressing to potentially
fatal peritonitis and toxemia
 Cycles between exacerbation and remission
Underlying Pathophysiology
 The base of the mucosal layer of the large
intestines becomes inflamed
 The colon’s mucosal surface becomes dark,
red, and velvety Inflammation leads to
erosions that coalesce and from ulcers
 The mucosa becomes become diffusely
ulcerated with hemorrhage, congestion, and
ulcerate
 Sloughing causes bloody, mucus filled stools
 Ulcerations are continuous
 Abscesses heal, scarring and thickening
may appear in the bowel’s inner muscle layer
 As granulation tissue replaces the muscle
layer, the colon narrows, shortens and loses
its characteristics pouches (haustral folds)
Causes
 Is a type of lung disease that occurs due to
blockages or obstructions in the airways.
 Blockages damage the lungs and cause their
airways to narrow. This damage leads to
difficulty breathing.
 In obstructive lung disease, less air flows in
and out of the alveoli and fewer gas
exchanges can happen. This can happen for
many reasons, depending on which type of
obstructive lung disease a person has.
Complications
 Recurrent bloody diarrhea (as many as 10-
20 stools per day) typically containing pus
and mucus (Hallmark sign), resulting from
accumulated blood and mucus in the bowel
 Abdominal cramping and rectal urgency from
accumulated blood and mucus
 Weight loss secondary to malabsorption
 Weakness related to possible malabsorption
and subsequent anemia
Nursing Management
 Accurately record intake and output.
particularly the frequency and volume of
stools.
 Watch for signs of vibration and electrolyte
imalance specially signs and symptoms of
hypokalemia, and hypernatremia.
 Monitor the patient’s hemoglobin level and
hematocrit and give blood transfusions as
ordered.
 Provide good mouth care for the patient who
is on nothing by mouth status.
 Provide good mouth care for the patient who
is on nothing by mouth status.
 After each bowel movement, thoroughly
clean the skin around the rectum.
 Provide an air mattress or cheap skin to help
prevent skin breakdown.
 Administer medications as ordered.
 Search for adverse effects of long
corticosteroid therapy. Such as moonface,
hirsutism, edema and gastric irritation.
 Be aware that corticosteroid therapy may
mask infection.
 Assess if patient needs TPN.
 Assess if patient is prone to bleeding.
 Watch closely for signs of complication.
 Promote bedrest, provide bedside
commode. Remove stool promptly. Provide
room deodorizers
 Restart oral fluid intake gradually. Offer clear
liquids hourly; avoid cold fluids.
 Commence stool chart user standardize tool
assessment tool such as Bristol Stool chart.
 Encouraged to increase oral fluid intake as
tolerated. Instruct to avoid cold drinks and
check if the patient is in any fluid restriction
before doing so.
 Help the patient to select appropriate dietary
choices to reduce the intake of milk products,
caffeinated drinks, alcohol, and avoid high
fiber, high fat foods.
 Start the patient on a nothing bailout status
and gradually progress to clear liquid's,
followed by bland diet and a low residue diet.
Medical Management
Anti-inflammatory drugs
- 5-aminosalicylates
- Corticosteroids.
Biologics
- Infliximab, Adalimumab and golimumab
- Vedolizumab (Entyvio)
- Ustekinumab (Stelara)
Immune system suppressors
- Azathioprine (Azasan, Imuran) and
mercaptopurine (Purinethol, Purixan).
- Cyclosporine(Gengraf,Neoral,
Sandimmune)
- Tofacitinib (Xeljanz)
Other medications
- Anti-diarrheal medications
 - Pain relievers
- Antispasmodics
- Iron supplements.
Diagnostic Procedures
Laboratory Procedures
- Blood Tests
- Stool Studies
Endoscopic procedures
- Colonoscopy
- Flexible sigmoidoscopy
Imaging procedures
- X -ray
- CT scan
- Computerized tomography (CT)
enterography and magnetic resonance (MR)
enterography
PERITONITIS
Definition
 Peritonitis is inflammation of the
peritoneum, the serous membrane lining
the abdominal cavity and covering the
viscera.
 Usually, it is a result of bacterial infection; the
organisms come from diseases of the GI
tract, or in women, from the internal
reproductive organs.
Pathophysiology
The pathophysiology of peritonitis involves.
 Leakage. Peritonitis is caused by leakage of
contents from abdominal organs into the
abdominal cavity.
 Proliferation. Bacterial proliferation occurs.
 Edema. Edema of the tissues occurs, and
exudation of fluid develops in a short time.
 Invasion. Fluid in the peritoneal cavity
becomes turbid with increasing amounts of
protein, white blood cells, cellular debris, and
blood.
 Response. The immediate response of the
intestinal tract is hypermotility, soon followed
by paralytic ileus with an accumulation of air
and fluid in the bowel.
Clinical manifestations
Symptoms depend on the extent and location of the
inflammation.
 Pain. At first, there is diffuse pain, which
tends to become constant, localized, and
more intense over the site of the pathologic
process.
 Tenderness. The affected area of the
abdomen becomes extremely tender and
distended, the muscles become rigid, and
movement could aggravate it further.
 Altered vital signs. A temperature of 37.8C
to 38.3C can be expected along with an
increased pulse rate.
Assessment and Diagnostic Findings
Assessing and diagnosing peritonitis involves the
following:
 Increased WBC. The white blood cell count
is almost always elevated.
 Serum electrolyte studies. Serum
electrolyte studies may reveal altered levels
of potassium, sodium, and chloride.
 Abdominal X-ray. An abdominal xray may
show air and fluid levels as well as distended
bowel loops.
 Abdominal ultrasound. Abdominal
ultrasound may reveal abscesses and fluid
collections.
 CT scan. A CT scan of the abdomen may
reveal abscess formation.
 MRI. MRI may be used for diagnosis of intra-
abdominal abscesses.
Medical Management
Fluid, colloid, and electrolyte replacement is the
major focus of medical management.
 Fluid. The administration of several liters of
an isotonic solution is prescribed.
 Analgesics. Analgesics are prescribed for
pain.
 Intubation and suction. Intestinal intubation
and suction assist in relieving abdominal
distention and in promoting intestinal
function.
 Oxygen therapy. Oxygen therapy by nasal
cannula or mask generally promotes
adequate oxygenation.
 Antibiotic therapy. Antibiotic therapy is
initiated early in the treatment of peritonitis.
Surgical Management
Surgical objectives include removing the infected
material and correcting the cause.
 Excision. Surgical treatment is directed
towards excision, especially if the appendix
is involved.
 Resection. Resection of the intestines may
be done with or without anastomosis.
 Fecal diversion. A fecal diversion may need
to be created with extensive sepsis.
Nursing Management
Intensive care is often needed for patients with
peritonitis.
Nursing Assessment
Assessment should be ongoing and precise.
 Pain. Pain should be assessed continuously
and should be acted upon.
 GI function. GI function should be monitored
to assess response to interventions.
 Fluid and electrolyte. F&E should be
balanced.
Nursing Diagnosis
Based on assessment data, the diagnoses
appropriate for the patient are:
 Acute pain related to peritoneal irritation.
 Deficient fluid volume related to massive
shifting of fluids towards the intestinal lumen
and depletion in the vascular space.
 Risk for shock related to septicemia or
hypovolemia.
Nursing Care Planning & Goals
The goals appropriate for a patient with peritonitis
include:
 Reduce level of pain.
  Restore fluid and electrolyte balance.
 Prevent complications.
 Restore normal GI functions.
Nursing Interventions
Nursing interventions focus on the following:

 Blood pressure monitoring. The patient’s

blood pressure is monitored by arterial line if
present.
 Medications. Administration of analgesic and
anti-emetics can be done as prescribed.
 Pain management. Analgesics and
positioning could help in decreasing pain.
 I&O monitoring. Accurate recording of all
intake and output could help in the
assessment of fluid replacement.
 IV fluids. The nurse administers and closely
monitors IV fluids.
 Drainage monitoring. The nurse must
monitor and record the character of the
drainage postoperatively.
PANCREATITIS
 Pancreatitis, which is the inflammation of the
pancreas, can be acute or chronic in nature.
It may be caused by edema, necrosis or
hemorrhage.
 In men, this disease is commonly associated
with alcoholism, peptic ulcer, or trauma; in
women, it’s associated with biliary tract
disease. Prognosis is usually good when
pancreatitis follows biliary tract disease, but
poor when the factor is alcoholism.
 Pancreatitis is an inflammation of the
pancreas and is a serious disorder.
 Pancreatitis can be a medical emergency
associated with a high risk of life-threatening
complications and mortality.
 Pancreatitis is commonly described as
autodigestion of the pancreas.
Classification
The most basic classification system divides the
disorder into acute and chronic forms.
 Acute pancreatitis. Acute pancreatitis does
not usually lead to chronic pancreatitis
unless complications develop.
 Chronic pancreatitis. Chronic pancreatitis
is an inflammatory disorder characterized by
progressive destruction of the pancreas.
Pathophysiology
Self-digestion of the pancreas caused by its own
proteolytic enzymes, particularly trypsin, causes
acute pancreatitis.
 Entrapment. Gallstones enter the common
bile duct and lodge at the ampulla of Vater.
 Obstruction. The gallstones obstruct the
flow of the pancreatic juice or causing reflux
of bile from the common bile duct into the
pancreatic duct.
 Activation. The powerful enzymes within the
pancreas are activated.
 Inactivity. Normally, these enzymes remain
in an inactive form until the pancreatic
secretions reach the lumen of the
duodenum.
 Enzyme activities. Activation of enzymes
can lead to vasodilation, increased vascular
permeability, necrosis, erosion, and
hemorrhage.
 Reflux. These enzymes enter the bile duct,
where they are activated and together with
bile, back up into the pancreatic duct,
causing pancreatitis.
Statistics and Epidemiology
 Pancreatitis affects people of all ages, but
the mortality rate associated with pancreatitis
increases with advancing age.
 Approximately 185, 000 cases of pancreatitis
occur in United States each year.
 150, 000 of these cases are the result of
cholelithiasis or sustained alcohol abuse.
 The overall mortality rate of patients with
pancreatitis is 2% to 10%.
 The incidence of pancreatitis varies in
different countries and also depends on the
cause (e.g., alcohol, gallstones, metabolic
factors, drugs). In the United States, acute
pancreatitis is related to alcohol consumption
more commonly than gallstones (second
most common); in England, the opposite is
true. (Black, 2009)
Causes
Mechanisms causing pancreatitis are usually
unknown but it is commonly associated with
autodigestion of the pancreas.
 Alcohol abuse. Eighty percent of the
patients with pancreatitis have biliary tract
disease or a history of long-term alcohol
abuse.
 Bacterial or viral infection. Pancreatitis
occasionally develops as a complication
of mumps virus.
 Duodenitis. Spasm and edema of the
ampulla of Vater can probably cause
pancreatitis.
 Medications. The use of corticosteroids,
thiazide diuretics, oral contraceptives, and
other medications have been associated with
increased incidences of pancreatitis.
Clinical Manifestations
The signs and symptoms of pancreatitis include:
 Severe abdominal pain. Abdominal pain is
the major symptom of pancreatitis that
causes the patient to seek medical care and
this results from irritation and edema of the
inflamed pancreas.
 Boardlike abdomen. A rigid or boardlike
abdomen may develop and cause abdominal
guarding.
 Ecchymosis. Ecchymosis or bruising in
the flank or around the umbilicus may
indicate severe pancreatitis.
 Nausea and vomiting. Both are also
common in pancreatitis and the emesis is
usually gastric in origin but may also be bile
stained.
 Hypotension. Hypotension is typical and
reflects hypovolemia and shock caused by
the large amounts of protein-rich fluid into the
tissues and peritoneal cavity.
Complications
Complications that arise in pancreatitis include the
following:
 Fluid and electrolyte disturbances. These
are common complications because of
nausea, vomiting, movement of fluid from the
 vascular compartment to the peritoneal
cavity, diaphoresis, fever, and use of gastric
suction.
 Pancreatic necrosis. This is a major cause
of morbidity and mortality in patients with
pancreatitis because of resulting
hemorrhage, septic shock, and multiple
organ failure.
 Septic shock. Septic shock may occur with
bacterial infection of the pancreas.
Assessment and Diagnostic Findings
 Serum amylase and lipase levels. These
are used in making a diagnosis, although
their elevation can be attributed to many
causes, and serum lipase remains elevated
for a longer period than amylase.
 WBC count. The WBC count is usually
elevated.
 X-ray studies. X-ray studies of the abdomen
and chest may be obtained to differentiate
pancreatitis from other disorders that can
cause similar symptoms.
 Ultrasound. Ultrasound is used to identify
an increase in the diameter of the pancreas.
 Blood studies. Hemoglobin and hematocrit
levels are used to monitor the patient for
bleeding.
 CT scan: Shows an enlarged pancreas,
pancreatic cysts and determines the extent
of edema and necrosis.
 Ultrasound of abdomen: May be used to
identifying pancreatic inflammation, abscess,
pseudocysts, carcinoma, or obstruction of
biliary tract
 Endoscopic retrograde
cholangiopancreatography: Useful to
diagnose fistulas, obstructive biliary disease,
and pancreatic duct strictures/anomalies (the
procedure is contraindicated in an acute
phase).
 CT–guided needle aspiration: Done to
determine whether the infection is present.
 Abdominal x-rays: May demonstrate
dilated loop of small bowel adjacent to the
pancreas or another intra-abdominal
precipitator of pancreatitis, presence of free
intraperitoneal air caused by perforation or
abscess formation, pancreatic calcification
Medical Management
Management of pancreatitis is directed towards
relieving symptoms and preventing or treating
complications.
 Pain management. Adequate
administration
of analgesia (morphine, fentanyl, or
hydromorphone) is essential during the
course of pancreatitis to provide sufficient
relief and to minimize restlessness, which
may stimulate pancreatic secretion further.
 Intensive care. Correction of fluid and blood
loss and low albumin levels is necessary to
maintain fluid volume and prevent renal
failure.
 Respiratory care. Aggressive respiratory
care is indicated because of the high-risk
elevation of the diaphragm, pulmonary
infiltrates and effusion, and atelectasis.
 Biliary drainage. Placement of biliary
drains (for external drainage)
and stents (indwelling tubes) in the
pancreatic duct through endoscopy has been
performed to reestablish drainage of the
pancreas.
Surgical Management
There are several approaches available for surgery.
The major surgical procedures are the following:
 Side-to-side pancreaticojejunostomy
(ductal drainage). Indicated when dilation of
pancreatic ducts is associated with septa
and calculi. This is the most successful
procedure with success rates ranging from
60% to 90%.
 Caudal pancreaticojejunostomy (ductal
drainage). Indicated for uncommon causes
of proximal pancreatic ductal stenosis not
involving the ampulla.
 Pancreaticoduodenal (right-sided)
resection (ablative) (with preservation of
the pylorus) (Whipple procedure).
Indicated when major changes are confined
to the head of the pancreas. Preservation of
the pylorus avoids usual sequelae of gastric
resection.
 Pancreatic surgery. A patient who
undergoes pancreatic surgery may have
multiple drains in place postoperatively, as
well as a surgical incision that is left open for
irrigation and repacking every 2 to 3 days to
remove necrotic debris.
Nursing Management
Assessment
Nursing assessment of a patient with pancreatitis
involves:
 Assessment of current nutritional status and
increased metabolic requirements.
 Assessment of respiratory status.
 Assessment of fluid and electrolyte status.
 Assessment of sources of fluid and
electrolyte loss.
 Assessment of abdomen for ascites.
Diagnosis
Based on the assessment data, the nursing
diagnoses for a patient with pancreatitis include:
 Acute pain related to edema, distention of
the pancreas, and peritoneal irritation.
  Imbalanced nutrition: less than body
requirements related to inadequate dietary
intake, impaired pancreatic secretions, and
increased nutritional needs.
 Ineffective breathing pattern related to
splinting from severe pain, pulmonary
infiltrates, pleural effusion, and atelectasis.
Planning & Goals
Planning and goals developed for a patient with
pancreatitis involve:

 Relief of pain and discomfort.

 Improvement in nutritional status.
 Improvement in respiratory function.
 Improvement in fluid and electrolyte status.
Nursing Interventions
Performing nursing interventions for a patient with
pancreatitis needs expertise and efficiency.

 Relieve pain and discomfort. The current

recommendation for pain management in
this population is parenteral opioids including
morphine, hydromorphone, or fentanyl via
patient-controlled analgesia or bolus.
 Improve breathing pattern. The nurse
maintains the patient in a semi-Fowler’s
position and encourages frequent position
changes.
 Improve nutritional status. The patient
receives a diet high in carbohydrates and low
in fats and proteins between acute attacks.
 Maintain skin integrity. The nurse carries
out wound care as prescribed and takes
precautions to protect intact skin from
contact with drainage.
CHOLECYSTITIS Cholecystitis can progress to gallbladder
complications, such as:
Definition
1. Empyema. An empyema of the bladder
Cholecystitis is the acute or chronic inflammation of
develops if the gallbladder becomes filled
the gallbladder.
with purulent fluid.
There are two classifications of cholecystitis: 2. Gangrene. Gangrene develops because the
tissues do not receive enough oxygen and
1. Calculous cholecystitis. In calculous nourishment at all.
cholecystitis, a gallbladder stone obstructs 3. Cholangitis. The infection progresses as it
bile outflow. reaches the bile duct.
2. Acalculous cholecystitis. Acalculous
cholecystitis describes acute inflammation in Assessment and Diagnostic Findings
the absence of obstruction by gallstones.
Studies used in the diagnosis of cholecystitis
Pathophysiology include:

Calculous and acalculous cholecystitis have 1. Biliary ultrasound: Reveals calculi, with
different origins. gallbladder and/or bile duct distension
(frequently the initial diagnostic procedure).
 Obstruction. Calculous cholecystitis occurs 2. Oral cholecystography (OCG): Oral
when a gallbladder stone obstructs the bile cholecystography is used if ultrasound
outflow. equipment is not available or if the
 Chemical reaction. Bile remaining in the ultrasound results are inconclusive. This
gallbladder initiates a chemical reaction; study may be performed to detect gallstones
autolysis and edema occur. and to assess the ability of the gallbladder to
 Compression. Blood vessels in the fill, concentrate its contents, contract, and
gallbladder compressed, compromising its empty.
vascular supply. 3. Endoscopic retrograde
cholangiopancreatography (ERCP): This
Causes
procedure examines the hepatobiliary
The causes of cholecystitis include: system via a side-viewing flexible fiberoptic
endoscope inserted through the esophagus
1. Gallbladder stone. Cholecystitis is usually to the descending duodenum
associated with gallstone impacted in the Nursing Implications
cystic duct. Before the procedure:
2. Bacteria. Bacteria plays a minor role in
 The patient is educated about the
cholecystitis; however, secondary infection procedure and their role in it.
of bile occurs in approximately 50% of cases.
 The patient takes nothing by mouth
3. Alterations in fluids and electrolytes.
for several hours before the
Acalculous cholecystitis is speculated to be
procedure.
caused by alterations in fluids and
 Moderate sedation is used.
electrolytes.
 Administer medications, such as
4. Bile stasis. Bile stasis or the lack of
glucagon or anticholinergic agents.
gallbladder contraction also play a role in the
During the procedure:
development of cholecystitis.
 The nurse monitors IV fluids,
Clinical Manifestations administers medications, and
positions the patient.
Cholecystitis causes a series of signs and
After the procedure:
symptoms:
 The nurse monitors the patient’s
1. Pain. Right upper quadrant pain occurs with condition, observing vital signs and
cholecystitis. assessing for signs of perforation or
2. Leukocytosis. An increase in the WBC infection.
occurs because of the body’s attempt to ward  The nurse also monitors the patient
off pathogens. for side effects of any medications
3. Fever. Fever occurs in response to the received during the procedure and for
infection inside the body. return of the gag and cough reflexes.
4. Palpable gallbladder. The gallbladder 4. Percutaneous transhepatic
becomes edematous as infection cholangiography (PTC):
progresses.  Fluoroscopic imaging distinguishes
5. Sepsis. Infection reaches the bloodstream between gallbladder disease and
and the body undergoes sepsis. cancer of the pancreas (when
jaundice is present); supports the
Complications
 diagnosis of obstructive jaundice and
reveals calculi in ducts.
 PTC involves the injection of dye
directly into the biliary tract. Because
of the relatively large concentration of
dye that is introduced into the biliary
system, including the hepatic ducts
within the liver, the entire length of the
common bile duct, the cystic duct,
and the gallbladder is outlined
clearly.
 This sterile procedure is performed
under moderate sedation on a patient
who has been fasting; the patient
also receives local anesthesia.
 Nursing Implications
- Closely observe the patient for
symptoms of bleeding, peritonitis,
and sepsis.
- Assesses the patient for pain and
indications of these complications
and reports them promptly to the
primary provider,
- Takes measures to reassure the
patient, and ensures patient
comfort.
5. Cholecystography (for chronic
cholecystitis): Reveals stones in the biliary
system. Note:Contraindicated in acute
cholecystitis because the patient is too ill to
take the dye by mouth.
6. Hepatobiliary (HIDA, PIPIDA) scan: May
be done to confirm diagnosis of cholecystitis,
especially when barium studies are
contraindicated. Scan may be combined with
cholecystokinin injection to demonstrate
abnormal gallbladder ejection.
7. Abdominal x-ray films (multipositional):
Radiopaque (calcified) gallstones present in
10%–15% of cases; calcification of the wall
or enlargement of the gallbladder.
8. CBC: Moderate leukocytosis (acute). Serum
bilirubin and amylase: Elevated.
9. CT scan. CT scan is a secondary imaging
test that can identify extra-biliary disorders
and acute complications of cholecystitis.
10. MRI. Magnetic resonance imaging is also a
possible secondary choice for confirming a
diagnosis of acute cholecystitis.
11. Oral cholecystography. Preferred method
of visualizing general appearance and
function of the gallbladder.
Medical Management
Management may involve controlling the signs and
symptoms and the inflammation of the gallbladder.
 Fasting. The patient may not be allowed to
drink or eat at first in order to take the stress
off the inflamed gallbladder; IV fluids are
prescribed to provide temporary food for the
cells.
 Supportive medical care. This may include
restoration of hemodynamic stability and
antibiotic coverage for gram-negative enteric
flora.
 Gallbladder stimulation. Daily stimulation
of gallbladder contraction with IV
cholecystokinin may help prevent the
formation of gallbladder sludge in patients
receiving TPN.
Pharmacologic Therapy
The following medications may be useful in patients
with cholecystitis:
 Antibiotic therapy. Levofloxacin and
Metronidazole for prophylactic antibiotic
coverage against the most common
organisms.
 Promethazine or Prochlorperazine may
control nausea and prevent fluid and
electrolyte disorders.
 Oxycodone or Acetaminophen may control
inflammatory signs and symptoms and
reduce pain.
Surgical Management
Because cholecystitis frequently recurs, most
people with the condition eventually require
gallbladder removal.
 Cholecystectomy. Cholecystectomy is
most commonly performed by using a
laparoscope and removing the gallbladder.
 Endoscopic retrograde
cholangiopancreatography (ERCP).
ERCP visualizes the biliary tree by
cannulation of the common bile duct through
the duodenum.
Nursing Management
Management of cholecystitis include the following:
Nursing Assessment
 Integumentary system. Assess skin and
mucous membranes.
 Circulatory system. Assess peripheral
pulses and capillary refill.
 Bleeding. Assess for unusual bleeding:
oozing from injection sites, epistaxis,
bleeding gums, petechiae, ecchymosis,
hematemesis, or melena.
 Gastrointestinal system. Assess for
abdominal distension, frequent belching,
guarding, and reluctance to move.
Planning
The major goals for the patient include:
 Relieve pain and promote rest.
 Maintain fluid and electrolyte balance.
 Prevent complications.
  Provide information about disease process,
prognosis, and treatment needs.
Nursing Interventions
Treatment of cholecystitis depends on the severity
of the condition and the presence or absence of
complications.

 Pain assessment. Observe and document

location, severity (0-10 scale), and character
of pain.
 Activity. Promote bedrest, allowing the
patient to assume a position of comfort.
 Diversion. Encourage use of relaxation
techniques, and provide diversional
activities.
 Communication. Make time to listen and to
maintain frequent contact with the patient.
 Calories. Calculate caloric intake to identify
nutritional deficiencies or needs.
 Food planning. Consult the patient about
likes and dislikes, foods that cause distress,
and preferred meal schedules.
 Promote appetite. Provide a pleasant
atmosphere at mealtime and remove
noxious stimuli.
 Laboratory studies. Monitor laboratory
studies: BUN, prealbumin, albumin, total
protein, transferrin levels.
PELVIC INFLAMMATORY DISEASE
 Pelvic inflammatory disease (PID) is an
inflammatory condition of the pelvic
cavity that may begin with cervicitis and
involve the uterus (endometritis), fallopian
tubes (salpingitis), ovaries (oophoritis),
pelvic peritoneum or pelvic vascular system.
 Infection (acute, subacute, recurrent or
chronic and localized or widespread) is
usually caused by bacteria but may be
attributed to a virus, fungus or parasite.
 Gonorrhea and Chlamydial organisms are
common causes, but most cases of PID are
polymicrobial.
 Short and long-term consequences can
occur
Pathophysiology
Risk Factors
 Early age at first intercourse
 Multiple sexual partners
 Frequent intercourse
 Intercourse without condoms
 Sex with a partner with an STI
 History of STIs
 Previous pelvic infection
Clinical Manifestations
Symptoms of pelvic infection usually begin with:
 Vaginal discharge
 Dyspareunia
 Dysuria
 Pelvic or lower abdominal pain
 Tenderness that occurs after menses
 Postcoital bleeding
Other symptoms include:
 Fever
 General malaise
 Anorexia Nausea Headache
 Vomiting
On pelvic examination, intense tenderness may be
noted on palpation of the uterus or movement of the
cervix (Cervical motion tenderness)
Symptoms may be acute, and severe or low-grade
and subtle
Complications
 Pelvic or generalized peritonitis
 Abscesses
 Strictures
 Fallopian tube obstruction - ectopic
pregnancy
 Adhesions
Assessment and Diagnostic Findings
There is no specific test that can identify pelvic
inflammatory disease (PID) with certainty. Instead,
the doctor will depend on a combination of results
from the following findings:
 Medical history- Ask all about your sexual
habits, history of sexually transmitted
infections (STIs) and methods of birth
control.
 Signs and symptoms- Tell your doctor
about any symptoms you are experiencing,
even if they are mild.
 Pelvic examination- During the exam, your
doctor will check your pelvic region for
tenderness and swelling. Your doctor may
also use cotton swabs to take fluid samples
from your vagina and cervix. The samples
will be tested at a lab for signs of infection
and organisms such as gonorrhea and
chlamydia. Most woman have negative
swabs but it does not rule out the diagnosis.
If a woman experiences discomfort during
this examination, she may have PID.
Other tests may be necessary to look for signs of
infection or inflammation, or to rule out other
possible interpretations of its symptoms, since
Pelvic Inflammatory Disease (PID) may be difficult to
diagnose. The following tests are as follows:·
 Blood and urine tests- These tests are
used to test for pregnancy, HIV or other
sexually transmitted infections, or to
measure white blood cell counts or other
markers of infection or inflammation.
 Ultrasound- This test uses sound waves to
create clear images of your reproductive
organs.
In some case if the diagnosis for Pelvic Inflammatory
Disease (PID) is still unclear, your doctor may
recommend additional tests, such as:
1. Laparoscopy- During this procedure, your
doctor inserts a thin, lighted instrument
through a small incision in your abdomen to
view your pelvic organs.
Nursing Responsibilities
Before
1. Explain the procedure to the patient, and tell
her that laparoscopy is used to detect
abnormalities of the uterus, fallopian tubes,
and ovaries.
2. Instruct the patient to fast for at least 8 hours
before surgery.
3. Tell the patient who will perform the
procedure and where it will take place.
4. Tell the patient whether she’ll receive a
general anesthetic and whether the
procedure will require an outpatient visit or
overnight hospitalization.
5. Warn the patient that she may experience
pain at the puncture site and in the shoulder.
6. Make sure that the patient or a responsible
family member has signed an informed
consent form.
7. Check the patient’s history for
hypersensitivity to the anesthetic.
8. Make sure laboratory work is completed and
results are reported before the test.
9. Instruct the patient to empty her bladder just
before the test.
During
1. Provide comfort.
2. Place the patient in a lithotomy position to
anesthetize.
3. Assist the doctor during the procedure.
4. Monitor the patient accordingly.
After
1. Instruct the patient to resume his usual diet.
2. Instruct the patient to restrict activity for 2 to
7 days.
3. Explain that abdominal and shoulder pain
should disappear within 24 to 36 hours.
4. Provide analgesics.
5. Monitor vital signs.
6. Monitor the patient for adverse reactions to
anesthetic.
7. Monitor intake and output.
8. Watch for bleeding and signs and symptoms
of infection.
2. Endometrial biopsy- During this procedure,
your doctor inserts a thin tube into the uterus
to remove a small sample of endometrial
tissue. The tissue is tested for signs of
infection and inflammation.
Nursing Responsibilities
Before
1. Explain that this procedure is uncomfortable
but that postprocedure pain medication can
offer relief.
2. Explain that the procedure causes vaginal
bleeding, and instruct the woman to use
perineal pads rather than tampons.
3. When the physician has informed the woman
about the results of the biopsy, encourage
her to ask questions and express her
feelings and concerns.
During
1. Ask the patient to undress fully or from the
waist down and put on a hospital gown.
2. Instruct to empty her bladder before the
procedure.
3. Instruct to lie on an exam table, with her feet
and legs supported as for a pelvic exam.
4. Assist the healthcare provider during the
procedure.
5. Monitor the patient accordingly.
After
1. Instruct to avoid intercourse until advised by
the physician.
2. Provide information about treatment options
or health maintenance activities related to
regular examinations and health screening.
 Culdocentesis- With a needle inserted
behind the vagina to remove fluid for
examination. This procedure is much more
rare then it used to be, but is sometimes
helpful.
Nursing Responsibilities
Before
1. Check informed consent.
2. Explain the procedure to the patient.
3. Explain in understandable terms the risks,
complications, alternatives, and possible
outcomes.
4. Instruct the patient to walk or sit for a short
time before the test will be done.
During
1. Ask the patient to undress fully or from the
waist down and put on a hospital gown.
2. Instruct to empty her bladder before the
procedure.
3. Instruct to lie on an exam table, with her feet
and legs supported as for a pelvic exam.
4. Assist the health care provider during the
procedure.
After
1. Ask someone to take home the patient if she
was given a sedative.
2. Instruct the patient that she may resume her
usual activities.
3. Instruct the patient to continue the use of
birth controls.
4. Let the patient use sanitary pads for her next
menstrual period. Avoid tampons because it
may lead to infection.
5. Instruct to follow the prescribed medicines,
as ordered.
 6. Advise the patient that there is no special diet  Encourage patient to have adequate rest and
needed. to eat healthy
7. Advise the patient to notify her physician if  Minimizes transmission of infection by
she experiences vaginal bleeding that is adhering to appropriate infection control
more than 1 pad/hr or any signs of infection. practices and performing meticulous hand
hygiene
Medical Management
 Advise patient to abstain from all sexual
Treatment of pelvic inflammatory disease (PID) activity until they and their partners are fully
addresses the relief of acute symptoms, eradication treated and they are symptom-free
of current infection, and minimization of the risk of  Give counselling on the complications of
long-term sequelae. These sequelae, including PID, the need for safe sex practices, and the
chronic pelvic pain, ectopic pregnancy, tubal factor risk of having multiple sex partners in PID
infertility (TFI), and implantation failure with in vitro recurrence.
fertilization attempts, may occur in as many as 25%  Inform patients of the need for precaution
of patients. and encourage them to take part in
procedures to prevent infecting others and
 Broad-spectrum Antibiotics- usually a
protect herself from reinfection.
combination of ceftriaxone (Rocephin),
 Explain that the use of condoms is essential
doxycycline, and metronidazole (Flagyl)
to prevent infection and sequelae
 Hospitalization- indication includes surgical
 Inform the patients of the symptoms she may
emergencies, pregnancy, no clinical
feel if reinfection occurs (i.e., Abdominal
response to oral antimicrobial therapy,
pain, nausea and vomiting, fever, malaise,
inability to follow or tolerate an outpatient oral
malodorous purulent vaginal discharge and
regimen, severe illnesses (i.e., nausea,
leukocytosis
vomiting or high fever) and tubo-ovarian
 Give patient education about how PID occur,
abscess
how they can be controlled and avoided, and
 Treatment of sexual partners- identification
its associated signs and symptoms
and treatment of current and recent partners
 Inform all the patients with PID about the
are indicated for further reduction of sexually
signs and symptoms of ectopic pregnancy
transmitted infections (STIs) and to prevent
(pain, abnormal bleeding, delayed menses,
reinfection.
faintness, dizziness, and shoulder pain).
 Patients should have follow-up within 48 to
72 hours after hospital discharge or initiation
of outpatient treatment to determine clinical
improvement and treatment tolerance.
 Patients should be tested for all STIs,
including HIV and syphilis.
Special Populations

 Pregnant Women- Pregnant patients with

PID warrant admission to the hospital for
parenteral antibiotics. The preferred regimen
does not include doxycycline
 Women with HIV- Women with PID who also
have HIV have similar symptoms and
respond similarly to treatment as those
without HIV; however, women with HIV are
at increased risk of tubo-ovarian abscesses
and have higher rates of mycoplasma and
streptococcal infections.
Nursing Management

 Assess for both the physical and emotional

effects of PID
 Prepares the patient for further diagnostic
evaluation and surgical intervention as
prescribed.
 Accurately record vital signs, intake and
output, and the characteristics and amount of
vaginall discharge
 Administers analgesic agents for pain relief
as prescribed
BENIGN PROSTATIC HYPERPLASIA (BPH)
Benign prostatic hyperplasia (BPH) is one of the
most common diseases in aging men.
 Benign prostatic hyperplasia (BPH) is the
enlargement, or hypertrophy, of the prostate
gland.
 The prostate gland enlarges, extending
upward into the bladder and obstructing the
outflow of urine. Incomplete emptying of the
bladder and urinary retention leading to
urinary stasis may result in hydronephrosis,
hydroureter, and urinary tract infections
(UTIs).
 The cause is not well understood, but
evidence suggests hormonal involvement.
 BPH is common in men older than 40 years.
 It can cause bothersome lower urinary tract
symptoms that affect quality of life by
interfering with daily normal activities and
sleep pattern.
Pathophysiology
The pathophysiology of BPH is as follows:
 Resistance. BPH is a result of complex
interactions involving resistance in the
prostatic urethra to mechanical and spastic
effects.
 Obstruction. The hypertrophied lobes of the
prostate may obstruct the bladder neck or
urethra, causing incomplete emptying of the
bladder and urinary retention.
 Dilation. Gradual dilation of the ureters and
kidneys can occur.
Statistics and Epidemiology
Here are the current statistics for BPH:
 BPH typically occurs in men older than 40
years of age.
 By the time they reach 60 years of age, 50%
of men have BPH.
 BPH affects as many as 90% of men by 85
years of age.
 BPH is the second most common cause of
surgical intervention in men older than 60
years of age.
Causes
The cause of BPH is not well understood, but
testicular androgens have been implicated.
 Elevated estrogen levels. BPH generally
occurs when men have elevated estrogen
levels and when prostate tissue becomes
more sensitive.
 Smoking. Smoking increases the risk of
acquiring BPH.
 Reduced activity level. A sedentary lifestyle
could also lead to the development of BPH.
 Western diet. A diet high in animal fat and
protein and refined carbohydrates while low
in fiber predisposes a man to BPH.
Clinical Manifestations
BPH may or may not lead to lower urinary tract
symptoms; if symptoms occur, they may range from
mild to severe.
 Urinary frequency. Frequent trips to the
bathroom to urinate may be an early sign of
a developing BPH.
 Urinary urgency. This is the sudden and
immediate urge to urinate.
 Nocturia. Urinating frequently at night is
called nocturia.
 Weak urinary stream. Decreased and
intermittent force of stream is a sign of BPH.
 Dribbling urine. Urine dribbles out after
urination.
 Straining. There is presence of abdominal
straining upon urination.
Assessment and Diagnostic Findings
There are several ways to diagnose benign prostatic
hypertrophy.
 Digital rectal examination (DRE). A DRE
often reveals a large, rubbery,
and nontender prostate gland.
 Urinalysis. A urinalysis to screen
for hematuria and UTI is recommended.
 Prostate specific antigen levels. A PSA
level is obtained if the patient has at least a
10-year life expectancy and for whom
knowledge of the presence of
prostate cancer would change management.
 Urinalysis: Color: Yellow, dark brown, dark
or bright red (bloody); appearance may be
cloudy. pH 7 or greater (suggests infection);
bacteria, WBCs, RBCs may be present
microscopically.
 Urine culture: May reveal Staphylococcus
aureus, Proteus, Klebsiella, Pseudomonas,
or Escherichia coli.
 Urine cytology: To rule out bladder cancer.
 BUN/Cr: Elevated if renal function is
compromised.
 Prostate-specific
antigen (PSA): Glycoprotein contained in
the cytoplasm of prostatic epithelial cells,
detected in the blood of adult men. Level is
greatly increased in prostatic cancer but can
also be elevated in BPH. Note: Research
suggests elevated PSA levels with a low
percentage of free PSA are more likely
associated with prostate cancer than with a
benign prostate condition.
 WBC: May be more than 11,000/mm3,
indicating infection if patient is not
immunosuppressed.
  Uroflowmetry: Assesses degree of bladder
obstruction.
 IVP with post voiding film: Shows delayed
emptying of bladder, varying degrees of
urinary tract obstruction, and presence of
prostatic enlargement, bladder diverticula,
and abnormal thickening of bladder muscle.
 Voiding cystourethrography: May be used
instead of IVP to visualize bladder and
urethra because it uses local dyes.
 Cystometrogram: Measures pressure and
volume in the bladder to identify bladder
dysfunction unrelated to BPH.
 Cystourethroscopy: To view degree of
prostatic enlargement and bladder-wall
changes (bladder diverticulum).
 Cystometry: Evaluates detrusor muscle
function and tone.
 Transrectal prostatic ultrasound:
Measures size of prostate and amount of
residual urine; locates lesions unrelated to
BPH.
Medical Management
The goals of medical management of BPH are to
improve the quality of life and treatment depends on
the severity of symptoms.
 Catheterization. If a patient is admitted on
an emergency basis because he is unable to
void, he is immediately catheterized.
 Cystostomy. An incision into the bladder
may be needed to provide urinary drainage.
Pharmacologic Management
 Alpha-adrenergic
blockers (eg, alfuzosin, terazosin),
which relax the smooth muscle of the bladder
neck and prostate, and 5alpha reductase
inhibitors.
 Hormonal manipulation with antiandrogen
agents (finasteride [Proscar]) decreases the
size of the prostate and prevents the
conversion of testosterone to
dihydrotestosterone (DHT).
 Use of phytotherapeutic agents and other
dietary supplements (Serenoa repens [saw
palmetto berry] and Pygeum africanum
[African plum]) are not recommended,
although they are commonly used.
 One herbal medication effective against BPH
is Saw Palmetto.
Surgical Management
Other treatment options include minimally invasive
procedures and resection of the prostate gland.
 Transurethral microwave heat treatment.
This therapy involves the application of heat
to prostatic tissue.
 Transurethral needle ablation (TUNA).
TUNA uses low-level radio frequencies
delivered by thin needles placed in the
prostate gland to produce localized heat that
destroys prostate tissue while sparing other
tissues.
 Transurethral resection of the prostate
(TURP). TURP involves the surgical removal
of the inner portion of the prostate through an
endoscope inserted through the urethra.
 Open prostatectomy. Open prostatectomy
involves the surgical removal of the inner
portion of the prostate via a suprapubic,
retropubic, or perineal approach for large
prostate glands.
Nursing Management
Nursing management of a patient with BPH includes
the following:
Nursing Assessment
Nursing assessment focuses on the health history of
the patient.
 Health history. The health history focuses
on the urinary tract, previous surgical
procedures, general health issues, family
history of prostate diseases, and fitness for
possible surgery.
 Physical assessment. Physical
assessment includes digital rectal
examination.
Nursing Diagnosis
Based on the assessment data, the appropriate
nursing diagnoses for a patient with BPH are:
 Urinary retention related to obstruction in
the bladder neck or urethra.
 Acute pain related to bladder distention.
 Anxiety related to the surgical procedure.
Nursing Care Planning & Goals
The goals for a patient with BPH include:
 Relieve acute urinary retention.
 Promote comfort.
 Prevent complications.
 Help patient deal with psychosocial
concerns.
 Provide information about disease
process/prognosis and treatment needs.
Nursing Interventions
Preoperative and postoperative nursing
interventions for a patient with BPH are as follows:
 Reduce anxiety. The nurse should
familiarize the patient with the preoperative
and postoperative routines and initiate
measures to reduce anxiety.
 Relieve discomfort. Bed rest and
analgesics are prescribed if a patient
experiences discomfort.
 Provide instruction. Before the surgery, the
nurse reviews with the patient the anatomy
of the affected structures and their function in
relation to the urinary and reproductive
systems.
 Maintain fluid balance. Fluid balance
should be restored to normal.
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
 Is a chronic disease that causes
inflammation in connective tissues, such as
cartilage and the lining of blood vessels,
which provide strength and flexibility to
structures throughout the body
 The signs and symptoms of SLE vary among
affected individuals, and can involve many
organs and systems, including the skin,
joints, kidneys, lungs, central nervous
system, and blood-forming (hematopoietic)
system
 SLE may first appear as extreme tiredness
(fatigue), a vague feeling of discomfort or
illness (malaise), fever, loss of appetite, and
weight loss.
 Females develop SLE about nine times more
often than males and it is most common in
younger women, peaking during the
childbearing years; however, 20 percent of
SLE cases occur in people over age 50.
 People with SLE have episodes in which the
condition gets worse (exacerbations) and
other times when it gets better (remissions).
Overall, SLE gradually gets worse over time,
and damage to the major organs of the body
can be life-threatening.
 The exact prevalence is difficult to determine
because many of the signs and symptoms of
SLE resemble those of other disorders
 Diagnosis may be delayed for years, and the
condition may never be diagnosed in some
affected individuals.
Clinical Manifestation
Some type of cutaneous system manifestation is
experienced in 80% to 90% of patients with SLE.
The most familiar skin manifestation is an acute
cutaneous lesion consisting of a butterfly-shaped
erythematous rash across the bridge of the nose and
cheek. Other skin manifestations:
 Subacute cutaneous lupus erythematosus
 Discoid rash
 Oral ulcers
 Splinter hemorrhages
 Alopecia
 Raynaud’s phenomenon.
Joint symptoms:
 Arthralgias and/or arthritis (synovitis)
 Joint swelling, tenderness, and pain on
movement are also common
Cardiac system:
 Pericarditis (most common cardiac
manifestation)
 Myocarditis
 Hypertension
 Cardiac dysrhythmias
 Valvular incompetence
Renal manifestation:
 Nephritis as a result of SLE
Central nervous system:
 Psychosis
 Cognitive impairment
 Seizures
 Peripheral and cranial neuropathies
 Transverse myelitis
 Strokes
Assessment and Diagnostic Findings
 Diagnosis of SLE is based on a complete
history, physical examination, and blood
tests.
 The skin is inspected for erythematous
rashes. Cutaneous erythematous plaques
with an adherent scale may be observed on
the scalp, face, or neck. The patient should
be questioned about skin changes (because
these may be transitory) and specifically
about sensitivity to sunlight or artificial
ultraviolet light. The scalp should be
inspected for alopecia and the mouth and
throat for ulcerations reflecting
gastrointestinal involvement.
 Cardiovascular assessment includes
auscultation for pericardial friction rub,
possibly associated with myocarditis and
accompanying pleural effusions.
 The following may be detected on physical
examination, joint swelling, tenderness,
warmth, pain on movement, stiffness, and
edema
 The neurologic assessment is directed at
identifying and describing any central
nervous system changes.
Criteria for Classifying Systemic Lupus
Erythematosus
The American College of Rheumatology (ACR)
established criteria are as follows:
 Malar rash
 Discoid rash
 Photosensitivity
 Oral ulcers
 Nonerosive arthritis
 Pleuritis or pericarditis
 Kidney disease
 Neurologic disease
 Hematologic disorder Immunologic disorder
 Positive antinuclear antibody
A person is diagnosed with systemic lupus
erythematosus, based on the 11 criteria above, if
any 4 or more of the criteria are met at any time.
Other laboratory tests include anti-DNA (antibody
that develops against the patient’s own DNA), anti-
ds DNA (antibody against DNA that is highly specific
to SLE, which helps differentiate it from drug-
induced lupus), and anti-Sm (antibody against Sm,
which is a specific protein found in the nucleus).
Other blood work includes the CBC, which may
reveal anemia, thrombocytopenia, leukocytosis, or
leukopenia.
Medical Management
Prognosis is improved with:
 Earlier diagnosis
 Earlier and better treatments regimen
 Careful monitoring from organ involvement
Goals of treatment:
 Preventing progressive loss of organ
function
 Reduce the likelihood of acute disease
 Minimize disease-related disabilities
 Prevent complications from therapy
Medications are most commonly used to control the
disease activity include:
 Corticosteroid
 NSAIDs
 Anti-malarial Drugs
 Immunosuppressive agents
 Biologics
Nursing Management
Assessment
 Indicate a dietary consultation.
 Instruct the patient about the importance of
continuing prescribed medications and their
side effects.
 Reiterate that adherence to treatment does
not necessarily halt progression
 Teach energy conservation and relaxation
exercises
 For joint problems, all the teaching for RA
related to joint protection, ROM, and
positioning to prevent contractures
 Smoking can worsen SLE symptoms and
patients shall be educated about the
importance of smoking cessation
 Instruct the client to clean, dry, and
moisturize intact skin; use warm (not hot)
water, especially over bony prominences;
use unscented lotion. Use a mild shampoo.
 Encourage the client to assume an
anatomically correct position with all joints.
Suggest that the client uses a small flat pillow
under the head and not use a knee gatch or
pillow to prop the knee.
 Instruct in lifestyle activities that can help
reduce flare-ups such as:
- Eating a balanced diet of fruits, grains,
and vegetables.
- Regular exercise
- Avoiding sun exposure
- Adequate rest

 Pain should be assessed continuously and

should be acted upon.
 Assess patient’s physical, psychologic, and
sociocultural problems with long-term
management of SLE
Nursing Diagnosis

 Acute Pain related to inflammation

associated with increased disease activity as
evidenced by guarding on motion of affected
joints
 Impaired skin integrity related to
exacerbation of disease process as
evidenced by skin rash, redness, and skin
breakdown.
 Fatigue related to chronic inflammation and
altered immunity as evidenced by lack of
energy, inability to maintain usual routine
 Deficient Knowledge related to new condition
or treatment as evidenced by verbalizing
inaccurate information
Nursing Interventions:

 Encourage adequate nutrition and hydration

 Instruct the patient to avoid exposure or to
protect themselves with sunscreen and
clothing.
 Make the patient understand the need for
routine periodic screenings as well as health
promotion activities.
CELLULAR ABBERATION OF LUNGS
Lung Cancer
 Is the uncontrolled growth of abnormal cells
that start off in one or both lungs; usually in
the cells that line the air passages.
 The abnormal cells do not develop into
healthy lung tissue, they divide rapidly and
form tumors.
 As tumors become larger and more
numerous, they undermine the lung’s ability
to provide the bloodstream with oxygen.
Statistics
Lung cancer (both small cell and non-small cell) is
the second most common cancer in both men and
women.
• About 14% of all new cancers are lung
cancers.
• About 1 out of 4 cancer deaths are from lung
cancer.
• Lung cancer mainly occurs in older people.
• About 2 out of 3 people diagnosed with lung
cancer are 65 or older, while less than 2%
are younger than 45.
• The average age at the time of diagnosis is
about 70.
Risk Factors
• Smoking. Your risk of lung cancer increases
with the number of cigarettes you smoke
each day and the number of years you have
smoked. Quitting at any age can significantly
lower your risk of developing lung cancer.
• Exposure to secondhand smoke. Even if
you don't smoke, your risk of lung cancer
increases if you're exposed to secondhand
smoke.
• Previous radiation therapy. If you've
undergone radiation therapy to the chest for
another type of cancer, you may have an
increased risk of developing lung cancer.
• Exposure to radon gas. Radon is produced
by the natural breakdown of uranium in soil,
rock and water that eventually becomes part
of the air you breathe. Unsafe levels of radon
can accumulate in any building, including
homes.
• Exposure to asbestos and other
carcinogens. Workplace exposure to
asbestos and other substances known to
cause cancer — such as arsenic, chromium
and nickel — can increase your risk of
developing lung cancer, especially if you're a
smoker.
• Family history of lung cancer. People with
a parent, sibling or child with lung cancer
have an increased risk of the disease.
Pathophysiology
 Predisposing factors
 Age
 Gender
 Family History
 Precipitating Factors
 Active smoking
 Passive smoking
 Exposure to carcinogenic
 Exposure to radiation
 Normal cell
 Cell damage (DNA damage)
 Escape in normal enzymatic mechanism
 Cells escape DNA repair mechanics or
apoptosis
 Cellular mutation occurs
 Uncontrolled cell division
 A cell invade or spread through the lymphatic
system or blood vessels
 Malignant transformation (cancer cell) or
pulmonary epithelial cell
 Abnormal proliferation of the lung cell. This
cells grows slowly and covers the segmental
bronchi and lobes of the lungs
 Non-specific inflammatory changes with
hypersecretion of mucus, desquamation of
the cells
 Lesions in the lung’s tissues involving the
bronchi, bronchioles or even alveoli
 Signs and Symptoms
 Cough
 Fatigue
 Breathing problems
 Stridor
 Blood in phlegm
 Lung infection
 Hemoptysis
 Hoarseness
 Hiccups
 Chest pain
 Weight loss
 Chest tightness
 Pleural effusion
Classification
Small cell lung cancer (SCLC) - this accounts for
10% to 15% of all cancers. This form of lung cancer
is the most aggressive and fastest-growing of all.
Cigarette smoking is strongly linked to
SCLC. SCLCs spread quickly throughout the body,
and they are usually discovered after they have
spread widely.
Non-small cell lung cancer (NSCLC) - is the most
common lung cancer, accounting for about 85% of
all cases. NSCLC is divided into three types based
on the cells found in the tumor. They are as follows:
 Adenocarcinomas - starts in glandular
cells, which secrete substances such as
mucus, and tends to develop in smaller
airways, such as alveoli
 Squamous cell carcinomas - arise most
frequently in the central chest area in the
bronchi.
  Large cell carcinomas - has a high
tendency to spread to the lymph nodes
and distant sites.
Assessment and Diagnostic Tests
Chest X-ray
 Performed to search for pulmonary density,
a solitary pulmonary nodule (coin lesion),
atelectasis and infection.
 A chest X-ray can produce images of your
lungs, airways, heart, blood vessels, and
bones of the chest and spine. It is often the
first imaging test a healthcare provider will
order if lung or heart disease is suspected. If
lung cancer is involved, chest X-rays can
sometimes detect larger tumors, but more
often than not fail to diagnose the disease.
Chest X-rays also fall short as a tool for lung
cancer screening.
Sputum cytology
 Is rarely used to make a diagnosis of lung
cancer
Fiberoptic bronchoscopy
• Is commonly used; it provides a detailed
study of the tracheobronchial tree and allows
for brushing, washing, and biopsies of
suspicious areas.
• A bronchoscopy is an endoscopic medical
procedure that is used to look inside the
airways (bronchi) and the lungs. It involves
inserting a bronchoscope—a narrow tube
that has a light and a camera on one end—
through the nose or mouth and guiding it
down through the trachea (windpipe) in order
to get an internal view of the respiratory
system. It may be done to diagnose a
disease or condition such as lung cancer or
infection, or to treat a medical problem such
as a foreign object that's lodged in the
airways.
A variety of scans may be used to assess for
metastasis of the cancer;
• Bone scan
• Abdominal scan
• Positron emission tomography (PET) scan
• Liver ultrasound
Used to detect central nervous system metastases:
• CT scan of the brain
• Magnetic resonance imaging (MRI), and
other neurologic diagnostic procedures
Mediastinoscopy or Mediastinotomy - Used to
obtain biopsy samples from lymph nodes in the
mediastinum. Endobronchial Ultrasound biopsy of
mediastinal nodes is also used. In some
circumstances, an endoscopy with esophageal
ultrasound may be used to obtain transesophageal
biopsy of enlarged subcarinal lymph nodes.
Part of the preoperative assessment
• Pulmonary function test
• Arterial blood gas analysis
• V/Q scans
• Exercise testing
Medical Management
Radiation therapy and Chemotherapy.
Chemotherapy is often used along with radiation
therapy to treat lung cancer. Together, chemo drugs
and radiation may work better to destroy cancer
cells. In some people with lung cancer, chemo can
keep the tumor small so that the radiation can work
better to destroy it. It may also keep the cancer cells
from growing back after radiation therapy.
Median Sternotomy. A type of surgical procedure
in which a vertical inline incision is made along the
sternum, after which the sternum itself is divided, or
"cracked". This procedure provides access to the
lungs for surgical procedures
SCLC Treatment. Iincludes surgery (but only if the
cancer is in one lung and there is no metastasis),
radiation therapy, laser therapy to open airways
blocked by tumor growth and endoscopic stent
placement (to open an airway). Although the cancer
cells are small, they grow very quickly and create
large tumors.
Medications
Crizotinib (Xalkori) - is a receptor tyrosine kinase
inhibitor used to treat metastatic non-small cell lung
cancer (NSCLC) where the tumors have been
confirmed tobbe anaplastic lymphoma kinase (ALK),
or ROS1-positive
Ceritinib (Zykadia) - is used to treat a certain type
of non-small cell lung cancer (NSCLC) that has
spread to other parts of the body. Ceritinib is in a
class of medications called kinase inhibitors. It works
by blocking the action of an abnormal protein that
signals cancer cells to multiply.
Gemcitabine (Gemzar) - a pyrimidine nucleoside
antimetabolite, has been one of the most effective
agents for patients with advanced non-small cell
lung cancer. It is unknown whether histological type
is a predictor of the outcome of treatment with this
agent.
Nab-paclitaxel (Abraxane) - treatment of locally
advanced or metastatic non-small-cell lung cancer
(NSCLC) in combination with carboplatin in patients
who are not candidates for curative surgery or
radiation therapy
Pemetrexed (Alimta) - one of the most frequently
prescribed chemotherapeutic agents for advanced
nonsquamous NSCLC treatment. It is now approved
for first-line, maintenance and second or third-line
treatment of nonsquamous NSCLC and is generally
well tolerated, with few grade 3 and 4 toxicities.
Vinorelbine (Navelbine) - is used alone and in
combination with other medications to treat non-
small cell lung cancer (NSCLC) that has spread to
nearby tissues or to other parts of the body.
Vinorelbine is in a class of medications called vinca  End of life treatment option
alkaloids. It works by slowing or stopping the growth
of cancer cells in your body.

Nursing Management

Managing Symptoms

 Educate the patient and family about the

potential side effects of the specific treatment
and strategies to manage them.
 Common symptoms: dyspnea, fatigue,
nausea, vomiting and anorexia

Relieving Breathing Problems

 Introduce to pt. and family the airway

clearance technique.
 Deep breathing exercise, chest
physiotherapy, directed cough, suctioning,
and bronchoscopy.
 Bronchodilator medication maybe prescribed
to promote bronchodilation.
 Some stage of the disease some
supplemental oxygen is needed
 Nursing measures focus on decreasing the
dyspnea
 Encourage patient to assume positions that
promote lung expansion and to perform
breathing exercise for lung expansion and
relaxation.
 Educate the patient about energy
conservation
 Referral to a pulmonary rehabilitation
program maybe helpful in managing
respiratory symptoms

Reducing Fatigue

 Assess the patient and treatment factors that

are associated with or increased fatigue
 Institute interventions to address factors
contributing to fatigues
 Encourage balance of rest and exercise
avoiding extended periods of inactivity.
Promote patients normal sleep habits
 Encourage protein, fat, and calorie intake at
least equal to that recommended for the
general public
 Encourage the use of relaxation technique
and guided imagery
 Encourage participation in planned exercise
programs involving aerobic, resistance, and
flexibility training based on individual
limitations and safety measures.

Providing Psychological Support

 The nurse must help the patient and family in

dealing with the following:
 The poor prognosis and relatively rapid
progression of this disease
 Informed decision making regarding the
possible treatment option
 Methods to maintain the patient’s quality of
life during the course of this disease.
BREAST CANCER
 Is the leading type of cancer in women. Most
breast cancer begins in the lining of the milk
ducts, sometimes the lobule.
 The cancer grows through the wall of the
duct and into the fatty tissue.
 Breast cancer metastasizes most commonly
to auxiliary nodes, lung, bone, liver, and the
brain.
 The most significant risk factors for breast
cancer are gender (being a woman) and age
(growing older). Controversial risk factors
include oral contraceptive use, alcohol use,
obesity, and increased dietary fat intake.
 A woman’s risk of breast cancer
approximately doubles if she has a first-
degree relative (mother, sister, daughter)
who has been diagnosed with breast cancer.
About 20-30% of women diagnosed with
breast cancer have a family history of breast
cancer.
Stages of Breast Cancer
Stages Stage Definition
Stage 0 Cancer cells remain inside the breast
duct, without invasion into normal
adjacent breast tissue.
Stage I Cancer is 2 centimeters or less and is
confined to the breast (lymph nodes are
clear).
Stage No tumor can be found in the breast, but
IIA cancer cells are found in the axillary
lymph nodes (the lymph nodes under
the arm)
OR
The tumor measures 2 centimeters or
smaller and has spread to the axillary
lymph nodes
OR
The tumor is larger than 2 but no larger
than 5 centimeters and has not spread
to the axillary lymph nodes.
Stage The tumor is larger than 2 but no larger
IIB than 5 centimeters and has spread to
the axillary lymph nodes
OR
The tumor is larger than 5 centimeters
but has not spread to the axillary lymph
nodes.
Stage No tumor is found in the breast. Cancer
IIIA is found in axillary lymph nodes that are
sticking together or to other structures,
or cancer may be found in lymph nodes
near the breastbone
OR
The tumor is any size. Cancer has
spread to the axillary lymph nodes,
which are sticking together or to other
structures, or cancer may be found in
lymph nodes near the breastbone.
Stage The tumor may be any size and has
IIIB spread to the chest wall and/or skin of
the breast
AND
May have spread to axillary lymph
nodes that are clumped together or
sticking to other structures, or cancer
may have spread to lymph nodes near
the breastbone. Inflammatory breast
cancer is considered at least stage IIIB.
Stage There may either be no sign of cancer
IIIC in the breast or a tumor may be any size
and may have spread to the chest wall
and/or the skin of the breast
AND
The cancer has spread to lymph nodes
either above or below the collarbone
AND
The cancer may have spread to axillary
lymph nodes or to lymph nodes near the
breastbone.
Stage The cancer has spread — or
IV metastasized — to other parts of the
body.
Pathophysiology
Predisposing Factors
 Genetics. 5-10% breast cancer cases are
considered directly related to inheritance of
mutations in BRCA1 or BRCA2. Women
carrying mutations in BRCA1/2 genes have
a 50-80% lifetime risk of breast cancer.
 Hormonal Factors. A number of
epidemiologic and pooled studies support an
elevated risk of breast cancer among women
with high estradiol levels. Current or recent
past users of HRT (Hormone Replacement
Therapy) have a higher risk of being
diagnosed with breast cancer.
 Age. Risk increases with advancing age.
Risk at age 40 is 1:217 and risk at age 80 is
1:10.
 Gender. Female: Primary risk factor.
Lifetime risk in females is 1:8 compared to
males at 1:1000.
 Family History. Women with close relatives
who've been diagnosed with breast cancer
have a higher risk of developing the disease.
Risk increases with the number of affected
relatives, especially with early-onset breast
cancer, bilateral breast cancer or male
breast cancer.
Precipitating Factors
 Radiation Exposure. Ionizing radiation:
Breast tissue is sensitive to carcinogenic
effects of radiation. Risk is highest in the
developing breast and absent after
menopause.
 Diet. Diet is thought to be at least partly
responsible for about 30% to 40% of all
cancers. Older women who are overweight
or obese have a higher risk of getting breast
cancer than those at a normal weight.
Alcohol has been shown to increase the
amount of circulating estrogen, possibly by
decreasing hepatic metabolism, increasing
 aromatase activity, or increasing adrenal sex
hormone production.
 Cigarette Smoking. First hand smoking at a
young age as well as before a first full term
pregnancy. Smoking allows tobacco
carcinogens to initiate breast cells prior
hormonal stimulation during young
adulthood and pregnancy. Cigarette smoke
contains at least 20 carcinogens that are
known to transform breast cells.
Normal breast cells become cancerous because of
changes (mutations) in DNA. When a proto-
oncogene mutates (changes) or there are too many
copies of it, it becomes a "bad" gene or oncogene
that can stay activated when it’s not supposed to be.
When this happens, the cell grows out of control and
makes more cells that grow out of control. Tumor
suppressor genes are normal genes that slow down
cell division (cell growth), repair DNA mistakes, or
tell cells when to die (a process known as apoptosis
or programmed cell death). When tumor suppressor
genes don't work properly, cells can grow out of
control, make more cells that grow out of control, and
cells don't die when they should. When the
oncogene activated or the tumor suppressor gene is
deactivated, neoplasm forms in the breast and
eventually, a primary tumor begins in the breast. If
not treated, the tumor becomes invasive and will
progress beyond the breast to regional lymph nodes.
Which in turn travels to other organ systems. As a
result, the functions of the other major organs will be
compromised and will eventually cause death. To
treat the primary tumor and destroy the cancer cell,
surgery, chemotherapy, and radiotherapy will be
performed.
Assessment
Inspection
 The breasts are inspected for size and
symmetry.
 A slight variation in the size of each breast is
common and generally normal. The skin is
inspected for color, venous pattern, and
thickening or edema.
 Erythema (redness) may indicate benign
local inflammation or superficial lymphatic
invasion by neoplasm.
 A prominent venous pattern can signal
increased blood supply required by a tumor.
 Edema and pitting of the skin may result from
a neoplasm blocking lymphatic drainage and
giving the skin an orange peel appearance
(peau d' orange), a classic sign of advanced
breast cancer.
Palpation
 The breasts are also palpated with the
patient sitting in an upright position. The
patient is the assisted to a supine position.
Before the breast is palpated, the patient's
shoulder is elevated by small pillow to
balance the breast on the chest wall.
 During palpation, the examiner notes tissue
consistency, patient-recorded tenderness or
masses. If a mass is detected, it is described
by its location (e.g. left breast, 2 cm from the
nipple at 2 o'clock position).
Physical Assessment: Male Breast
 Because breast cancer can occur in men,
examination of the male breast and axillae is
an important part of the physical
assessment. The nipple and areola are
inspected for masses.
 Gynecomastia (overdeveloped mammary
glands in the male) is differentiated from the
soft, fatty enlargement of obesity by the by
the firm enlargement of grandular tissue
beneath and immediately surrounding the
areola.
Diagnostic Evaluation
Breast self-examination (BSE)
 Breast self-examination (BSE) is a screening
method used in an attempt to detect early
breast cancer. The method involves the
woman herself looking at the feeling each
breast for possible lumps, distortions or
swelling.
Mammography
 Screening mammography is a specific type
of breast imaging that uses low-dose X-Rays
to detect cancer early before women
experience symptoms when it is most
treatable.
 Is a breast-imaging technique that can detect
non palpable lesions and assist in
diagnosing palpable masses.
Ultrasound
 Breast ultrasound is an imaging test that
uses sound waves to look at the inside of
your breasts. It can help your healthcare
provider find breast problems. It also lets
your healthcare provider see how well blood
is flowing to areas in your breasts.
Magnetic Resonance Imaging (MRI)
 MRI of breast or breast MRI is a test used to
detect breast cancer and other abnormalities
in the breast. A breast MRI captures multiple
images of your breast.
Fine Needle Aspiration (Tissue Analysis)
 Fine needle aspiration is a type of biopsy
procedure. In fine needle aspiration, a thin
needle is inserted into an area of abnormal
appearing tissue or body fluid.
 As with other types of biopsies, the sample
collected during fine needle aspiration can
 help make a diagnosis or rule out conditions
such as cancer.
Surgical Management
1. Removing breast cancer (lumpectomy)
 During a lumpectomy, which may be referred
to as breast-conserving surgery or wide local
excision, the surgeon removes the tumor and
a small margin of surrounding healthy tissue.
 A lumpectomy may be recommended for
removing smaller tumors. Some people with
larger tumors may undergo chemotherapy
before surgery to shrink a tumor and make it
possible to remove completely with a
lumpectomy procedure.
 This is also referred to as breast- conserving
therapy. The surgeon removes the
cancerous area and a surrounding margin of
normal tissue. A second incision may be
made in order to remove the lymph nodes.
2. Removing the entire breast (mastectomy)
 A mastectomy is an operation to remove all
of your breast tissue. Most mastectomy
procedures remove all of the breast tissue —
the lobules, ducts, fatty tissue and some skin,
including the nipple and areola (total or
simple mastectomy).
 Newer surgical techniques may be an option
in selected cases in order to improve the
appearance of the breast. Skin-sparing
mastectomy and nipple-sparing mastectomy
are increasingly common operations for
breast cancer.
3. Removing a limited number of lymph nodes
(sentinel node biopsy).
 To determine whether cancer has spread to
your lymph nodes, your surgeon will discuss
with you the role of removing the lymph
nodes that are the first to receive the lymph
drainage from your tumor.
 If no cancer is found in those lymph nodes,
the chance of finding cancer in any of the
remaining lymph nodes is small and no other
nodes need to be removed.
 A negative SLNB result suggests that
cancer has not yet spread to nearby
lymph nodes or other organs. If the sentinel
node is negative for cancer, a patient may be
able to avoid more extensive lymph node
surgery, reducing the potential complications
associated with having many lymph nodes
removed.
 A positive SLNB result indicates that
cancer is present in the sentinel lymph
node and that it may have spread to other
nearby lymph nodes (called regional lymph
nodes) and, possibly, other organs. This
information can help a doctor determine the
stage of the cancer (extent of the disease
within the body) and develop an appropriate
treatment plan.
 All surgery to remove lymph nodes, including
SLNB, can have harmful side effects,
although removal of fewer lymph nodes is
usually associated with fewer side effects,
particularly serious ones such as
lymphedema. The potential side effects
include:
 Lymphedema, or tissue swelling.
 Seroma, or a mass or lump caused by
the buildup of lymph fluid at the site of the
surgery
 Numbness, tingling, swelling, bruising, or
pain at the site of the surgery, and an
increased risk of infection
 Difficulty moving the affected body part
 Skin or allergic reactions to the blue dye
used in SLNB
 A false-negative biopsy result
4. Removing several lymph nodes (axillary
lymph node dissection).
 If cancer is found in the sentinel lymph
nodes, your surgeon will discuss with you the
role of removing additional lymph nodes in
your armpit.
5. Removing both breasts.
 Some women with cancer in one breast may
choose to have their other (healthy) breast
removed if they have a very increased risk of
cancer in the other breast because of a
genetic predisposition or strong family
history. (contralateral prophylactic
mastectomy)
 Most women with breast cancer in one breast
will never develop cancer in the other breast.
Discuss your breast cancer risk with your
doctor, along with the benefits and risks of
this procedure.
Medical Management
1. Radiation therapy
Radiation therapy uses high-powered beams of
energy, such as X-rays and protons, to kill cancer
cells. Radiation therapy is typically done using a
large machine that aims the energy beams at your
body (external beam radiation). But radiation can
also be done by placing radioactive material inside
your body (brachytherapy).
2. Chemotherapy
Chemotherapy uses drugs to destroy fast-growing
cells, such as cancer cells. If your cancer has a high
risk of returning or spreading to another part of your
body, your doctor may recommend chemotherapy
after surgery to decrease the chance that the cancer
will recur.
Chemotherapy is sometimes given before surgery in
women with larger breast tumors. The goal is to
shrink a tumor to a size that makes it easier to
remove with surgery.
Chemotherapy side effects depend on the drugs you
receive. Common side effects include hair loss,
nausea, vomiting, fatigue and an increased risk
of developing an infection. Rare side effects can
include premature menopause, infertility (if
premenopausal), damage to the heart and kidneys,
nerve damage, and, very rarely, blood cell cancer.
Chemotherapy drugs used for breast cancer
Chemotherapy can be given before surgery
(neoadjuvant) or after surgery (adjuvant). In most
cases, chemo is most effective when combinations
of drugs are used. Today, doctors use many different
combinations, and it's not clear that any single
combination is clearly the best.
Adjuvant and neoadjuvant drugs
 Anthracyclines, such as doxorubicin
(Adriamycin) and epirubicin (Ellence)
 Taxanes, such as paclitaxel (Taxol) and
docetaxel (Taxotere)
 5-fluorouracil (5-FU) or capecitabine
 Cyclophosphamide (Cytoxan)
 Carboplatin (Paraplatin)
Most often, combinations of 2 or 3 of these drugs are
used.
Drugs for breast cancer that has spread (advanced
breast cancer)
 Taxanes, such as paclitaxel (Taxol),
docetaxel (Taxotere), and albumin-bound
paclitaxel (Abraxane)
 Anthracyclines (Doxorubicin, pegylated
liposomal doxorubicin, and Epirubicin)
 Platinum agents (cisplatin, carboplatin)
 Vinorelbine (Navelbine)
 Capecitabine (Xeloda)
 Gemcitabine (Gemzar)
 Ixabepilone (Ixempra)
 Eribulin (Halaven)
3. Hormone therapy
Hormone therapy — perhaps more properly termed
hormone-blocking therapy — is used to treat breast
cancers that are sensitive to hormones. Doctors
refer to these cancers as estrogen receptor positive
(ER positive) and progesterone receptor positive
(PR positive) cancers.
Hormone therapy can be used before or after
surgery or other treatments to decrease the chance
of your cancer returning. If the cancer has already
spread, hormone therapy may shrink and control it.
Treatments that can be used in hormone therapy
include:
 Medications that block hormones from
attaching to cancer cells (selective estrogen
receptor modulators)
 Medications that stop the body from making
estrogen after menopause (aromatase
inhibitors)
 Surgery or medications to stop hormone
production in the ovaries
4. Immunotherapy
Immunotherapy uses your immune system to fight
cancer. Your body's disease-fighting immune
system may not attack your cancer because the
cancer cells produce proteins that blind the immune
system cells. Immunotherapy works by interfering
with that process.
Immunotherapy might be an option if you have triple-
negative breast cancer, which means that the
cancer cells don't have receptors for estrogen,
progesterone or HER2. For triple-negative breast
cancer, immunotherapy is combined with
chemotherapy to treat advanced cancer that's
spread to other parts of the body.
5. Supportive (palliative) care
Palliative care is specialized medical care that
focuses on providing relief from pain and other
symptoms of a serious illness. Palliative care
specialists work with you, your family and your other
doctors to provide an extra layer of support that
complements your ongoing care. Palliative care can
be used while undergoing other aggressive
treatments, such as surgery, chemotherapy or
radiation therapy.
Nursing Management
Nursing Diagnosis: Fatigue related to
consequence of chemotherapy for breast cancer
(e.g., immunosuppression and malnutrition) and/or
emotional distress due to the diagnosis, as
evidenced by overwhelming lack of energy,
verbalization of tiredness, generalized weakness,
and shortness of breath upon exertion
Desired Outcome: The patient will establish
adequate energy levels and will demonstrate active
participation in necessary and desired activities.
Nursing Interventions:
 Ask the patient to rate fatigue level. Assess
the patient’s activities of daily living, as well
as actual and perceived limitations to
physical activity. Ask for any form of exercise
that he/she used to do or wants to try.
 For patients with grade 3 fatigue (severe
fatigue), consider discussing having a
treatment break with the oncology team.
 Encourage progressive activity through self-
care and exercise as tolerated. Explain the
need to reduce sedentary activities such as
watching television and using social media
 for long periods. Alternate periods of physical
activity with rest and sleep.
 Teach deep breathing exercises and
relaxation techniques. Provide adequate
ventilation in the room.
 Refer the patient to the physiotherapy/
occupational therapy team as required.
Nursing Diagnosis: Imbalanced Nutrition: Less
than Body Requirements related to consequences of
chemotherapy for breast cancer, as evidenced by
abdominal cramping, stomach pain, diarrhea or
constipation, bloating, weight loss, nausea and
vomiting, and loss of appetite
Desired Outcome: The patient will be able to
achieve a weight within his/her normal BMI range,
demonstrating healthy eating patterns and choices.
Nursing Interventions:
 Explore the patient’s daily nutritional intake
and food habits (e.g. meal times, duration of
each meal session, snacking, etc.) Create a
daily weight chart and a food and fluid chart.
Discuss with the patient the short term and
long-term nutrition and weight goals.
 Help the patient to select appropriate dietary
choices to increase dietary fiber, caloric
intake and alcohol and coffee intake.
 Refer the patient to the dietitian.
 Symptom control: Administer the prescribed
medications for abdominal cramping and
pain, such as antispasmodics. Promote
bowel emptying using laxatives as
prescribed for constipation. On the other
hand, provide advice on taking antidiarrheal
medications for diarrhea.
Nursing Diagnosis: Deficient Knowledge related to
new diagnosis of breast cancer as evidenced by
patient’s verbalization of “I want to know more about
my new diagnosis and care”
Desired Outcome: At the end of the health teaching
session, the patient will be able to demonstrate
sufficient knowledge of breast cancer and its
management.
Nursing Interventions:
 Assess the patient’s readiness to learn,
misconceptions, and blocks to learning
Explain what breast cancer is and its
symptoms. Avoid using medical jargons and
explain in layman’s terms.
 Educate the patient about his/her breast
cancer treatment plan.
 Inform the patient the details about the
prescribed medications for supportive care,
such as pain medications, antiemetics and
bowel medications. Explain how to properly
self-administer each of them. Ask the patient
to repeat or demonstrate the self-
administration details to you.
 Use open-ended questions to explore the
patient’s lifestyle choices and behaviors that
can be linked to the development of breast
cancer. Teach the patient on how to modify
these risk factors.
Nursing Diagnosis: Body image disturbance
related to significance of loss of part or all of the
breast
Nursing Interventions:
 Monitor for adverse effects of radiation
therapy such as fatigue, sore throat, dry
cough, nausea, anorexia.
 Monitor for adverse effects of chemotherapy;
bone marrow suppression, nausea and
vomiting, alopecia, weight gain or loss,
fatigue, stomatitis, anxiety, and depression.
 Realize that a diagnosis of breast cancer is a
devastating emotional shock to the woman.
Provide psychological support to the patient
throughout the diagnostic and treatment
process.
 Involve the patient in planning and
treatment.
 Describe surgical procedures to alleviate
fear.
 Prepare the patient for the effects of
chemotherapy, and plan ahead for alopecia,
fatigue.
 Administer antiemetics prophylactically, as
directed, for patients receiving
chemotherapy.
 Administer I.V. fluids and hyperalimentation
as indicated.
 Help patient identify and use support
persons or family or community.
 Suggest to the patient the psychological
interventions may be necessary for anxiety,
depression, or sexual problems. Teach all
women the recommended cancer-screening
procedures.